Multimodal Ultrasound Versus MRI for the Diagnosis and Monitoring of Achilles Tendinopathy: A Prospective Longitudinal Study

Background: The diagnosis and monitoring of Achilles tendinopathy with imaging are challenging. There is a lack of studies comparing the diagnostic accuracy of magnetic resonance imaging (MRI), brightness mode ultrasound (B-mode), and power Doppler ultrasound with recent technologies such as ultrasound tissue characterization (UTC) and shear wave elastography (SWE). Purpose: To assess whether SWE and UTC, which offer quantitative values, show a superior diagnostic accuracy and capacity to detect structural improvement in Achilles tendinopathy compared with MRI, B-mode, or power Doppler. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Patients with insertional (n = 28) and midportion (n = 38) Achilles tendinopathy were evaluated at baseline and 6-month follow-up using MRI, B-mode, power Doppler, SWE, and UTC. Asymptomatic controls (n = 37) were evaluated at T 0. Diagnostic accuracy was analyzed based on a quantitative receiver operating characteristic (ROC) analysis with quantitative cutoff values (anteroposterior diameter, Öhberg score, UTC echo type, Young modulus) and by semiquantitative Likert scale–based assessment of experienced physicians. Results: For diagnosing insertional Achilles tendinopathy, semiquantitative MRI and power Doppler were most favorable (diagnostic accuracy, 95%), while the cross-sectional area of MRI revealed 89% accuracy in the ROC analyses (area under the curve [AUC], 0.911; P < .001). For diagnosing midportion Achilles tendinopathy, semiquantitative MRI and B-mode were most favorable (diagnostic accuracy, 87%), while UTC echo types 3 and 4 revealed 86% and 87% accuracy, respectively, in the ROC analyses (AUC, 0.911 and 0.941, respectively; P < .001). However, for quantitative and semiquantitative evaluation of diagnostic accuracy in both insertional and midportion Achilles tendinopathy, there was no significant difference in favor of one imaging modality over the others. Compared with baseline, only SWE showed a significant change at the 6-month follow-up ( P = .003-.035), but there were only fair to poor monitoring accuracies of 71% (insertion) and 60% (midportion). However, compared with the other modalities, the monitoring accuracy of SWE was significantly higher ( P = .002-.039). Conclusion: There was no statistically significant difference in favor of one imaging modality over the others, but MRI revealed the highest overall diagnostic accuracy for the diagnosis of both insertional and midportion Achilles tendinopathy.

Effect of Autologous Expanded Bone Marrow Mesenchymal Stem Cells or Leukocyte-Poor Platelet-Rich Plasma in Chronic Patellar Tendinopathy (With Gap >3 mm): Preliminary Outcomes After 6 Months of a Double-Blind, Randomized, Prospective Study

Background: Patellar tendinopathy is common. The success of traditional management, including isometric or eccentric exercises combined with shockwave therapy and even surgery, is limited. Therefore, it is important to determine whether biological treatments such as ultrasound-guided intratendinous and peritendinous injections of autologous expanded bone marrow mesenchymal stem cells (BM-MSCs) or leukocyte-poor platelet-rich plasma (Lp-PRP) improve clinical outcomes in athletic patients with patellar tendinopathy. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A prospective, double-blinded, randomized, 2-arm parallel group, active controlled, phase 1/2 single-center clinical study was performed in patients who had proximal patellar tendinopathy with a lesion >3 mm. A total of 20 participants (age 18-48 years) with pain for >4 months (mean, 23.6 months) and unresponsive to nonoperative treatments were randomized into 2 groups. Of these, 10 participants were treated with BM-MSC (20 × 106 cells) and 10 with Lp-PRP. Both groups performed the same postintervention rehabilitation protocol. Outcomes included the Victorian Institute of Sport Assessment for pain (VISA-P), self-reported tendon pain during activity (visual analog scale [VAS]), muscle function by dynamometry, tendon thickness and intratendinous vascularity by ultrasonographic imaging and Doppler signal, ultrasound tissue characterization (UTC) echo type changes, and magnetic resonance imaging (MRI) T2-weighted mapping changes. Participants were followed longitudinally for 6 months. Results: The average VAS scores improved in both groups at all time points, and there was a significant reduction in pain during sporting activities ( P < .05). In both groups, the average mean VISA-P scores at 6 months were significantly increased compared with baseline (66 BM-MSC group and 72.90 Lp-PRP group), with no significant differences in VAS or VISA-P scores between the groups. There were statistically significant greater improvements in tendon structure on 2-dimensional ultrasound and UTC in the BM-MSC group compared with the Lp-PRP group at 6 months. Similarly, the BM-MSC group demonstrated significant evidence of restoration of tendon structure on MRI compared with the Lp-PRP group at 6 months. Only the participants in the BM-MSC group showed evidence of normalization of tendon structure, with statistically significant differences between the groups on T2-weighted, fat-saturated sagittal and coronal scans and hypersignal in T2-weighted on spin-echo T2-weighted coronal MRI scan. Both treatments were safe, and no significant adverse events were reported in either group. Conclusion: Treatment with BM-MSC or Lp-PRP in combination with rehabilitation in chronic patellar tendinopathy is effective in reducing pain and improving activity levels in active participants. Participants who received BM-MSC treatment demonstrated greater improvement in tendon structure compared with those who received Lp-PRP. Registration: 2016-001262-28 (EudraCT identifier); NCT03454737 (ClinicalTrials.gov identifier)

Evaluation of Current Symptoms in Postoperative Achilles Tendons: A Multimodal Ultrasound Study

(1) Background: It is unknown which imaging parameters are associated with clinical persistent symptoms in postoperative Achilles tendons. This study used B-Mode, Power Doppler (PD-US), Ultrasound Tissue Characterization (UTC) and Shear Wave Elastography (SWE) to investigate which imaging parameters are associated with persistent symptoms in postoperative Achilles tendon tissue. (2) Methods: Retrospective, cross-sectional, multimodal imaging study. Based on the VISA-A score, postoperative tendons were assigned to two groups: 1. asymptomatic (VISA-A ≥ 90, n = 18); 2. symptomatic (VISA-A < 90, n = 10). The following imaging parameters were analyzed: UTC (echo type I, II, III, IV), B-Mode (diameter, cross sectional area, calcification, fiber irregularity), PD-US (Öhberg score) and SWE (SWE 3 mm, SWE area) using a t-test and a Mann–Whitney U test. (3) Results: SWE and PD-US showed significantly reduced elasticity and increased neovascularization in symptomatic tendons (SWE 3 mm p = 0.031, SWE area p = 0.046, Öhberg score p < 0.001). The only significant correlation between imaging parameters and the VISA-A score was assessed for SWE 3 mm (r = 0.378; p = 0.047) and the Öhberg score (r = −0.737; p < 0.001). Conclusions: Symptomatic postoperative Achilles tendons showed increased neovascularization and lower SWE values than asymptomatic ones. Future studies should examine the diagnostic accuracy of PD-US and SWE in detecting current symptoms in postoperative Achilles tendons.

Introduction of the Grayscale Median for Ultrasound Tissue Characterization of the Transplanted Kidney

Ultrasound examination is advised for early post-kidney transplant assessment. Grayscale median (GSM) quantification is novel in the kidney transplant field, with no systematic assessment previously reported. In this prospective cohort study, we measured the post-operative GSM in a large cohort of adult kidney transplant recipients (KTR) who consecutively underwent Doppler ultrasound directly after transplantation (within 24 h), compared it with GSM in nontransplanted patients, and investigated its association with baseline and follow-up characteristics. B-mode images were used to calculate the GSM in KTR and compared with GSM data in nontransplanted patients, as simulated from summary statistics of the literature using a Mersenne twister algorithm. The association of GSM with baseline and 1-year follow-up characteristics were studied by means of linear regression analyses. In 282 KTR (54 ± 15 years old, 60% male), the median (IQR) GSM was 55 (45–69), ranging from 22 to 124 (coefficient of variation = 7.4%), without differences by type of donation (p = 0.28). GSM in KTR was significantly higher than in nontransplanted patients (p < 0.001), and associated with systolic blood pressure, history of cardiovascular disease, and donor age (std. β = 0.12, −0.20, and 0.13, respectively; p < 0.05 for all). Higher early post-kidney transplant GSM was not associated with 1-year post-kidney transplant function parameters (e.g., measured and estimated glomerular filtration rate). The data provided in this study could be used as first step for further research on the application of early postoperative ultrasound in KTR.

Line- and Point-Focused Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Placebo-Controlled RCT Study

Background: Extracorporeal shock wave therapy (ESWT) is a widely considered treatment option for Achilles tendinopathy. Line-focused ESWT is a novel technique treating a larger tendon area than point-focused ESWT. Monitoring capacities of clinical symptoms with ultrasound under ESWT treatment are unknown. Hypothesis: Point- and line-focused ESWT have a superior outcome than placebo ESWT. ESWT leads to morphological tendon changes detectable with ultrasound. Study Design: Single-blinded placebo-controlled randomized contolled trial. Level of Evidence: Level 1. Methods: The study was conducted in 3 cohorts, namely ESWT point (n = 21), ESWT line (n = 24), and ESWT placebo (n = 21). Victorian Institute of Sports Assessment–Achilles (VISA-A) score was measured before the intervention (T0), after 6 weeks (T1), and after 24 weeks (T2). All cohorts performed daily physiotherapy for 24 weeks and received 4 sessions of point-focused, line-focused, or placebo ESWT in the first 6 weeks. Ultrasound was performed with B-mode, power Doppler, shear wave elastography (SWE) at T0 and T2 and with ultrasound tissue characterization (UTC) at T0, T1, and T2. Data were analyzed with a mixed analysis of variance and t test. Results: There was a significant VISA-A improvement over time for all groups ( P < 0.001). ESWT point had the strongest VISA-A score improvement +23 (ESWT line: +18; ESWT placebo: +15), but there was no significant interaction between time and any of the groups: F(4, 116) = 1.393; P = 0.24. UTC, power Doppler, and B-mode could not show significant alterations over time. SWE revealed a significant increase of elastic properties for ESWT point in the insertion ( t = −3.113, P = 0.03) and midportion ( t = −2.627, P = 0.02) over time. Conclusion: There is a significant VISA-A score improvement for all study groups without a statistically significant benefit for ESWT point or ESWT line compared with ESWT placebo. Tendon adaptation could only be detected with SWE for ESWT point. Clinical Relevance: The present study could not detect any statistically relevant effect of ESWT compared to placebo. SWE is able to demonstrate tendon adaptation.

Patellar Tendon Quality and Knee Symptoms in Male Athletes Before the Anterior Cruciate Ligament Reconstruction

Background: It is unknown if the quality of the patellar tendon is affected by an anterior cruciate ligament (ACL) injury. ACL deficient patients (ACL-D) have shown to have knee pain, quadriceps weakness and reduced knee function. Ultrasound tissue characterization (UTC) has been used to assess the quality of tendons by quantifying the proportion of echo-types using a numerical grading system from best to worst (I-IV). The primary aims of this cross-sectional study were to investigate the patellar tendon quality in athletes with unilateral ACL injuries, and to compare them to asymptomatic control tendons. The secondary aims were to assess the impact of anterior knee pain (AKP) in the patellar tendons of ACL-D, and to explore possible correlations between tendon quality and knee pain, knee extensor strength and time from ACL injury. Methods: UTC was used to scan both patellar tendons of 81 ACL-D athletes and 20 control tendons. Echo-types distribution was calculated to compare the quality between limbs of ACL-D and control tendons; and to compare ACL-D with AKP, other knee pain, and without pain. Associations between the variables of tendon quality and knee symptoms were explored. Results: No difference in tendon quality was found between limbs of ACL-D. Both tendons of ACL-D displayed more echo-type II at the patellar apex, and same or less echo-types III and IV than controls. The proximal half of the control tendons displayed better quality than the distal half. ACL-D knees with pain displayed less extensor strength, however, in addition to the lack of difference in tendon quality regardless of the presence and location of pain, there was no meaningful association between pain, extensor strength and tendon quality. Nevertheless, there were weak to moderate associations between tendon quality and time from ACL injury. Conclusion: Despite the ACL injury, there is no difference in tendon quality between ACL-D limbs, or when subgrouping ACL-D tendons by presence and location of knee pain. Different areas of the patellar tendon may present different characteristics that might be related to training. Tendon quality is better if a person has longer time from injury.