Ultrasonographic Evaluation of Achilles Tendon Thickness in the Emergency Department: A Novel Measurement Method

Öz

Objective: Increased Achilles tendon thickness is associated with hypercholesterolemia and cardiovascular disease, and ultrasonography is the preferred method for its assessment. This study aimed to evaluate the agreement between Achilles tendon ultrasonographic measurements obtained in different supine positions and those acquired using the standard prone technique. Materials and Methods: This prospective methodological study included 180 healthy adults (70 women, 110 men), representing 360 Achilles tendons. Individuals with systemic disease, regular medication use, or Achilles tendon pathology were excluded. Tendon thickness, width, and cross-sectional area were measured ultrasonographically using four positioning techniques: the conventional prone position (Method 1) and three supine alternatives: leg extended beyond the examination table (Method 2), ankle over the contralateral knee (Method 3), and hip and knee flexed at 90° (Method 4). Measurements were obtained 2 cm proximal to the calcaneal insertion. Results: No significant differences were found between Method 1 and Method 2 for tendon thickness, width, or cross-sectional area (For all parameters; p>0.05). Strong correlations were observed for thickness and cross-sectional area (r>0.8), while width showed a moderate correlation (r=0.6-0.8). Conclusion: Method 2 demonstrated good agreement with the standard prone technique and may serve as a practical alternative for Achilles tendon ultrasonography, particularly when prone positioning is not feasible. This approach may facilitate cardiovascular risk assessment using Achilles tendon thickness in a wider range of clinical settings.

Anahtar Kelimeler

• Achilles tendon
• cardiovascular risk
• emergency medicine
• ultrasonography

Etik Beyan

This study was approved by the Non-Interventional Ethics Committee of Sakarya University, Republic of Turkey (Date: 19.09.2024, decision no: E-43012747-050.04-399468-15). The study was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all participants. The study is registered with ClinicalTrials.gov, No. NCT06867211.

Aşil Tendon Kalınlığının Acil Serviste Ultrasonografik Değerlendirmesi: Yeni Bir Ölçüm Yöntemi

Öz

Amaç: Artmış Aşil tendonu kalınlığı, hiperkolesterolemi ve kardiyovasküler hastalık ile ilişkilidir ve değerlendirilmesi için tercih edilen yöntem ultrasonografidir. Bu çalışma, farklı supin (sırtüstü) pozisyonlarda elde edilen Aşil tendonu ultrasonografik ölçümleri ile standart pron (yüzüstü) tekniği kullanılarak elde edilen ölçümler arasındaki uyumu değerlendirmeyi amaçlamıştır. Materyal ve Metot: Bu prospektif metodolojik çalışmaya 180 sağlıklı yetişkin (70 kadın, 110 erkek) dahil edilmiştir ve toplamda 360 Aşil tendonu değerlendirilmiştir. Sistemik hastalığı olan, düzenli ilaç kullanan veya Aşil tendon patolojisi olan bireyler dışlandı. Tendon kalınlığı, genişliği ve kesitsel alanı dört farklı pozisyonda ultrasonografi ile ölçüldü: standart yüzüstü yöntem (Yöntem 1), bacağı masa dışına uzatılmış sırtüstü (Yöntem 2), ayak bileği karşı diz üzerine yerleştirilmiş sırtüstü (Yöntem 3) ve kalça ile diz 90° fleksiyonda sırtüstü (Yöntem 4). Ölçümler kalkaneal insersiyonun 2 cm proksimalinden yapıldı. Bulgular: Yöntem 1 ile Yöntem 2 arasında tendon kalınlığı, genişliği ve kesitsel alan açısından anlamlı bir fark saptanmadı (Tüm parametreler için p>0.05). Kalınlık ve kesitsel alan ölçümlerinde güçlü (r>0.8), genişlik ölçümlerinde ise orta düzeyde korelasyon bulundu(r=0.6-0.8). Sonuç: Yöntem 2, standart yüzüstü yöntemle iyi uyum göstermiş olup, yüzüstü pozisyonun uygulanamadığı hastalarda Aşil tendon ultrasonografisi için pratik bir alternatif olabilir. Bu yöntem, Aşil tendon kalınlığının kardiyovasküler risk değerlendirmesinde daha geniş hasta gruplarında kullanılmasına katkı sağlayabilir.

Anahtar Kelimeler

• Acil tıp
• aşil tendonu
• kardiyovasküler risk
• ultrasonografi

Etik Beyan

Bu çalışma, Türkiye Cumhuriyeti Sakarya Üniversitesi Müdahalesel Olmayan Etik Komitesi tarafından onaylanmış (Tarih: 19.09.2024, karar no: E-43012747-050.04-399468-15). Çalışma, Helsinki Bildirgesi uyarınca gerçekleştirilmiştir. Tüm katılımcılardan bilgilendirilmiş onayı alınmıştır. Çalışma, ClinicalTrials.gov, No. NCT06867211.

Kaynakça

1. 1. Las 10 principales causas de defunción. https://www.who.int/es/news-room/fact-sheets/detail/the-top-10-causes-of-death. Accessed February 17, 2025.
2. 2. Herrero-Fernandez B, Gomez-Bris R, Somovilla-Crespo B, Gonzalez-Granado JM. Immunobiology of Atherosclerosis: A Complex Net of Interactions. Int J Mol Sci. 2019;20(21):5293. doi:10.3390/ijms20215293
3. 3. Medina-Leyte DJ, Zepeda-García O, Domínguez-Pérez M, González-Garrido A, Villarreal-Molina T, Jacobo-Albavera L. Endothelial Dysfunction, Inflammation and Coronary Artery Disease: Potential Biomarkers and Promising Therapeutical Approaches. Int J Mol Sci. 2021;22(8):3850. doi:10.3390/ijms22083850
4. 4. Marchio P, Guerra-Ojeda S, Vila JM, Aldasoro M, Victor VM, Mauricio MD. Targeting Early Atherosclerosis: A Focus on Oxidative Stress and Inflammation. Oxid Med Cell Longev. 2019;2019:8563845. doi:10.1155/2019/8563845
5. 5. Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37(29):2315-2381. doi:10.1093/eurheartj/ehw106
6. 6. Ibrahim MA, Jialal I. Hypercholesterolemia. In: StatPearls. Treasure Island (FL): StatPearls Publishing; April 23, 2023.
7. 7. Fernandez AB, Thompson PD. Eye markers of cardiovascular disease. BMJ. 2011;343:d5304. doi:10.1136/bmj.d5304
8. 8. Pejic RN. Familial hypercholesterolemia. Ochsner J. 2014;14(4):669-672.

9. 9. Harada-Shiba M, Arai H, Ishigaki Y, et al. Guidelines for Diagnosis and Treatment of Familial Hypercholesterolemia 2017. J Atheroscler Thromb. 2018;25(8):751-770. doi:10.5551/jat.CR003
10. 10. Murugan A, Kanakaraju K, R M S, Sanjoy Mishra V. Achilles Tendon Softness and Thickness in Patients With Hypercholesterolemia. Cureus. 2022;14(8):e28340. doi:10.7759/cureus.28340
11. 11. Durrington PN, Adams JE, Beastall MD. The assessment of Achilles tendon size in primary hypercholesterolaemia by computed tomography. Atherosclerosis. 1982;45(3):345-358. doi:10.1016/0021-9150(82)90235-0
12. 12. Harada T, Inagaki-Tanimura K, Nagao M, et al. Frequency of Achilles Tendon Xanthoma in Patients with Acute Coronary Syndrome. J Atheroscler Thromb. 2017;24(9):949-953. doi:10.5551/jat.37770
13. 13. Steinmetz A, Schmitt W, Schuler P, Kleinsorge F, Schneider J, Kaffarnik H. Ultrasonography of achilles tendons in primary hypercholesterolemia. Comparison with computed tomography. Atherosclerosis. 1988;74(3):231-239. doi:10.1016/0021-9150(88)90242-0
14. 14. Yuzawa K, Yamakawa K, Tohno E, et al. An ultrasonographic method for detection of Achilles tendon xanthomas in familial hypercholesterolemia. Atherosclerosis. 1989;75(2-3):211-218. doi:10.1016/0021-9150(89)90178-0
15. 15. Del Baño-Aledo ME, Martínez-Payá JJ, Ríos-Díaz J, Mejías-Suárez S, Serrano-Carmona S, de Groot-Ferrando A. Ultrasound measures of tendon thickness: Intra-rater, Inter-rater and Inter-machine reliability. Muscles Ligaments Tendons J. 2017;7(1):192-199. doi:10.11138/mltj/2017.7.1.192
16. 16. Okamura T, Tsukamoto K, Arai H, et al. Japan Atherosclerosis Society (JAS) Guidelines for Prevention of Atherosclerotic Cardiovascular Diseases 2022. J Atheroscler Thromb. 2024;31(6):641-853. doi:10.5551/jat.GL2022
17. 17. Otter S, Payne C, Jones AM, Webborn N, Watt P. Differences in Achilles tendon stiffness in people with gout: a pilot study. BMC Musculoskelet Disord. 2020;21(1):658. doi:10.1186/s12891-020-03598-3
18. 18. Silbernagel KG, Shelley K, Powell S, Varrecchia S. Extended field of view ultrasound imaging to evaluate Achilles tendon length and thickness: a reliability and validity study. Muscles Ligaments Tendons J. 2016;6(1):104-110. doi:10.11138/mltj/2016.6.1.104
19. 19. Tharwat S, Saleh M, Elrefaey R, Nassar MK, Nassar MK. Clinical and Ultrasonographic Characteristics of the Achilles Tendon in Hemodialysis Patients. Medicina (Kaunas). 2023;59(12):2181. doi:10.3390/medicina59122181
20. 20. Edelson DP, Sasson C, Chan PS, et al. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association. Circulation. 2020;141(25):e933-e943. doi:10.1161/circulationaha.120.047463
21. 21. Hsu CH, Considine J, Pawar RD, et al. Cardiopulmonary resuscitation and defibrillation for cardiac arrest when patients are in the prone position: A systematic review. Resusc Plus. 2021;8:100186. doi:10.1016/j.resplu.2021.100186
22. 22. Fujiwara R, Yahiro R, Horio T, et al. Achilles tendon thickness is associated with coronary lesion severity in acute coronary syndrome patients without familial hypercholesterolemia. J Cardiol. 2022;79(2):311-317. doi:10.1016/j.jjcc.2021.09.021
23. 23. Kitahara H, Nakayama T, Fujimoto Y, Kobayashi Y. Association between Achilles tendon xanthoma and severity of coronary artery disease in patients undergoing percutaneous coronary intervention. J Cardiol. 2020;75(6):654-658. doi:10.1016/j.jjcc.2020.01.002
24. 24. Matsumoto I, Kurozumi M, Namba T, Takagi Y. Achilles Tendon Thickening as a Risk Factor of Cardiovascular Events after Percutaneous Coronary Intervention. J Atheroscler Thromb. 2023;30(5):491-501. doi:10.5551/jat.63607
25. 25. Tsouli SG, Xydis V, Argyropoulou MI, Tselepis AD, Elisaf M, Kiortsis DN. Regression of Achilles tendon thickness after statin treatment in patients with familial hypercholesterolemia: an ultrasonographic study. Atherosclerosis. 2009;205(1):151-155. doi:10.1016/j.atherosclerosis.2008.10.032
26. 26. Scott I, Malliaras P, Tardioli A, et al. Achilles tendon thickness reduces immediately after a marathon. J Orthop Surg Res. 2022;17(1):562. doi:10.1186/s13018-022-03448-z
27. 27. Sharifaskari A, Goodarzi A, Davoody N, Kianmehr N, Sepyani A, Haghighi A. Sonographic assessment of Achilles tendon in patients with cutaneous psoriasis. Caspian J Intern Med. 2024;15(2):313-317. doi:10.22088/cjim.15.2.313
28. 28. Canbolat M, Özbağ D, Özdemir Z, Demirtaş G, Kafkas AŞ. Effects of Physical Characteristics, Exercise And Smoking On Morphometry Of Human Achilles Tendon: an Ultrasound Study. Anatomy. 2016;9(3):128-134. doi:10.2399/ana.15.022