Christina Vong 24244058

A Comparison of MRI and US Findings

in Tendinosis

Christina Vong
24244058
Bachelor of Radiography and Medical Imaging,
Monash University

Supervisor
A/Prof Ronnie Ptasznik
Deputy Director Monash Imaging
Director of Clinical Informatics,
Monash Medical Centre, Monash Health

Journal: American Journal of Roentgenology

Word Limit: 3750 (5000 for Monash University assignment requirements)
Word Count: 4932

1
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Abstract

The
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Introduction

Tendon imaging has been widely researched in the past due to the prevalence of tendon

injury in both recreational and elite athletes. Majority of sports-related issues are due to repetitive

tendon use rather than acute trauma (1). Overuse tendon injury (tendinopathy) is frequently seen

in activities such as tennis, golf, volleyball and endurance sports such as long distance running (2,

3).

Tendinosis is a common type of tendinopathy describing a condition caused by a failed

healing response in tendons suffering from repetitive stress and loading (4). As opposed to the

inflammatory features that denote tendinitis, tendinosis results in degenerative changes, ultimately

leading to tendon morbidity and reduced function of the associated joint (3, 5). It is the pathological

basis of most chronic tendon pain and is commonly seen in the patellar, Achilles, rotator cuff,

posterior tibialis and the wrist extensor tendons (2).

Previously, the evaluation of tendon conditions was achieved by use of tenography and

conventional radiography, however the advent of ultrasound (US) and magnetic resonance imaging

(MRI) has superseded these imaging techniques (6). While both of these modalities are well suited

for tendon imaging, each have their respective benefits and pitfalls (1).

The main aim of this paper is to evaluate the imaging capabilities of US and MRI in the

diagnosis and assessment of tendinosis. Relevant literature will be reviewed to outline and

compare the advantages and disadvantages of the two modalities.

Background – Basic Anatomy of the Tendon

Tendons are anatomical structures that connect muscle and bone to allow transmission of

force generated in the muscle to the attached bone, so that joint movement in the body is
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achievable (7). They also function to stabilize the related joint and absorb sudden shocks to protect

from muscle damage (4).

Each muscle has a proximal and distal tendon, which are the muscle origin and insertion

sites respectively. The myotendinous junction (MTJ) is where the tendon meets muscle, while the

bone end is the osteotendinous junction (OTJ). A gradual transition of connective tissue from

tendon to fibrocartilage and then to bone, occurs at the OTJ (2).

While the shape of tendons may vary throughout the body, the fundamental structure of

them is the same. The basic unit of a tendon is the collagen fibril; a bunch of these form a collagen

fibre, which in turn, comprise a collagen fibre bundle (7). Tendons are arranged in many tightly

packed collagen fibre bundles which can be further divided into three categories; the primary,

secondary (fascicles) and tertiary bundles. Primary bundles are collected into the fascicles, which

are then clustered together to form the tertiary bundles and tendon itself (4). Each of these

collagen fibre bundles is bound together by a network of crisscrossed collagen fibrils known as the

endotenon. This then extends out to the epitenon, a dense connective tissue that surrounds the

entire tendon (Figure 1) (7).

Depending on their function, tendons in the body have different structures surrounding the

collagen fibre bundles. Tendons in areas of increased mechanical stress, such as in the hands and

feet, are enclosed by a synovial sheath comprised of an outer and inner layer. The outer fibrous

sheath covers a two-layered inner sheet, which consists of a parietal and visceral component (8).

Synovial fluid is encapsulated within the tendon sheath to improve lubrication. Where there is no

true synovial sheath, the epitenon of the tendon is instead contiguous to an external layer called

the paratenon (Figure 1). The paratenon is a loose areolar connective tissue comprised of collagen

fibrils, elastin fibrils, as well as an inner lining of synovial cells. It functions to reduce friction
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between the tendon and its surrounding anatomy and is identifiable in the Achilles and patellar

tendons (7, 9).

In addition to collagen, tendons also have a cellular and extracellular component (ground

substance). Tenocytes and tenoblasts are tendon cells distributed evenly throughout the collagen

fibrils that are responsible for the synthesis of the extracellular matrix (7, 8). The ground substance

of the tendon mainly constitutes water, proteoglycans and glycoproteins, and is a viscous

hydrophylic gel that improves the tendon’s ability to sustain shear and compressive forces (7).

Vascular supply to the tendon occurs via two intrinsic systems at the MTJ and OTJ, and one

extrinsic system through the synovial sheath or paratenon. Vessels originating from the muscle

supply the proximal area of the tendon at the MTJ, while blood supply at the OTJ is limited to the

insertion zone, leaving the mid-tendon region between these two junctions susceptible to potential

vascular compromise (2, 10). In tendons with synovial sheaths, major vessels branch into the sheath

to supply the tendon superficially while some extend deeper into the epitenon and endotenon. On

the other hand, tendons in the absence of a synovial sheath receive their extrinsic vascular supply

by vessels that course through the paratenon to penetrate the epitenon and form a complex

vascular plexus (11).

Similarly, surrounding muscular and peritendinous trunks supply nerve innovation in

tendons (2). Networks of nerve fibres cross the MTJ to branch into the epitenon and terminate at

the surface of the tendon body. At the OTJ, there are an abundance of Golgi tendon organ

mechanoreceptors, which terminate as nerve fibre endings between collagen fibre bundles.

Myelinated nerve fibres sense changes in pressure and tension in the tendon, while fibres with

unmyelinated nerve endings detect and convey pain signals (2, 10).

Pathogenesis of Tendinosis
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Tendinosis is a condition that affects all elements of the tendon, including the collagen, cells

and extracellular matrix. The tendon responds to overload by various degenerative changes and cell

proliferation (5). Cellular density is initially highly variable, with some areas of the tendon

containing an abnormally large amount of tenocytes and other regions with less tenocytes than the

norm (12). Histopathological findings demonstrate that there is an absence of inflammatory cells in

tendinosis, although paratenonitis can be an associated response to the mechanical stress (13).

Instead of tightly packed and clearly defined parallel collagen fibre bundles, the fibres

become wavy, loose and disorganised, and the overall density of collagen is decreased (8, 13).

Microtears in the collagen may also occur, resulting in an increase in tendon repair cells (12).

Additionally, the amount of Type I collagen (the collagen type usually found in normal fibre

bundles), is decreased, while an increase in Type III collagen is seen. Type III collagen is produced by

tendon cells as a reparative response, however its properties make them more difficult to bind

together in comparison to Type I collagen (14). Furthermore, collagen degeneration results in an

amorphous grey-brown structure lacking the glistening white appearance seen in healthy tendons

(11).

The disruption in the arrangement of collagen fibre bundles leads to a consequent increase

in ground substance that causes separation of the collagen fibres. The excess extracellular matrix

also contains more proteoglycans than in a normal tendon. The hydrophylic property of these

proteins causes changes in the matrix due to an increase in bound water molecules (14).

Neovascularisation is characteristic of tendinosis, with ingrowth of new vessels that are

organised randomly in the tendon (2). The new vessels are thick-walled with small lumen and do

not appear to have high levels of blood flow within them (15). As such, the function of this

increased vascularity is uncertain, as the tendon around these areas do not seem to have
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accelerated or superior repair processes (14). However, the amount of abnormal vascularity in the

tendon appears to correlate with the intensity of pain in symptomatic tendinopathy (16).

With further progression of cell and matrix disturbances, acellularity occurs as a

consequence of apoptosis or trauma, and the resultant tendon is weaker, with less capacity to

adequately respond to tensile loading (3, 5). As such, extensive degenerative changes in the tendon

can predispose to tendon rupture (5).

Methods

A review of literature was performed on the Scopus and CINAHL Plus databases using key

words and variations of the search terms ‘Tendinosis’, ‘Imaging’, ‘Ultrasound’ and ‘Magnetic

Resonance Imaging’. Abstracts were read and evaluated and articles from peer-reviewed journals

were selected based on relevance and analysis quality.

Imaging in Tendinosis

While some bony abnormalities associated with dystrophic changes in the tendon may be

detected on plain radiographs, conventional radiography plays a minor role in tendon evaluation

(17). Technological developments in the medical imaging field now allow for detailed

representations of the tendon itself through the use of modalities such as US and MRI (18).

Ultrasound

Basic Principles

Images in ultrasound are produced via the use of sound waves and their interaction with

tissue. The generation and emission of sound waves occurs through the inverse piezoelectric effect

in the transducer (19). As pulses of ultrasound are transmitted through the body, reflections are
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caused by their encounters with tissue boundaries. These return echoes are received by the

transducer and undergo signal processing before they are used in image formation (20).

Imaging Technique

Sonography of suspected tendinosis is typically performed with an ultrasound system

capable of colour and power Doppler imaging as well as a high frequency transducer (usually 7-12

MHz) for adequate resolution and visualisation of the internal tendon structure (21). At higher

frequencies, penetration of the sound waves is reduced, hence the depth of the tendon will

determine the optimal transducer frequency (22). Linear array transducers are ideally used in

tendon imaging, as accurate tendon assessment requires that the ultrasound beam is aligned

perpendicular to the axis of the collagen fibres (23). Alteration of the probe orientation along the

axis of the collagen fibres may result in sonographic appearances that mimic tendinosis (tendon

anisotrophy) (17, 22, 23).

Imaging Appearances on Grey-scale Ultrasound and their Clinical Relevance

The ultrasound appearance of a normal tendon in the longitudinal plane demonstrates a

homogenous fibrillar structure containing multiple reflective parallel lines depicting the acoustic

borders between the fascicles (17, 22). The anisotrophy effect results in a loss of this echogenic

appearance and the normal tendon is instead displayed artifactually hypoechoic (1). In tendons

that have synovial sheaths, a small amount of synovial fluid is identifiable on ultrasound as a thin

rim of low reflectivity around the tendon. Conversely, the paratenon in tendons without a synovial

sheath, such as the Achilles, is recognizable as a hypoechogenic outline (6, 17, 21).

The sonographic features of tendinosis have a strong correspondence with the

histopathological findings of this condition (15, 24). The excess ground substance and
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disorganisation of collagen fibres in tendinosis manifests as indistinct areas of decreased

echogenicity (17, 18, 22). Fusiform swelling and tendon thickening is also seen due to the increased

spaces between the hyperechoic fascicles (25).

However, while these ultrasound findings may indicate tendinosis, the correlation between

abnormal echogenic changes and symptomatic status of the tendon is poor. In a study by Cook et

al. (26), the patellar tendons of 160 elite athletes were assessed for comparison against 27

nonathletic controls. Of the 320 subject tendons, 69 were found to have hypoechoic zones

consistent with symptomatic tendinosis (22%) (26). Moreover, 35 sonographic examinations of 250

(14%) patellar tendons in athletes who had had no previous history of anterior knee pain also

revealed the presence of hypoechoic regions (26). Similarly, Cook et al. (27) reported comparable

results where hypoechogenicities were seen in 22% of junior basketball players who had never had

anterior knee pain and the prevalence of sonographic tendon abnormalities in the study was three

times as common as clinical symptoms (27). Abnormal ultrasound features such as patellar tendon

thickening and echogenic changes, were also seen in 24% of asymptomatic male volleyball players

in a study by Lian et al. (28). As such, the sole use of grey-scale sonography is insufficient for

accurate diagnosis of tendinosis (15).

Doppler Mode and its Use in Tendinosis Imaging

Besides the use of conventional grey-scale mode in tendinosis imaging, Doppler mode in

ultrasound allows for visualisation of vascular abnormalities that are attributed to tendinosis.

Neovascularisation can be detected on ultrasound through the use of colour and power Doppler (6,

18, 21).

Colour Doppler ultrasound is applied in conjunction with grey-scale sonography to generate

colour-coded images using velocity information obtained from the transducer (29). As colour
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Doppler does not register low blood flow rates, vascularity in the normal tendon is not detected,

however intratendinous neovascularisation could be depicted in studies by Boesen et al. (30) and

Weinberg et al. (31). In fact, Weinberg et al.’s study (31) found the sensitivity and specificity of

colour Doppler in patellar tendinosis to be 92% and 100% respectively.

Alfredson et al.’s study (32) examined 25 tendons with clinically verified painful Achilles

tendinosis using colour Doppler and grey-scale ultrasound imaging. This imaging technique

demonstrated neovascularisation in all 25 painful tendons, with vessel ingrowth mainly seen within

and outside the anterior part of the affected tendon area (32). However, colour Doppler findings in

a study by Hoksrud et al. (33) did not show neovascularisation in all symptomatic tendons with

patellar tendinosis. While this apparent discrepancy cannot be attributed to a specific reason,

several studies have shown that neovascularisation is somewhat associated with tendon pain in

chronic tendinosis (16, 33, 34). The conflicting results in different studies suggests the need for

further investigations to be conducted in order to clearly establish the significance of

neovascularisation in painful tendinosis.

In addition to detecting neovascularised areas on ultrasound, colour Doppler also functions

as a measurement tool for quantification of tendon pathology (35). Cook et al.’s (35) study

validated the reliability and efficiency in estimating the length of tendon vessels from colour

Doppler ultrasound measurements. The implication of being able to estimate vessel length in

tendons is that quantifiable changes in vascularity over time can be analysed and its relevance in

tendon morbidity can be further explored (35).

However, colour Doppler is limited in its ability to obtain accurate velocity information, as it

relies on the angle of the incident beam to do so. Estimations of tissue vascularity in power Doppler

mode can be made independent from the incident beam angle (18, 36). Power Doppler is more

sensitive than colour Doppler imaging in detection of flow and is particularly valuable in sonography
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of small vessels (37). Findings from Richards et al.’s study (38) indicate that proliferation of vessels

relating to abnormalities seen in tendinopathy can be shown using power Doppler ultrasound.

A study by Peers et al. (36) investigated the potential relationship between power Doppler

measured neovascularisation in Achilles tendons, and the clinical severity of Achilles tendinopathy.

Symptomatic Achilles tendons of 25 people were assessed with both conventional ultrasound and

power Doppler. A positive correlation between power Doppler imaging results and tendon

thickness was found, suggesting that neovascularisation and tendon flow measured by power

Doppler ultrasound may function as an indication of the degree of tendon degeneration (18, 36).

Advantages and Disadvantages of Ultrasound

The use of sonography in tendinosis imaging presents several practical advantages. It is an

inexpensive and readily available modality that is ideal for imaging of superficial tendons (25, 39).

Ultrasound is a fast and non-invasive technique that allows for dynamic evaluation of the tendon

(6). As such, tendons can be appreciated from different angles and under stress (22). In cases of

advanced tendon degeneration which result in tendon tear, this feature is useful in the distinction

of partial tear and full rupture (1). Additionally, tendon subluxation and discontinuity occasionally

require motion and real-time dynamic imaging for easier diagnosis (40).

Detailed assessment of the fibrillar architecture in tendons can be achieved due to the

development of high-resolution transducers in ultrasound (41). Continual advancement in

sonographic technology has also permitted the visualisation of the entire tendon via panoramic or

extended-view modes (1, 25). Additionally, abnormal tendon blood flow such as neovascularisation

can be identified with the use of imaging capabilities such as colour and power Doppler modes,

which are exclusive to ultrasound (21, 25).

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Sonography can also play an important role in certain treatment options for tendinopathy;

percutaneous procedures are often guided by ultrasound (1). In fact, Ohberg and Alfredson (42)

proposed ultrasound guided sclerosis of neovessels as a new treatment for painful chronic Achilles

tendinosis and reported optimistic results in its efficacy.

On the other hand, a major limitation of ultrasound is its operator-dependent nature (43). In

general, it is agreed that reliability and accuracy of sonographic results in tendon imaging rely on

the experience of the sonographer (17, 34). Performance of ultrasound examinations and

interpretation of sonograms are affected by the operator’s level of experience (21, 31). A high level

of accuracy can be expected from the imaging technique of an experienced operator, while in the

hands of a less experienced sonographer or radiologist, accuracy would likely decrease (17).

Operators should be aware of the relevant imaging limitations, such as tendon anisotrophy, to

avoid misinterpretation or misdiagnosis (17).

Another disadvantage of ultrasound is that it requires an acoustic window for adequate

imaging. Sound waves cannot penetrate through bone and therefore sonographic evaluation of

tendons that are deep to the body surface is not possible (22). Moreover, the penetration of

ultrasound is inversely proportional to its frequency. With the high frequency transducers used in

tendon imaging, high-resolution images can only be obtained from very superficial structures (40).

Wave penetration in tendon imaging of obese individuals is hence quite limited, making it difficult

to acquire adequate images for diagnosis.

Magnetic Resonance Imaging

Basic Principles

In MRI, an external magnetic force is used to align hydrogen protons in the body with the

axis of the magnetic field. Signals for image formation are created through the application of a
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radiofrequency (RF) pulse that causes excitation of the protons (44). Once the RF pulse is

terminated, the protons relax and emit energy that is used to generate MR images. The relaxation

rates (T1 and T2) and energy released are unique to each tissue type and depend on the properties

of the tissue, thereby making it possible to characterize the different receive signals (45).

Signal intensities in MRI are displayed as areas of brightness or darkness. Image contrast is

influenced by T1 and T2 relaxation times, as well as the density of mobile protons in the tissue of

interest (proton density) (46). Varying the imaging sequence can produce differently weighted

images that highlight specific anatomical structures (45). The two main sequence types used are

gradient echo (GRE) and spin echo (SE), which also encompasses fast spin echo and inversion

recovery MRI (44). Imaging parameters in these sequences such as echo time (TE), time of

repetition (TR) and inversion recovery (TI), are manipulated to create T1 weighted, T2 weighted or

proton density (PD) images with the option of fat-suppression (44).

Image quality is affected by the signal-to-noise ratio (SNR), which is a measure of the

amplitude of the desired signal against the interference from externally produced background

noise. SNR is roughly proportional to the magnet field strength, hence, the more powerful the

magnet, the better the SNR (22, 46).

The Magic Angle Effect

Conventional MRI of tendons shows a lack of signal enhancement due to the strong dipole

interactions caused by the highly ordered tendon structure (22, 47-49). The enhanced dipole

interactions are angular dependent and result in extremely short T2 relaxation times (47).

Consequently, tendons imaged using conventional MR sequences parallel to the static magnetic

field are demonstrated as dark signal voids (49, 50).

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The effects of dipole interactions in tendon imaging can be diminished by increasing the

angle between the tendon fibres and magnetic field (22). By orientating the tendon at the “magic

angle” (47, 48) of 55° relative to the magnetic field, the T2 value of collagen is increased and signal

intensity is higher, depending on the sequence type and TE (22, 48).

A study by Oatridge et al. (49) compared conventional T2 weighted MRI scans of the same

Achilles tendon positioned at 0° and 55° to the magnetic field. In one participant with a chronic

ruptured Achilles, the image obtained at 0° only demonstrated tendon thickening without any

signal from inside the tendon. At 55°, a small region of normal tendon was identified, as well as

increased signal intensities from other areas of the tendon (49).

However, the magic angle phenomenon can result in anisotrophic effects and false

pathological appearances, as the orientation of collagen fibres in the tendon may change in its

course (17). The use of longer echo times will eliminate artifacts associated with the magic angle

effect (17, 22, 51).

Imaging Technique

MRI of tendon pathology should incorporate the application of both T1 weighted and fat-

suppressed T2 weighted sequences to acquire images in at least two planes, parallel and

perpendicular to the course of the tendon (25). Sagittal images are particularly helpful in the

proximal-to-distal assessment of the tendon, as a full length view is obtainable in this plane (23).

Sequences that are typically employed in tendon imaging include T1 weighted SE, short-tau

inversion recovery (STIR) and fat-suppressed T2 or PD SE (41). Spin echo imaging without fat

saturation offers accurate border demarcation of the tendon, muscle and fat tissues, making it an

important sequence in tendon imaging. In contrast, GRE sequences (with or without fat saturation)

are less commonly used, as they are inferior to SE in detecting tendon changes (52).
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Additionally, sensitivity to tendon abnormalities is improved in images with shorter echo

times, while T2 weighted MRI best demonstrates intratendinous fluid signals such as increased

water content that is associated with tendinopathy (22, 23, 53).

Imaging Appearances and their Clinical Relevance

Normal tendons exhibit low signal intensities and appear as homogenous, hypointense

anatomical structures on all MRI sequences (6, 44). The paratenon may be visualised as a thin

outline around the tendon, with an intermediate signal intensity on T1 weighted GRE and STIR

sequences (17, 41). Depending on the tendon, normal thickness is varied, however in general,

tendon thickness should be uniform throughout the body and taper near the MTJs (17).

MR imaging appearances of tendinosis are also comparable to those found in the

histopathology of tendon degeneration (44). Swelling is denoted by tendon thickening that can be

fusiform, nodular or diffuse (41). Well-defined or poorly delineated areas of increased signal

intensity are also seen (17). As opposed to the normal low intensity signal, the degenerated tendon

displays signal heterogeneity, with focal areas of slightly increased signals in the tendon (1, 39). The

sensitivity and specificity of MR imaging in detecting abnormalities related to Achilles tendinosis

was found to be 94% and 81% respectively in a study performed by Karjalainen et al (54).

However, it is important to note that MRI findings in tendinosis are not exclusive to

symptomatic tendons. In a retrospective study by Haims et al. (55), MR scans from 64 clinically

symptomatic Achilles tendons were evaluated for abnormalities to compare with MRI findings in 30

control tendons. They found that imaging features consistent with tendinosis such as

intratendinous signals in T2 weighted images, were not only seen in symptomatic tendons, but also

in asymptomatic individuals (55). Furthermore, a number of other studies have reported

inhomogeneous signal intensities within the tendon on certain pulse sequences (56-58). The
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overlap of seemingly pathological findings in symptomatic and asymptomatic individuals indicates

that the normal appearance of tendons in MRI is variable and should be interpreted carefully to

avoid misdiagnosis (56).

Advantages and Disadvantages of MRI

MR imaging is valuable in the assessment of tendon pathology as it offers high spatial

resolution in addition to high intrinsic tissue contrast (6, 59-61). Not only does this allow for

detailed visualisation of tendon anatomy, but it also makes it possible to differentiate between

normal and abnormal tendon (59, 60). High-resolution images are achievable in MRI as SNR

increases with the strength of the magnetic field (22, 51, 62). With appropriate technique

modification, 3.0T MRI machines can provide better image resolution and high SNRs compared with

1.5T MRI (63, 64). Machines with stronger magnetic field strengths can therefore potentially

improve detection of full and partial-thickness tendon tears (22, 64). Additionally, high-resolution

MRI can also be obtained through the use of surface coils (22, 52, 63, 65).

MRI is especially sensitive to pathological changes that occur due to tendinosis (14, 52, 66,

67). Intratendinous abnormalities are visualised particularly well on images with shorter echo times

(22, 53). Consequently, structural defects and small areas of degeneration that are clinically

impalpable are identifiable on MRI (25, 66). In particular, T2 weighted images demonstrate fluid

signals resulting from tendinopathy well (22). Superior sensitivity in MR imaging can also assist in

evaluating the extent of tendon injury (60).

As MRI is a non-invasive examination and does not involve ionising radiation, it has become

an attractive option in radiologic evaluation of tendon injuries (51). The ability to acquire

multiplanar images of the anatomy (in the axial, sagittal and coronal planes) in MRI is also beneficial

in tendon imaging (6, 59, 67). Moreover, an objective anatomical overview of the tendon of interest
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can be obtained in MRI so surrounding structures can be assessed for any associated pathology

such as oedema (1, 17, 22, 25, 67).

While the use of MRI in tendon imaging presents numerous technical advantages, it also has

several drawbacks. The elevated costs and reduced availability of MRI are factors that limit its

widespread use in tendon imaging (6, 39, 60). Long scan times that are required for MR acquisitions

are a definite practical limitation of this modality, and the addition of enclosed bores make MRI

problematic for patients who suffer from claustrophobia (6, 59). Furthermore, patients with

implanted electronic devices were previously contraindicated for MR imaging due to the safety

hazards associated with the torque forces of the magnetic field (51, 63). Advances in technology

have reduced risks to these patients, however MRI of people with medical implants must be

performed with caution (51).

The variability in MR findings of normal tendon anatomy and tendinosis is another

disadvantage of MRI, as this could lead to inaccurate diagnosis (59). In addition, MR imaging is

affected by the magic angle phenomenon. Even if the tendon itself does not rotate along its axis,

bright signal artifacts that result from the magic angle effect can still occur from internal twisting of

collagen fibres (52). Technicians performing tendon imaging with MRI should be aware of the

imaging parameters and techniques that can be utilised to overcome such issues (T2 weighted

images are not susceptible to magic angle artifacts) (52, 68, 69).

Studies Comparing Ultrasound and Magnetic Resonance imaging

There have been few studies that directly compare US with MRI in the detection of

tendinosis specifically. In Ibrahim and Elsaeed’s prospective study (70), where 28 symptomatic

Achilles tendons were assessed with both grey-scale US and MRI, it was found that US and MRI

were equally as good as each other in the diagnosis of tendinopathy and full-thickness tendon
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tears, although MRI performed better in the detection of partial-thickness tears and in

distinguishing between peritendinosis and tendinosis. Åstrom et al.’s study (71) also reported that

both MRI and US provided similar intratendinous information when compared with surgical

findings. Additionally, these results complement findings from Khan et al.’s study (72), in which US

and MRI examinations of the Achilles tendon were compared with the clinical yardstick.

However, another study by Cook et al. (73) found that US was more accurate in confirming

the diagnosis of patellar tendinopathy. Thirty symptomatic participants, who were clinically

diagnosed with patellar tendinopathy by a physical therapist, underwent MRI, grey-scale

sonography and colour Doppler US. Results from these examinations were compared with those

from an asymptomatic group, which served as a control. The diagnostic accuracy of MRI, grey-scale

sonography and colour Doppler US was found to be 70%, 83% and 83% respectively (73). Similarly,

US showed better sensitivity (100%) and accuracy (94.4%) than MRI (sensitivity of 23.4% and

accuracy of 65.75%) in the detection of ankle tendon tears in Rockett et al.’s study, where surgery

was used as the gold standard (74).

While the discrepancy in results may be attributed to the use of different MR imaging

sequences, the overall evidence does not explicitly indicate that either imaging modality is

significantly superior to the other in detecting tendon abnormalities (18, 73, 75, 76). Therefore, it

would be feasible to suggest sonography as the primary imaging tool for investigation of

symptomatic tendons due to its relative inexpensiveness and availability. Not only is imaging of

specific tendons is particularly suited to US, but the use of colour and power Doppler modes can

potentially enhance visualisation of tendinopathy (17, 18). For tendons that are located more

deeply, MRI is better equipped to assessed them (25). MRI is also more adequate in cases where a

wider differential diagnosis is considered, as a global evaluation of the area of concern can be

obtained (1, 17, 18).

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Conclusion

In summary, the available literature suggests that a variety of imaging techniques, such as

colour and power Doppler, can be employed when using US and MRI to assess tendinosis. Both

modalities are suitable for tendon imaging and play a significant role in the evaluation of overuse

tendon injuries. As tendon structure is closely related to imaging appearances of both normal and

abnormal tendons on US and MRI, a strong correlation exists between the histological findings of

tendinosis and its manifestations on radiologic images. It is therefore important to recognise the

micro-anatomical features of tendinopathy in order to correctly identify pathological tendon

changes in sonography and MR imaging. The relevant literature has also indicated that awareness

of the imaging capabilities and limitations is a crucial aspect in the accurate diagnosis and

interpretation of tendon abnormality. The benefits and constraints of US and MRI in tendon

imaging have been well documented in a plethora of studies, however, further research is required

to conclusively determine the role of these modalities in the treatment and management of

tendinosis.
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