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Journal of the Anatomical Society of India

An Ultrasonographic Study Of The Anatomy And Pathology Of Tendons And Review of Literature

Author(s): *Kabiraj, S.P., **Pradhan, P., **Deb, S.

Vol. 51, No. 1 (2002-01 - 2002-06)

*Department of Radiodiagnosis &
**Department of Anatomy, North Bengal Medical College, Sushrutanagar, Darjeeling, W.B., INDIA.


Many pathological conditions of tendons are often very difficult to diagnose clinically. Most of these pathologies can be diagnosed almost accurately with the help of MRI; but it is neither cost effective nor widely available. Again, CT scan is also not very helpful in this regard to diagnose those cases. However, with help of the newer generation ultrasonography we can diagnose most of the musculoskeletal pathologies almost accurately. Again it is a rapid, non-invasive, less expensive and widely available method. Real-time dynamic examination can be done in any orientation. Its disadvantages are very negligible and can be overcome easily. Therefore, ultrasonography should be the first choice of investigation, paritcularly in our country. In this study we examined fifty-two patients with various types of pathological conditions of tendons of both upper and lower limbs.

Key words: High frequency ultrasonography / US / USG. Pathology of muscles and tendons.


Recently introduced harmonic, high frequency transducer is said to produce more detail of pictures of better resolution as well as better tissue differentiation and even the finest fibres of the tendons can be visualised with the exact anatomical disposition. But, ultrasound has very limited acceptance in the imaging of subcutaneous tissue and musculo-skeletal system till date.

The objective of this study was to get an initial experience to diagnose the normal anatomy and different pathologies of the tendons, particularly where clinical evaluation was difficult.

Subjects and Methods:

Fifty-two patients with suspected unilateral pathology of different tendons of limbs were selected from the departments of Orthopaedics and Physical Medicine of N.B. Medical College & Hospital, Darjeeling. After taking a brief history and clinical examination, straight X-rays of the involved anatomical parts were taken.

The affected limb was then examined by a linear 7.5 MHz transducer, compared with the normal opposite side and photographs were taken. Images were obtained in both longitudinal and transverse planes. They were examined during active contraction of the respective muscles (dynamic evaluation) and also at rest. 5 MHz transducer was used to evaluate deep-seated pathologies. (Mack et al, 1991; Fornage, 1991; Van Holsbeeck et al, 1995).

The transducer was applied directly to the skin with gel in most cases. In case of tendo-achilles and other superficial tendons, standoff pad was used to minimise artifacts (Fornage, 1991).


During our study we came across fifty-two patients of ankle sprain with injury to tendo-achilles, injury and pain at the shoulder including cases of frozen shoulder, rotator cuff trauma and several other cases of injury, infection and inflammation of different tendons. Here it is short listed in Table-I.

Table - I: Different types of pathologies of tendons, found during this study

  Type of Injury No. of Cases
I Ankle injuries including tendo-achilles trauma  
1 Ankle sprain with normal tendo-achilles 20
2 Complete tear of tendo-achilles 8
3 Partial tear of tendo-achilles 6
4 Haematoma at the site of torn tendo-achilles 4
5 Haematoma and calcification at the site of torn tendo-achilles 2
II Shoulder injury including rotator cuff trauma  
1 Supraspinatus tendinitis 2
2 Supraspinatus tendinitis with calcification 2
3 Other injuries with normal rotator cuff 6
III Other tendon injury  
1 Triceps tendon tear 2
  Total number of patients 52


For many decades, low kilo-voltage radiography and xero-radiography were the only techniques for imaging the tendons (Fornage et al, 1984; Fornage, 1991; Bhargava, 1996). These methods can silhoutte the tendons, particularly when these are surrounded by fat. But the macroscopic structures of the tendons are not visualied. However they are the best interpreters to diagnose calcifications in the tendons as well as different pathologies of bursae (Fornage et al, 1984; Fornage, 1991; Bachmann et al, 1997).

Tenography is a neglected and obsolete imaging method, which may provide detailed, global views of the sheath walls but cannot demonstrate the anatomical details. The procedure is gruesome and may cause infection. (Gilula et al, 1984).

C.T. is thought to be a useful technique to diagnose musculo-skeletal pathologies. But as it is limited to transverse scans of the extremities in routine practice, it has rarely been used in tendon imaging. It has also the disadvantages of high cost and hazards of radiation (Rosenberg, 1988). M.R.I. is also thought to be the most accurate modality for imaging most of lesions of the soft tissues, muscles and tendons. But the method is not so much used for tendon imaging due to its high cost and less availability (Bhargava, 1996). Again according to some research workers, the results of ultrasound are more sensitive and accurate than MRI in detection of some injuries, like ankle tendon tear (Rockett et al, 1998; Waitches et al, 1998). The recent advance in high frequency ultrasonography has markedly improved the rate of correct diagnosis of musculo-skeletal pathologies. So, USG may be the investigation of choice for detecting the pathology of tendon, especially in our country for its easier availability and low cost. Superficial tendons are specially suited for US evaluation.

Kainberger et al (1990) investigated different abnormalities of tendo achilles on three human cadavers, twenty-four healthy volunteers, and seventy-three symptomatic patients, and the results are compared with surgical or other final findings. Kovacs et al (2001) measured the dimension of artificially injured tendons in cadavers almost accurately. Sell et al (1996) also studied postmortem tendo-achilles lesion. All of them suggested that sonography is valuable in the detection of various lesions of the achilles tendon and its surrounding tissue.

The tendons, which are commonly affected are the tendo-achilles, other ankle tendons, rotator cuff, patellar (quadriceps), biceps brachii and long tendons of the hand (Fornage, 1991; Waitches et al, 1998).

Overview of Relevant Anatomy of Tendons

(Williams et al, 1995)

The strap-like or cord-like non-contractile fibrous end of skeletal muscle is known as tendon. It is largely composed of longitudinally oriented bundles of Type-I collagen fibres, separated by the small amount of ground substance containing few fibroblasts. They are round, oval or elongated in cross sections and consist of fasicles of collagen fibres, mostly running parallel to the long axis. The fasicles may be large enough to give the tendon a longitudinally striated appearance. The areolar connective tissue, which permeates the tendon between its fasicles providing a route for vessels and nerves, is condensed on its surface into a so- called sheath or epitendineum. The surface of the sheath is continuous with surrounding areolar tissue. In many places, however, tendons are separated completely or partially from their surrounding rough surface of bone, osseo-fibrous tunnel or tough fascial sling, band or retinaculae by sacs or sheath of synovial membrane, e.g., at the olecranon and patella. The arrangement is a closed double-layered cylinder, the internal or visceral layer of which is attached to the tendons by loose areolar tissue and the external or parietal layer to neighbouring connecting tissue structures or periosteum. The visceral and parietal layers are often connected by an elongated meso-tendon. At the musculotendinous junction, there is an interdigitation between the muscle fibres and the collagen fibres. The bony insertion is usually markedly calcified and characterised by presence of cartilagenous tissue.

US appearance of normal tendons

(Fornage and Rifkin, 1986; Fornage, 1986; Van Holsbeeck et al, 1995):

When the transducer is in correct position, i.e., the US beam is perpendicular to the tendon, it is moderately hyperechoic relative to that of the skeletal muscle, with a typical fibrillar pattern of parallel internal echoes. On longitudinal scans, the peritendinous sheath is seen as a very thin, highly echogenic line on either side of the tendon (Fig.-1, 2). An important point of identification of tendons is their movement under real time US monitoring of longitudinal scans. On a transverse scan, the fibre- bundles give rise to a finely punctate echogenic pattern and the thickness of tendon can thus be most accurately measured. (Fig.-3, 6). The refinement of high frequency harmonic transducers has improved the ability of ultrasound to detect the characteristic echo-textural patterns of tendons, which closely resemble histological patterns.

Tendo achilles:

It is the largest tendon of the human body, formed by the fusion of aponeuroses of soleus and gastrocnemius muscles, and is inserted into the posterior aspect of the calcaneum, where a deep retrocalcaneal bursa is frequently seen (Williams et al, 1995) and can be visualised by USG (Fig.-4). Different pathologies of tendo-achilles are very common among sports personnel as well as manual workers, due to repeated microtrauma. The patient is examined in prone position, with the feet hanging from the edge of the table. The normal tendon in adults measures about 6 cm. in length and 4-6 mm. in thickness. On transverse scan, the tendon is elliptical and tapers medially. Real-time imaging during planter flexion and dorsiflexion shows the functional anatomy in longitudinal scans (Fornage, 1986).

The following pathologies are commonly encountered during studies of tendo-achilles (Blei et al, 1986; Fornage, 1986, 1991; Merk 1989; Kainberger et al, 1990; Fessel and van Holsbeeck, 1999: Gibbon et al, 1999, 2000).

Complete tears of the tendon are visible as complete disruption of fibres i.e., a full thickness discontinuity with variable amount of retraction of fragments from one another. The interval between the fragments is filled up with haematoma, which has a variable echo pattern. The gap may be minimised by planter flexion. There may be an echogenic fibrous scar at the injured site in case of an old tear. Haematoma may calcify. (Fig. 5).

Partial tears are difficult to diagnose clinically and to differentiate it from focal tendinitis. They appear as focal hypo-echoic defects within the tendon or at the insertion due to disruption of fibres and presence of oedema. Calcification may be present. (Fig. - 6).

Achilles tendinitis occurs frequently in athletes, particularly in long distance and competitive runners due to chronic stress on the tendons. US appearance of different types of achilles tendinitis are as follows—

Acute: The tendon is thickened and margins are ill defined. There is also a diffuse decrease in echogenicity.

Chronic: Tendinosis or tendinopathy is a more accurate term than chronic tendinitis. Here, the tendon shows a bumpy appearance. Microtears along with minute intra-tendinous calcifications may be present. (Fig. 7)

Healing: Sonographic decrease in size of the inflamed tendon and a return to normal echogenicity indicates healing.

Peritendinitis: It is characterised by hypo- echoic thickening of the peritendon, but the tendon is not much affected. (Fig. 8).

Other Ankle Tendons:

Tears of the peroneal, tibialis posterior, flexor digitorum longus tendons can be diagnosed by the following criteria-

  1. disruption of uniform tendon architecture by hypoechoic linear or globular cleft, found in partial tear.
  2. discontinuity or gap within the tendon or complete non-visualisation of tendon, found in complete rupture.

Ultrasound results are highly sensitive and specific and even more accurate than MRI in the detection of ankle tendon tear (Waitches et al, 1998; Rockett et al, 1998).

Patellar and Quadriceps Tendon:

The quadriceps tendon of thigh comprises of four tendons, i.e., the tendons of rectus femoris, vastus lateralis, vastus medialis and vastus intermedius. The tendon lies beneath the subcutaneous fat and anterior to a fat pad and the collapsed suprapatellar bursa. The patellar tendon, which extends from the inferior angle of patella to the tibial tuberosity, is about 8 cms in length. On transverse section, it is shown with a convex anterior and a flat posterior surface. At its mid portion the tendon is about 5 mm thick and about 20-25 mm. wide. It is widest near patella. The deep infra-patellar bursa appears as a flattened anechoic structure, 2-3 mm in thickness. The patient must be examined in the supine position with the partially flexed knee joint to straighten the tendons. Comparison with the contra-lateral normal side is necessary (Bhargava and Jain, 1997).

Rupture (Fig.-9)., haematoma and tendinitis may occur due to acute trauma or chronic repetitive stress. The sonographic features are same as described under tendo-achilles.

Tendons of the hands and wrist:

In the carpal tunnel, the flexor tendons of the fingers are surrounded by the hypo-echoic bursa. best seen when the wrist is moderately flexed. (Fig. -2 ). In the palm and fingers the play of the tendons is appreciated during flexion and extension of the fingers on longitudinal scans. On transverse scan the tendons appear as rounded echogenic structures adjacent to the hypo-echoic lumbrical muscles (Fornage and Rifkin, 1986; Martinoli et al, 1999).

Acute tenosynovitis of the long tendons may be detected with increase in diameter with surrounding hypo-echoic areas, when compared with the normal contra-lateral side (Jeffrey Jr. et al, 1987). Sonography is also very useful in management of deQuervan's disease. The high frequency ultrasonography has proved to be very helpful for diagnosing changes due to strain as well as finger injuries in Rock-climbers, especially in cases, where the clinical examination was difficult to perform (Klauser and Frauscher, 2000). Fluid in the sheath, even in minimal quantity can be identified by USG. Internal echoes representing debris can be seen in suppurative tenosynovitis.

Chronis tenosynovitis is characterised by a hypoechoic thickening of the synovium, most often with little or no fluid (Jeffrey Jr. et al, 1987).

Rotator cuff Tendons :

The normal US anatomy outlines the subcutaneous tissue, deltoid muscle, subdeltoid or sub-acromial bursa, the rotator cuff, biceps tendon and the greater tuberosity of the humerus (Mack et al, 1991; Bhargava and Jain, 1997). The subcutaneous tissue shows a mixed echo-texture of variable thickness. The deltoid muscle is relatively hypoechoic. Inferior to the deltoid, the sub-acromial bursa is seen as a bright thin band, <1-mm in thickness. The supraspinatus is a beak shaped band of homogeneous echogenicity (slightly hyperechoic) running parallel to the fascial planes with its insertion to the greater tuberosity (Fig.-1). The average thickness of the tendon is 6 mm and usually equals the overlying deltoid thickness.

The patient is examined in sitting position, where the shoulder is in neutral position, the elbow is semiflexed and the arm is abducted, with forearm resting on thigh. Subsequently, the arm is hyperextended and internally rotated. This maneuver rotates the greater tubercle and the attached cuff tendon away from the overlying acromion and also accentuates small tears, by increasing stress on the tendon. Both the shoulders are examined at the same sitting, both parallel and perpendicular to the tendon of supraspinatus, using sagittal and transverse planes respectively. The supraspinatus tendon is readily identified anteromedially and its insertion to the greater tubercle is also well visualised. The infraspinatus and teres minor tendons are seen more laterally. Externally rotating the shoulder and identifying the independent insertion to the lesser tuberosity, the subscapularis tedon is examined.

Tears, tendinitis and calcification of the rotator cuff : Trauma to the rotator cuff tendons may be in the form of acute major trauma or chronic overuse. This may result in full or partial thickness tears or tendinitis or calcification within a tendon (Mack et al, 1991; Bhargava and Jain, 1997).

Tears of rotator cuff most commonly involve the supraspinatus tendon. Ultrasonography is highly accurate for detecting full thickness rotator cuff tears. In case of very large tears, there may be thinning and discontinuity of echogenic homogenecity of the tendon, bicps tendon may be dislocated, and the deltoid muscle may directly approximate the surface of the humeral head (Ahovuo et al, 1989; Teefey et al, 2000).

In small or partial tears, there is a focal nonvisualisation or absence of the tendon and a sharp demarcation with an abrupt transition from normal to abnormal cuff. Thinning and discontinuity of echogenic homogenecity of the tendons of the rotator cuff were the most reliable ultrasonographic signs of a total tear of tendons. The echogenicity is also altered with focal, poorly defined hyper-echoic areas. Though the diagnosis of partial thickness tear is a little bit difficult, but most of them can be diagnosed accurately by using the following criteria (van Holsbeeck, 1995):

(i) a mixed hyper-and hypo-echoic focus in the crucial zone of the supraspinatus tendon and
(ii) a hypo-echoic lesion visualised in two orthogonal imaging planes with either articular or bursal extension.

A midsubstance location and presence of joint or bursal fluid were more commonly associated with an acute tear (Teefey et al, 2000). After acute injury, hypoechoic areas due to haemorrhage may also be seen. The Outer border of the cuff may be concave or flattened instead of convex. Secondary signs of tear include subdeltoid bursal effusion, fluid in the bicipital tendon sheath, joint effusion and elevation of the humerus with respect to the acromion.

A non-visualised cuff as well as absence of joint and bursal fluid is more commonly observed with a chronic tear (Teefey et al, 2000).

Pitfalls in US interpretation of painful shoulder joint are as follow (Middleton et al, 1985; Paavolainen and Ahovuo, 1994; Teefey et al, 2000):

  1. tear in biceps tendon may appear as normal biceps.
  2. calcification can be misinterpreted as a tear,
  3. humeral fracture may distort the anatomy, so that scans are inconclusive,
  4. previous shoulder surgery may mimic disruption of normal tissue planes and distortions of muscles and tendons

Inspite of that, in experienced hands, USG of rotator cuff has been shown to be a sensitive technique, particularly to diagnose the cause of painful shoulder, and suspected rotator cuff tears, associated lesions of the biceps tendon as well as recurrent tears after surgery (Ahovuo et al, 1989; van Moppes et al, 1995). The arthroscopic findings of rotator cuff integrity are compared with the diagnosis made from ultrasonography by some research workers (Porcellini et al, 1994; Roberts et al, 2001). According to them, the diagnostic ultrasound is effective for screening of the suspected rotator cuff tear.

Conclusion :

MRI is the most accurate modality for imaging the tendons, but the high cost and less or non- availability are the major disadvantages. CT scan is also not very helpful in evaluation of the pathophysiology of tendons. The advantages of high frequency ultrasonography (van Moppes et al, 1995; Bachmann et al, 1997; Rasmussen, 2000; Kovacs et al, 2001; Miayuchi et al, 2001) are listed in Table-II.

Table - II : Advantages of high frequency ultrasonography to evaluate tendon pathologies

  1. It is the only real-time cross-sectional imaging technique.
  2. It is a rapid non-invasive examination and acutely ill patients can be examined painlessly without any special preparation.
  3. Scanning can be done in virtually any plane or body section with the patient in any position.
  4. No hazards of ionising radiation or contrast materials.
  5. It has got an excellent spatial resolution.
  6. Percentage of lesion can be determined in some partial tendon tears.
  7. It has high specificity and sensitivity rates.
  8. It is very useful in the evaluation of changes of the pathology with time, i.e. help in follow-up.
  9. It is an widely available, low cost procedure.

The disadvantages of ultrasonography are very negligible and can be overcome easily (van Moppes et al, 1995; Sell et al, 1996; Rasmussen, 2000; Wallny et al, 2000 Miyayuchi et al, 2001) These are listed in Table III.

Table - III : Disadvantages of high frequency ultrasonograhy to evaluate tendon pathologies

  1. it is operator dependant.
  2. It has a long learning curve.
  3. considerable experience is necessary for accurate result.
  4. there may be some technique related artifacts, e.g., -hypo-echogenicity in case of obliquity of the transducer beam etc (Fig.-10).
  5. it is often difficult to detect the exact anatomical extension of the relatively very large lesion.

Evaluation of tendons by very recently invented high resolution (harmonic) ultrasound, competes and sometime exceeds MR imaging (Rockett et al, 1998; Martinoli et al, 1999; Fessel and van Holsbeeck, 1999; Miller and Adler, 2000; Rasmussen, 2000). So, only when the US findings are doubtful, further investigations, like MRI, CT, arthroscopy etc. are to be performed (Chiodi and Morini, 1994; Porcellini et al, 1994; Bachmann et al, 1997; Teefey et al 2000 Miayuchi et al, 2001). Thus it can be concluded that the use of modern ultrasonography, which is still underutilised, specially in our country, must be used properly, extensively and routinely to confirm the diagnosis of different pathologies of tendons, and thereby help in their clinical management.


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Fig. 1.Longitudinal scan of normal supraspinatus muscle (right) showing beak-shaped echogenic bands, running parallel to fascial planes and humeral surface.

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Fig. 2.Longitudinal scan of normal tendon, surrounded by hypoechoic synovial bursa, in front of wrist (right)

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Fig. 3 Transverse scan of normal tendo-achilles (left), showing finely punctate echogenic pattern of fibre bundles.

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Fig. 4. Longitudinal scan of normal tendo-achilles (left), showing parallel internal echoes and deep retro-calcaneal bursa.

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Fig. 5 Longitudinal scan of tendo-achilles (right), showing complete disruption of fibres (tear) along with swelling of the region.

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Fig. 6 Longitudinal scan of tendo-achilles (right), showing focal hypoechoic defect (partial tear) at its deeper aspect along with calcification.

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Fig. 7 Longitudinal scan of Achilles tendinosis (left), showing minute intratendinous calcification and hypoechogenicity at its insertion.

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Fig. 8 Longitudinal scan of tendo-achilles (left), showing peritendinitis, where tendon is not much affected except a small calcification near insertion.

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Fig. 9 Longitudinal scan of quadriceps (right), showing disruption of fibres (tear).

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Fig. 10 Longitudinal scans of otherwise normal tendo-achilles (right), showing hypo-echogenicity artifact due to obliquity of beam.

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