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Aim: To investigate the feasibility and reproducibility of real-time freehand ultrasound elastography (RTE) of the normal Achilles tendon and to describe its elastographic appearances. Materials and methods: Fifty normal Achilles tendons were prospectively examined using RTE performed by tissue compression using the hand-held transducer. The information was colour-coded (red = soft, green = medium, blue = hard) and superimposed on the B-mode image. Each tendon was examined three times transversely and longitudinally by two radiologists and the ratio between tendon and retro-Achilles fat strain (strain index) was calculated. The reproducibility of the elastograms was assessed qualitatively and quantitatively using the strain index inter and intra observer variation coefficient (intra/inter-CV and intra/inter-CC, respectively). Results: All tendons were clearly visualized on the elastograms. Nineteen tendons (19/50, 38%) appeared homogeneously green/blue (type 1). Thirty-one tendons (31/50, 62%) appeared green with longitudinal red stripes (type 2). The intra- and inter-CC values of the strain index were lower for the transverse plane than for the longitudinal plane (0.43, 0.45, 0.41 and 0.78, 0.66, 0.51, respectively). The intra-CV and inter-CV values were higher for the transverse than for the longitudinal plane measurements (39%, 37%, 30% and 30.50%, 30.10%, 29.60%, respectively). Conclusion: RTE of the normal Achilles tendon is a feasible method. The reproducibility of the strain index is good and higher for longitudinal elastograms. Qualitative assessment enables the discrimination of two distinct elastographic patterns. Further studies are required to assess the clinical value of this method. © 2009 The Royal College of Radiologists.

Original publication




Journal article


Clinical Radiology

Publication Date





1196 - 1202