Real-time sonoelastography and ultrasound evaluation of the Achilles tendon in patients with diabetes with or without foot ulcers: a cross sectional study

J Diabetes Complications. Nov-Dec 2015;29(8):1124-9. doi: 10.1016/j.jdiacomp.2015.08.012. Epub 2015 Aug 20.


Background: Diabetes mellitus (DM) is an endocrine disease characterized by metabolic abnormalities and long-term complications. The Achilles tendon (AT) plays an important role in foot biomechanics. We aimed to investigate the effect of DM on the Achilles tendon, which may contribute to long-term complications in the foot-ankle complex.

Methods: Seventy-eight patients with diabetes, with (35 patients, group I) or without (43 patients, group II) foot ulcers were recruited from the endocrinology clinic. Thirty-three age-, gender-, and BMI-matched healthy individuals were selected as controls. All participants underwent ultrasonography and sonoelastography of their AT in order to evaluate Achilles tendon thickness (ATT) and stiffness (ATS). Each patient was also tested for fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1C) as a measure of diabetes control. Other chronic complications were also evaluated in all patients with diabetes.

Results: The AT was significantly thicker in group I compared to group II and the controls. HbA1C, FPG, and duration of diabetes were higher in group I. We observed that ATT was positively correlated with neuropathy, retinopathy, nephropathy, peripheral arterial disease and coronary arterial disease in group II while this correlation was not detected in group I. ATS was reduced in group I more than group II and control groups.

Conclusion: Changes in the structure of the AT may precede foot ankle disorders in patients with diabetes. This is the first study that reported the results of sonoelastosonography of AT in patients with diabetes and revealed the correlation between ATT and other chronic complications of diabetes.

Keywords: Achilles tendon stiffness; Achilles tendon thickness; Diabetes mellitus; Diabetic foot ulcers; Sonoelastography; Ultrasonography.

MeSH terms

  • Achilles Tendon / diagnostic imaging*
  • Aged
  • Cross-Sectional Studies
  • Diabetes Mellitus, Type 2 / complications*
  • Diabetes Mellitus, Type 2 / therapy
  • Diabetic Angiopathies / complications
  • Diabetic Angiopathies / physiopathology
  • Diabetic Foot / blood
  • Diabetic Foot / diagnostic imaging*
  • Diabetic Foot / physiopathology
  • Diabetic Nephropathies / complications
  • Diabetic Nephropathies / physiopathology
  • Diabetic Neuropathies / complications
  • Diabetic Neuropathies / physiopathology
  • Elasticity
  • Elasticity Imaging Techniques
  • Female
  • Glycated Hemoglobin A / analysis
  • Hospitals, University
  • Humans
  • Hyperglycemia / prevention & control*
  • Male
  • Middle Aged
  • Outpatient Clinics, Hospital
  • Severity of Illness Index
  • Turkey


  • Glycated Hemoglobin A
  • hemoglobin A1c protein, human