In Achilles tendinopathy, the neovascularization, detected by contrast-enhanced ultrasound (CEUS), is abundant but not related to symptoms

Knee Surg Sports Traumatol Arthrosc. 2018 Jul;26(7):2051-2058. doi: 10.1007/s00167-017-4710-8. Epub 2017 Oct 27.


Purpose and hypothesis: Mid-portion Achilles tendinopathy is characterized by a proliferation of small vessels, called neovascularization, which can be demonstrated by power Doppler sonography (PD). Neovascularization can be correlated with diagnosis and consequent therapies focused on vascular supply. Published data regarding the relationship between neovascularisation and symptoms, such as pain and disability, are contradictory. The hypothesis that contrast-enhanced ultrasound (CEUS) could detect with more sensibility than PD the new vessel ingrowth in human degenerated Achilles tendons and therefore the correlation of neovascularization with pain and disability, was evaluated.

Methods: Thirty consecutive patients of recalcitrant Achilles tendinopathy were studied with ultrasound greyscale (US), PD, CEUS and magnetic resonance imaging. Neovascularization was recorded as percentage on the whole extension of examined area. The vascularization time was recorded as venous and arterial type. Imaging data were classified both concurrently with the examination and in a secondary blinded assessment; any difference in the subjective assessment was discussed and a consensus view formed. Pain and disability were assessed by Western Ontario McMaster Universities Arthritis Index (WOMAC) and EuroQuality of life 5-dimension-5-level questionnaire and visual analogue scale (EQ-VAS). All results were analysed with suitable statistical methods.

Results: 76.7% of cases were degenerated; 23.3% had also partial discontinuity of the fibres. PD detected vascularization in 54% of cases, whereas CEUS in 83% of cases: in 13 cases, PD did not detect vascularization. The vascularization time was rapid (< 20 s, arterial type) in 60% of cases. WOMAC pain mean value is 6.4 and SD 3.4; WOMAC total score mean value is 21.6 and SD 12.8. EQ-VAS mean value is 56 and SD 18.3. No statistically significant correlation emerged between vascularization and pain/disability.

Conclusions: CEUS showed a greater ability to detect neovessels than PD in chronic Achilles tendinopathies. Nevertheless in 30 consecutive tendinopathies, no correlation between pain/disability and neovascularization was found: the role of multiple neovessels continue to be unclear. The possibility to discriminate arterial from venous vessels ('vascularization time') could be useful to understand the pathophysiology of tendinopathies and its healing process.

Study type: Diagnostic study.

Level of evidence: II.

Keywords: Achilles tendon; Angiofibroblastic degeneration; Contrast-enhanced ultrasound (CEUS); Magnetic resonance imaging (MRI); Neovascularization; Power Doppler ultrasonography; Tendinopathy; Tendinosis.

MeSH terms

  • Achilles Tendon / diagnostic imaging*
  • Achilles Tendon / physiopathology
  • Aged
  • Female
  • Humans
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Neovascularization, Pathologic / diagnostic imaging*
  • Neovascularization, Pathologic / physiopathology
  • Ontario
  • Pain
  • Pain Measurement
  • Surveys and Questionnaires
  • Tendinopathy / diagnostic imaging*
  • Tendinopathy / physiopathology
  • Ultrasonography
  • Visual Analog Scale