Application of shear wave elastography and B-mode ultrasound in patellar tendinopathy after extracorporeal shockwave therapy

A Correction to this article was published on 11 June 2020

This article has been updated



The purpose of this study was to investigate changes in morphological and elastic properties, as estimated by B-mode ultrasound (B-US) and shear wave elastography (SWE), in volleyball athletes with patellar tendinopathy (PT) and changes after extracorporeal shockwave therapy (ESWT) as well as their relationships with US measurements and Victorian Institute of Sport Assessment-Patella (VISA-P) scores in PT.


Twelve healthy athletes (24 patellar tendons) and 31 volleyball athletes with PT (48 tendons) were included. All were examined by US and received VISA-P scores before the start of the study. The athletes received 3 months of ESWT and underwent US and VISA-P at 1 month and 3 months. VISA-P scores were used to evaluate therapeutic efficacy. Tendon thickness and cross-sectional area (CSA) were detected by B-US, and the elastic modulus was measured by SWE. Correlations between VISA-P and US measurements were calculated.


Thickness, CSA, and elastic modulus of the patellar tendon in PT were higher than those in healthy athletes (P < 0.000). In PT with ESWT, VISA-P scores decreased by 22.1% (P < 0.000) and thickness decreased by 11.2% relative to baseline (P < 0.000). CSA decreased by 1.4% (P < 0.000). The elastic modulus decreased by 15.2% (P < 0.000). Elastic modulus, thickness, and CSA had significant negative correlations with VISA-P scores (P ≤ 0.005), with a stronger correlation between elastic modulus and VISA-P.


Athletes with PT had stiffer and larger tendons than healthy athletes. SWE combined with B-US could clearly show the changes in tendon thickness, CSA, stiffness in PT, and changes after treatment. SWE combined with B-US provided visualization with quantitative, reproducible, and noninvasive imaging in the follow-up evaluation of PT and is worth promoting clinically.

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Change history

  • 11 June 2020

    In the original publication of the article the Fig. 1 has been removed, as the authors did not obtain the appropriate permission from the rights holder to use the image in this article.


  1. 1.

    Lian OB, Engebretsen L, Bahr R. Prevalence of jumper’s knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med. 2005;33:571–7.

    Article  Google Scholar 

  2. 2.

    Kettunen JA, Kvist M, Alanen E, et al. Long-term prognosis for jumper’s knee in male athletes. A prospective follow-up study. Am J Sports Med. 2002;30:689–92.

    Article  Google Scholar 

  3. 3.

    Cook JL, Khan KM, Kiss ZS, et al. Patellar tendinopathy in junior basketball players: a controlled clinical and ultrasonographic study of 268 patellar tendons in players age 14-18 years. Scand J Med Sci Sports. 2010;10:216–20.

    Article  Google Scholar 

  4. 4.

    van Leeuwen MT, Zwerver J, van den Akker-Scheek I. Extracorporeal shockwave therapy for patellar tendinopathy: a review of the literature. Br J Sports Med. 2009;43:163–8.

    Article  Google Scholar 

  5. 5.

    Aspenberg P. Stimulation of tendon repair: mechanical loading, GDFs and platelets. A mini-review. Int Orthop. 2007;31:783–9.

    Article  Google Scholar 

  6. 6.

    de Vos RJ, van Veldhoven PLJ, Moen MH, et al. Autologous growth factor injections in chronic tendinopathy: a systematic review. Br Med Bull. 2010;95:63–77.

    Article  CAS  Google Scholar 

  7. 7.

    Zwerver J, Verhagen E, Hartgens F, et al. The TOPGAME-study: effectiveness of extracorporeal shockwave therapy in jumping athletes with patellar tendinopathy. Design of a randomised controlled trial. BMC Musculoskelet Disord. 2010;11:28.

    Article  Google Scholar 

  8. 8.

    Klauser AS, Miyamoto H, Tamegger M, et al. Achilles tendon assessed with sonoelastography: histologic agreement. Radiology. 2013;267:837–42.

    Article  Google Scholar 

  9. 9.

    Cortes DH, Suydam SM, Sibernagel KG, et al. Continuous shear wave elastography: a new method to measure in vivo viscoelastic properties of tendons. Ultrasound Med Biol. 2015;41:1518–29.

    Article  Google Scholar 

  10. 10.

    Drakonaki EE, Allen GM, Wilson DJ. Ultrasound elastography for musculoskeletal applications. Br J Radiol. 2012;89:1435–45.

    Article  Google Scholar 

  11. 11.

    Ogon P, Zadpanah K, Eberbach H, et al. Prognostic value of MRI in arthroscopic treatment of chronic patellar tendinopathy: a prospective cohort study. BMC Musculoskelet Disord. 2017;18:146.

    Article  Google Scholar 

  12. 12.

    Fredberg U, Stengaard-Pedersen K. Chronic tendinopathy tissue pathology, pain mechanisms, and etiology with a special focus on inflammation. Scand J Med Sci Sports. 2008;18:3–15.

    Article  CAS  Google Scholar 

  13. 13.

    Gisslen K, Gyulai C, Söderman K, et al. High prevalence of jumper’s knee and sonographic changes in Swedish elite junior volleyball players compared to matched controls. Br J Sports Med. 2005;39:298–301.

    Article  CAS  Google Scholar 

  14. 14.

    Kulig K, Landel R, Chang YJ, et al. Patellar tendon morphology in volleyball athletes with and without patellar tendinopathy. Scand J Med Sci Sports. 2013;23:e81–8.

    Article  CAS  Google Scholar 

  15. 15.

    Warden SJ, Kiss ZS, Malara FA, et al. Comparative accuracy of magnetic resonance imaging and ultrasonography in confirming clinically diagnosed patellar tendinopathy. Am J Sports Med. 2007;35:427–36.

    Article  Google Scholar 

  16. 16.

    Garra BS. Elastography: current status, future prospects, and making it work for you. Ultrasound Q. 2011;27:177–86.

    Article  Google Scholar 

  17. 17.

    Zhang ZJ, Gabriel YF, Lee WC, et al. Changes in morphological and elastic properties of patellar tendon in athletes with unilateral patellar tendinopathy and their relationships with pain and function disability. PLoS One. 2014;9:e108337.

    Article  CAS  Google Scholar 

  18. 18.

    Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am. 2005;87:187–202.

    Google Scholar 

  19. 19.

    Kader D, Saxena A, Movin T, et al. Achilles tendinopathy: some aspects of basic science and clinical management. Br J Sports Med. 2002;36:239–49.

    Article  CAS  Google Scholar 

  20. 20.

    Cheng Y, Zhang J, Cai Y. Utility of ultrasonography in assessing the effectiveness of extracorporeal shock wave therapy in insertional achilles tendinopathy. Biomed Res Int. 2016;2016:2580969.

    PubMed  PubMed Central  Google Scholar 

  21. 21.

    Garra BS. Imaging and estimation of tissue elasticity by ultrasound. Ultrasound Q. 2007;23:255–68.

    Article  Google Scholar 

  22. 22.

    Lerner RM, Huang SR, Parker KJ. ‘‘Sonoelasticity’’ images derived from ultrasound signals in mechanically vibrated tissues. Ultrasound Med Biol. 1990;16:231–9.

    Article  CAS  Google Scholar 

  23. 23.

    Tas S, Onur MR, Yılmaz S, et al. Shear wave elastography is a reliable and repeatable method for measuring the elastic modulus of the rectus femoris muscle and patellar tendon. J Ultrasound Med. 2017;36:565–70.

    Article  Google Scholar 

  24. 24.

    Gao L, Yuan JS, Heden GJ, et al. Ultrasound elasticity imaging for determining the elastic properties of human posterior tibial tendon: a cadaveric study. IEEE Trans Biomed Eng. 2015;62:1179–84.

    Article  Google Scholar 

  25. 25.

    Waugh CM, Morrissey D, Jones E, et al. In vivo biological response to extracorporeal shockwave therapy in human tendinopathy. Eur Cells Mater. 2015;15:268–80.

    Article  Google Scholar 

  26. 26.

    Zhao H, Ren Y, Wu YN, et al. Ultrasonic evaluations of Achilles tendon elastic properties poststroke. J Appl Physiol. 2009;106:843–9.

    Article  Google Scholar 

  27. 27.

    Hsu RW, Hsu WH, Tai CL, et al. Effect of shock-wave therapy on patellar tendinopathy in a rabbit model. J Orthop Res. 2004;22:221–7.

    Article  Google Scholar 

  28. 28.

    Helland C, Bojsen-Møller J, Raastad T, et al. Elastic properties of the patellar tendon in elite volleyball players with and without patellar tendinopathy. Br J Sports Med. 2013;47:862–8.

    Article  Google Scholar 

  29. 29.

    Arya S, Kulig K. Tendinopathy alters mechanical and material properties of the Achilles tendon. J Appl Physiol. 2010;108:670–5.

    Article  Google Scholar 

  30. 30.

    Ophir J, Céspedes I, Ponnekanti H, et al. Elastography: a quantitative method for imaging the elasticity of biological tissues. Ultrason Imaging. 1991;13:111–34.

    Article  CAS  Google Scholar 

  31. 31.

    Szczepanek-Parulska E, Wolinski K, Stangierski A, et al. Comparison of diagnostic value of conventional ultrasonography and shear wave elastography in the prediction of thyroid lesions malignancy. PLoS One. 2013;8:e81532.

    Article  CAS  Google Scholar 

  32. 32.

    Hall TJ. AAPM/RSNA physics tutorial for residents: topics in US: beyond the basics: elasticity imaging with US. Radiographics. 2003;23:1657–71.

    Article  Google Scholar 

  33. 33.

    Lin TWTW, Cardenas L, Soslowsky LJLJ. Biomechanics of tendon injury and repair. J Biomech. 2004;37:865–77.

    Article  Google Scholar 

  34. 34.

    Soslowsky LJ, Thomopoulos S, Tun S, et al. Neer Award 1999. Overuse activity injures the supraspinatus tendon in an animal model: a histologic and biomechanical study. J Shoulder Elbow Surg. 2000;9:79–84.

    Article  CAS  Google Scholar 

  35. 35.

    Malliaras P, Purdam C, Maffulli N, et al. Temporal sequence of grey scale ultrasound changes and their relationship with neovascularity and pain in the patellar tendon. Br J Sports Med. 2010;44:944–7.

    Article  CAS  Google Scholar 

  36. 36.

    Dirrichs T, Quack V, Gatz M, et al. Shear wave elastography SWE for the evaluation of patients with tendinopathies. Acad Radiol. 2016;23:1204–13.

    Article  Google Scholar 

  37. 37.

    Ooi CC, Richards PJ, Maffulli N, et al. A soft patellar tendon on ultrasound elastography is associated with pain and functional deficit in volleyball players. J Sci Med Sport. 2016;19:373–8.

    Article  Google Scholar 

  38. 38.

    Ryan M, Bisset L, Newsham-West R. Should we care about tendon structure? The disconnect between structure and symptoms in tendinopathy. J Orthop Sports Phys Ther. 2015;45:823–5.

    Article  Google Scholar 

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The authors appreciate the cooperation of the volleyball team.

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Correspondence to Wen Zhang.

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The authors declare that they have no conflicts of interest.

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All procedures performed in this study were in accordance with the ethical standards of our institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all individual participants included in the study.

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The original version of this article was revised: In the original publication of the article the Fig. 1 has been removed, as the authors did not obtain the appropriate permission from the rights holder to use the image in this article.

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Zhang, C., Duan, L., Liu, Q. et al. Application of shear wave elastography and B-mode ultrasound in patellar tendinopathy after extracorporeal shockwave therapy. J Med Ultrasonics 47, 469–476 (2020).

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  • Patellar tendinopathy
  • Shear wave elastography
  • B-mode