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Chapter

Imaging of Tendons
Stephanie C. Torres-Ayala, Alvaro Bravo-Martínez,
Amanda P. Marrero-González, Luis R. Rodriguez-Ortíz
and Jorge A. Vidal

Abstract

Magnetic resonance imaging (MRI) and ultrasound (US) are useful radiologic
modalities that allow adequate evaluation of tendon anatomy and integrity. Each
modality contains unique advantages as diagnostic tools, allowing detection of
tendon injuries and pathology. This chapter focuses on the key imaging features of
tendons in both ultrasound and magnetic resonance, with emphasis on the major
joints such as the shoulder, elbow, hand/wrist, hip, knee and foot/ankle joints. Each
section provides a review of standard magnetic resonance imaging protocols and
ultrasound technique, along with a discussion of the radiologic appearance of the
most common tendon pathology affecting each joint.

Keywords: tendons, ultrasound, magnetic resonance imaging, radiology

1. Introduction

Imaging modalities play a significant role in the evaluation of tendon pathol-

ogy. Knowledge of anatomical landmarks of the tendons is of utmost importance
in order to differentiate and accurately diagnose pathologic processes. Ultrasound
(US) and Magnetic Resonance Imaging (MRI) are currently the imaging modalities
of choice to evaluate tendon pathology, each with its own unique advantages as
diagnostic tools. Tendons are characteristically seen as echogenic fibrillar structures
on US and as homogeneous hypointense structures on MRI.
This chapter focuses on the key imaging features of tendons in US and MRI
modalities, with emphasis on the shoulder, elbow, hand, hip, knee and foot joints.
Each chapter section will provide a review of the anatomical landmarks, normal
US and MRI appearance, imaging protocols, and discussion of common pathology
affecting the tendons in each joint.

2. Shoulder

2.1 MRI protocol

The patient is positioned supine with the arm at the side in neutral position or
slight external rotation in order to put some tension on the long head of the biceps
tendon. A small field of view (approximately 14–16 cm) is obtained in three imaging
planes: axial, coronal oblique, and sagittal oblique. The axial images are acquired
from the top of the acromioclavicular joint through the proximal humeral shaft

1
Tendons

including the insertion of the pectoralis muscle. The coronal oblique images are
obtained with planes made parallel to the supraspinatus tendon or in a plane per-
pendicular to the articular surface of the glenoid, ranging from the coracoid process
to the infraspinatus muscle. Finally, the sagittal oblique images are acquired with
planes parallel to the articular surface of the glenoid, from the scapular neck through
the lateral aspect of the humerus [1]. A standard shoulder MRI usually includes
sagittal oblique T1-weighted image (T1WI), fast spin echo (FSE) T2-weighted image
(T2WI) with fat suppression, coronal oblique FSE T2WI with fat suppression, and
axial FSE T2WI and FSE proton density (PD) with fat suppression.

2.2 Ultrasound examination technique

Sonographic evaluation of the shoulder can be performed with the following

steps [2]:

1. Long head of biceps brachii tendon: The patient places the hand on his or
her lap, as this position rotates the bicipital groove anteriorly. The trans-
ducer is placed in the axial plane over the anterior aspect of the shoulder
to identify the bicipital groove, where the long head of the biceps brachii
tendon is found. The long head of the biceps brachii tendon is followed
proximally to where the bicipital groove becomes shallow and then distal to
the level of the pectoralis major tendon. The transducer is then turned 90°
to visualize the tendon in long axis from the humeral head to the pectoralis
tendon.

2. Subscapularis tendon: The transducer is placed in the axial plane, as in the

previous step, to first visualize the bicipital groove and then centered over the
lesser tuberosity at the medial aspect of the bicipital groove. Then the patient
rotates the shoulder externally to pull the subscapularis tendon laterally, which
will orient the tendon fibers perpendicular to the transducer sound beam and
eliminate anisotropy. Then it may be moved laterally over the bicipital groove
to ensure that the long head of the biceps brachii tendon is within the bicipital
groove, and rule out subluxation or dislocation, which may be present only in
external rotation [3]. The subscapularis tendon can also be evaluated in short
axis by turning the transducer 90°.

3. Supraspinatus and infraspinatus tendon: One way to evaluate the supraspina-

tus tendon is to ask the patient to place the dorsum of his or her ipsilateral hand
behind the back, called the Crass position [4]. This position pulls the tendon
out from under the acromion. The Crass position is very helpful in localizing
the greater tuberosity but its limitations include poor visualization of the
rotator interval and patient discomfort [3]. Because of these disadvantages
the modified Crass position is more commonly used, by asking the patient
to place his or her ipsilateral hand on the hip or buttock region. This position
places the greater tuberosity more lateral than with the Crass position, and also
allows easy visualization of the rotator interval with little patient discomfort
[5]. Either in the Crass or modified Crass position, supraspinatus evaluation
should begin by observing the tendon in long axis as this allows visualiza-
tion of the three surfaces (articular, bursal, greater tuberosity) [6]. Scanning
should be continued anteriorly along the greater tuberosity until the intra-
articular portion of the biceps tendon is identified. The infraspinatus tendon
is evaluated by moving the transducer posteriorly over the middle facet of the
greater tuberosity.

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DOI: http://dx.doi.org/10.5772/intechopen.84521

2.3 Supraspinatus tendon

The supraspinatus tendon arises from the supraspinous fossa, runs between the
undersurface of the acromion and the top of the humeral head, and inserts into
the most superior facet of the greater tuberosity of the humerus. On MRI, the entire
length of the supraspinatus tendon can be seen well in the coronal oblique plain,
running at an angle of approximately 45° [7]. The musculotendinous junction of
the tendon normally is located just lateral to the acromioclavicular joint. On sagittal
oblique images, the supraspinatus tendon is imaged in cross section, which is valu-
able to confirm the status of the tendon when abnormalities are seen in the plane of
imaging, where the tendon is viewed longitudinally.
The normal sonographic appearance of the supraspinatus tendon is hyper-
echoic and fibrillar with a convex superior margin at the level of the superior
facet of the greater tuberosity of the humerus [8]. It parallels the curved contour
of the humeral head, flattening out as it inserts into the greater tuberosity. The
subacromial-subdeltoid bursa should be seen as a single thin hyperechoic line
paralleling the tendon superiorly.
The supraspinatus tendon is the most commonly affected when compared to the
other tendons of the shoulder [8]. There are multiple pathologies that may limit the space
within the coracoacromial arch, producing impingement of this tendon. Abnormalities
from impingement range from tendon degeneration to partial-thickness or full-thickness
tears. Most partial-thickness tears occur in the articular aspect of the tendon, rather than
on the bursal surface. Tears are usually located distally, either near its attachment to the
greater tuberosity or in the critical zone located approximately 1 cm proximal to its inser-
tion, and start in the anterior portion as rim rent tears and spread posteriorly [7]. Rim
rent tears refer to disruption of the insertional fibers on the greater tuberosity. Complete
disruption of the fibers with communication between the joint and the overlying bursa
indicates a full-thickness tear (Figure 1).
Tendon degeneration usually demonstrates increased signal intensity on T1WI
and T2WI, although not as high signal as fluid. However, a partial thickness tear
demonstrates increased signal intensity on T2WI similar to fluid. Indications of a
full thickness tear include: tendon discontinuity, fluid signal in tendon gap, and
retraction of musculotendinous junction [7].
Tears in ultrasound are demonstrated as anechoic or hypoechoic defects,
although acute tears will more likely appear anechoic like fluid [8]. As a supraspina-
tus tendon tear enlarges, tendon retraction and volume loss occur, with loss of the
normal superior convex shape. The length or degree of retraction of a full thickness
tear can be measured on longitudinal views oriented parallel to the long axis of the
cuff and the width can be measured on transverse views oriented perpendicular to
the long axis of the cuff [2]. On the other hand, tendinosis is usually less defined,
and may be associated with increased tendon thickness, and not usually associated
with adjacent cortical irregularity of the greater tuberosity.

2.4 Long head of biceps brachii tendon

The long head of biceps brachii tendon originates from the supraglenoid tuber-
cle of the scapula, courses intra-articularly to the entrance of the bicipital groove
and continues caudally, inserting along the radial tuberosity of the proximal radius.
On MRI, portions of this tendon can be evaluated on coronal oblique images, from
its origin at the superior labrum and inferiorly in the bicipital groove. The portion
that is located within the bicipital groove is seen on axial images as a round or oval
structure, and sometimes it may blend with the low signal intensity cortex of the
humerus, making it difficult to identify. It is normal to find a small amount of fluid

3
Tendons

Figure 1.
Magnetic resonance arthrogram T1 fat saturated coronal oblique image shows a full thickness tear of the
supraspinatus tendon with contrast leaking from the joint capsule into the subdeltoid space.

in the dependent side of the long head of the biceps tendon sheath, as the tendon
sheath normally communicates with the glenohumeral joint. High signal round
structures found lateral to the tendon within the bicipital groove represent the
anterior circumflex humeral artery/vein and should not be confused with tenosy-
novitis [7].
The long head of biceps brachii tendon should be found within the intertuber-
cular groove upon sonographic evaluation of the shoulder. The tendon fibers should
be seen without tears, heterogeneity or thickening. The normal tendon will appear
hyperechoic; however, because the tendon courses deep, it may appear artifactually
hypoechoic due to anisotropy [8]. Adjusting the transducer to aim the sound beam
perpendicular to the tendon fibers can eliminate this artifact.
The proximal aspect of the tendon may be affected by impingement in the same
ways as the supraspinatus tendon because of its similar location and course beneath
the supraspinatus tendon. Tears associated with impingement usually occur proxi-
mal to the bicipital groove and are usually seen in the older population. Acute tears
unrelated to impingement are commonly secondary to a traumatic injury in young
individuals, and usually occur distally in the tendon, near the musculotendinous
junction [7]. When a full-thickness tear occurs, axial MRI images of the shoulder
may show an empty bicipital groove, without evidence of the oval, low signal long
head of the biceps tendon. An empty bicipital groove may also indicate tendon
dislocation, which is also associated with disruption of the transverse humeral liga-
ment that holds the biceps tendon in place. In this case, the low signal round tendon
is seen medial to the bicipital groove, either deep or superficial to the subscapularis
tendon, which usually also tears as well.

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DOI: http://dx.doi.org/10.5772/intechopen.84521

When shoulder effusion is present, fluid may be seen sonographically sur-

rounding the biceps tendon at the level of the bicipital groove given the normal
communication between the tendon sheath and joint. Joint effusion appears
anechoic, however if fluid is complex it may be hypoechoic, isoechoic or hyper-
echoic relative to muscle, resembling synovial hypertrophy [8]. Tenosynovitis is
favored over joint fluid extending into the sheath if there is focal distention of the
tendon sheath with hyperemia and it is symptomatic with transducer pressure.
Tendinosis of the long head of the biceps brachii should be considered when the
tendon is abnormally hypoechoic and increased in thickness with lack of fiber
disruption. Anechoic clefts or surface irregularity of the tendon favor a partial-
thickness tear [9]. The primary finding in a full-thickness tear is lack of visualiza-
tion of the biceps tendon or empty bicipital groove. As mentioned before, one must
also consider tendon subluxation or dislocation when encountered with an empty
bicipital groove. In this case, the tendon can be seen medially displaced, usually
superficial to the lesser tuberosity.

3. Elbow

3.1 MRI protocol

Patients should be supine in a comfortable position with the arm to be imaged in

supine position as well. Images should include from the distal humeral metaphysis
up to the radial tuberosity and this area should be imaged in axial, coronal and sag-
ittal planes. Sequences should include non-fat saturated T1, PD, and fat-saturated
T2WI; gradient echo (GRE) may also be included depending on the pathology
suspected [10].

3.2 Ultrasound examination technique

Ultrasound of the elbow usually focuses on the area of clinical interest, nonethe-
less, the anterior, lateral, medial and posterior compartments should all be evalu-
ated. A high frequency linear transducer of 12–17 mHZ is preferred. To evaluate
the anterior compartment of the elbow, which includes the distal biceps tendon, it
should be extended with a supine forearm. Evaluation should include transverse
and longitudinal planes from 5 cm proximal and distal to the joint. The lateral elbow
compartment, which includes the common extensor tendon, is evaluated with the
arm placed in internal rotation and elbow joint in flexion. The medial compartment
includes the common flexor tendons, which is evaluated sonographically by extend-
ing the forearm in forceful external rotation. Lastly, the posterior elbow, which
contains the distal triceps tendon, is evaluated by placing the elbow in 90° flexion
with the arm internally rotated [11].

3.3 Common extensor tendon

The common extensor tendon attaches to the humeral lateral epicondyle uniting
the individual tendons of the extensor carpi radialis brevis, extensor digitorum,
extensor digiti minimi and the extensor carpi ulnaris. Normally the common exten-
sor tendon is a band of low signal intensity on both T1WI and T2WI, seen superfi-
cial to the radial collateral ligament complex and the tendon should show complete
fibers at its insertion in the lateral epicondyle.
A common cause for elbow pain is lateral epicondylitis, also known as tennis
elbow. In these cases, the tendon may appear thickened with increased intermediate

5
Tendons

signal intensity on T1WI and T2WI. Abnormal fluid signal intensity may be seen
traversing the tendon fibers in partial tendon tears, most common in the extensor
carpi radialis brevis tendon [12] (Figure 2). If there is a fluid signal intensity gap
with discontinuity of the tendon fibers, a full thickness tear is present. Avulsion
injuries may be present when there is associated bone marrow edema at the ten-
dinous insertion site. The US evaluation of lateral epicondylitis shows a heteroge-
neous tendon with focal hypoechoic areas.

3.4 Distal biceps tendon

The distal biceps brachii tendon is located at the anterior elbow compart-
ment, coursing through the antecubital fossa with its distal insertion at the
radial bicipital tuberosity. Its superficial fibers form the lacertus fibrosis which
course medially to form the distal portion of the tendon. Pathology of the distal
biceps tendons is most common in people who perform heavy weightlifting, with
increased risk in those who use anabolic steroids [12]. A distal biceps tendon tear
results in retraction of the myotendinous junction, clinically known as a Popeye’s
sign or mass in the proximal arm. This is seen as complete discontinuity of the
tendon fibers, best appreciated in axial and sagittal planes. In order to be able

Figure 2.
Proton density fat saturated coronal image of the elbow shows fluid signal at the insertion of the common
extensor tendon consistent with a tendon tear.

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DOI: http://dx.doi.org/10.5772/intechopen.84521

to visualize the retracted tendon and area of avulsion at its distal insertion the
arm may be supine, flexed and abducted. If there is a partial tear present, then
on magnetic resonance imaging there will be peritendinous increased T2 signal
intensity [12].

4. Hand/wrist

4.1 MRI protocol

For MR imaging of the hand the patient is placed in prone position, with
the arm elevated above the head, also known as the “superman position”. When
specifically imaging the thumb, the latter should be fully extended and at the
center of the scanner and foam pads may be used for fixation of the area of inter-
est. Small surface or dedicated hand or wrist coils are important in order to obtain
high quality images. Axial images with respect to the fingers are first obtained
and these are then used to plan sagittal and coronal views. When imaging the
thumbs, coronal and sagittal views should be tilted 90° to sesamoids at the level
of the metacarpophalangeal joint (Figure 3) [13]. It is always important to include
adjacent fingers within the field of view of the image for comparison [14]. Three-
Tesla MRIs are preferred due to the high resolution and detail provided for these
small anatomical regions. Standard sequences used to evaluate for hand tendinous
or ligamentous injury are: coronal PD, axial T1, coronal T1, sagittal T1, axial T2
and sagittal T2W sequences. When evaluating the wrist, the wrist should be at the
center of the scanner with dedicated surface coils as well. Coronal images should
be oriented between the radial and styloid ulnar processes and sagittal images
prescribed 90° to coronals. The axial images should include approximately 2–3 cm
proximal to the radiocarpal joint and at least 1 cm distal to the carpometacarpal
joints [13].

4.2 Ultrasound examination technique

US of the wrist and hand are usually tailored to an area of interest, according to
patient symptoms. The wrist is separated into a dorsal and ventral compartment.
The hand is placed in prone position and a transverse sweep allows evaluation of the
6-extensor compartments. The hand is later supinated, allowing evaluation of the
carpal tunnel and Guyon’s canal.

4.3 De Quervain tenosynovitis

It is the second most common stenosing synovitis, presenting with pain

and swelling at the styloid process region when moving the thumb or wrist.
Anatomically, the abductor pollicis longus (APL) and extensor pollicis brevis (EPB)
tendons are held within a fibro-osseous sheath called the extensor retinaculum.
Repetitive trauma results in thickening of the tendons and retinaculum resulting
in inflammation and edema. In some cases, a septum has been found between both
tendons, thought to worsen symptoms.
On US, the APL and EPB tendons are thickened at the level of the radial
styloid with increased fluid within the first extensor compartment. A halo sign
has been described, secondary to peritendinous subcutaneous edema. Doppler
imaging should show increased vascularity secondary to hyperemia and inflam-
mation [15].

7
Tendons

Figure 3.
On the left side, we have a T2WI showing the tendon as a hypointense structure; while on the right side we see a
composite US image of the flexor tendon of the finger with some areas of anisotropy.

On MRI, tenosynovitis is seen as increased signal intensity on T2WI and low to

intermediate signal on T1WI of the tendon sheath. The retinaculum will also appear
thickened with increased T2 signal intensity. When the tendon is thickened, mostly
seen at the radial styloid at its medial aspect, with increased T1 and T2 intra-tendi-
nous signal and a striated tendinous signal, tendinosis is said to be present. These
may also be accompanied by a longitudinal tendinous tear, where linear T2 signal
will be seen traversing the tendon, most common in the APL, due to fluid within the
tendinous rupture.

4.4 Flexor tendon/trigger finger

Trigger finger is a stenosing tenosynovitis secondary to repetitive micro-

trauma. This results in inflammation and thickening of the flexor tendon
and tendon sheath, causing transient locking of the digit in a flexed position.

8
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DOI: http://dx.doi.org/10.5772/intechopen.84521

Figure 4.
Thickening of the A1 pulley in the 3rd flexor tendon of the hand consistent with clinical picture of “trigger
finger”.

This pathology is mainly evaluated with US instead of MRI (Figure 4). On US,
the flexor tendon and A1 pulley will be thickened with a diameter greater than
1.1 mm. Hypoechoic fluid may also be seen around the tendon sheath, represent-
ing an effusion [16].

5. Knee

5.1 MRI protocol

The knee is positioned in a relaxed state, with about 5° of external rotation so

that the anterior cruciate ligament is orthogonal to the sagittal plane of imaging. A
small field of view is used, usually between 14 and 16 cm, and multiplanar imaging is
obtained with coronal, sagittal, and axial images [17]. Sequences of a knee MRI should
include any combination of fluid-sensitive sequences with anatomic sequences. Fluid-
sensitive images can be either fat-sat PDW, or T2W spin-echo images versus STIR
images. Anatomic sequences may include either T1W or PDW, spin-echo images [18].

5.2 Ultrasound examination technique

Ultrasound evaluation may be completed with the patient supine, although the
posterior structures are better seen in the prone position [19]. Examination may be

9
Tendons

focused over the area that is relevant to the patient’s history; nonetheless a complete
examination of all areas should be performed. Sonographic examination may be
divided in four methods: anterior, medial, lateral, and posterior evaluation of the knee.

1. Anterior knee: Evaluated with patient in a supine position and knee slightly
flexed 20–30°. The primary structures evaluated in this approach include the
quadriceps tendon, patella, patellar tendon, patellar retinaculum, suprapatellar
joint recess, the medial and lateral recesses, and the anterior knee bursae [20].
Evaluation begins with transducer in the sagittal plane, proximal to the patella,
to evaluate the quadriceps tendon. Deep to the quadriceps tendon, the suprapa-
tellar recess is identified. Next, the transducer is moved inferiorly in the sagittal
plane to evaluate the patellar tendon. The transducer is then moved to both the
medial and lateral margins of the patella in the transverse plane, to evaluate the
medial and lateral patellar retinacula, and the underlying medial and lateral
recesses. Finally, the knee is placed in a 90° flexed position to evaluate the
femoral trochlear cartilage in the transverse plane superior to the patella.

2. Medial knee tendons: The patient remains supine and rotates hip externally for
evaluation of the medial aspect of the knee. The tendinous structures that are
evaluated in this region are the pes anserine tendons [19].

3. Lateral knee: The patient is in supine position, with internal rotation of the hip,
and knee slightly flexed. The key structures that are examined include the ilioti-
bial band, lateral collateral ligament (LCL), biceps femoris tendon, popliteus,
common peroneal nerve, and body and anterior horn of the lateral meniscus
[19]. The transducer may be initially placed over the long axis of the patellar
tendon, and then moved laterally to identify the iliotibial band. Next, the trans-
ducer is moved laterally to the coronal plane over the lateral femoral condyle to
identify the groove for the popliteal tendon, an important bone landmark. Using
this groove as a landmark, the proximal end of the transducer is stabilized on
the femur, and the distal aspect is rotated posterior to visualize the fibular head.
At this site, LCL is identified. After the transducer is moved along the LCL to its
fibular attachment, the distal end of the transducer is anchored to the fibular
head while the proximal aspect is rotated posteriorly in the coronal plane to
visualize the biceps femoris tendon. As the transducer is moved posteriorly from
the coronal plane view, the common peroneal nerve can be identified. Upon
return to the popliteal groove, the distal popliteal tendon may be followed.

4. Posterior knee: The posterior aspect of the knee is evaluated with the patient in
prone position and extended knee. The structures that may be identified are the
posterior horns of the menisci, posterior cruciate ligament, the popliteal neuro-
vascular bundle, and the presence of a Baker cyst [20]. The transducer is placed
in the transverse plane of the mid-calf to identify the deep soleus and medial and
lateral heads of the gastrocnemius muscles. The medial head of the gastrocnemius
is followed proximally until the semimembranosus tendon is identified medially.
If a Baker cyst is present, it will be visualized between these two structures.

5.3 Patellar tendon

The patellar tendon is part of the extensor mechanism of the knee, which origi-
nates at the patellar apex and inserts at the tibial tuberosity. It is located anteriorly
to Hoffa’s fat pad, and is usually about half of the thickness of the quadriceps

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Figure 5.
Quadriceps and patellar tendons showing the dark signal qualities on PDWI.

tendon (approximately 0.5 cm), as seen on sagittal MRI with low homogeneous
signal in all sequences (Figure 5) [18]. When visualizing it with ultrasound,
the patellar tendon should normally exhibit an echogenic, fibrillar appearance.
Deep to the tendon, Hoffa’s fat pad appears hyperechoic or isoechoic to muscle.
The region around the distal patellar tendon is also evaluated for infrapatellar
bursal fluid.
Focal patellar tendinosis of the proximal deep insertional fibers is termed
jumper’s knee in adults, usually presenting as pain in the inferior patellar region. It is
often visualized on MRI as thickening of the proximal patellar tendon with increased
signal on T2W images [21]. A similar finding in children (often associated with
cerebral palsy) is known as Sinding-Larsen-Johansson disease. A complete rupture of
the tendon is usually easily identified, due to the secondary finding of a patella alta.
Ultrasound can be very useful in the evaluation of tendinosis and partial tears.
Tendinosis will appear as focal or diffuse hypoechogenicity and thickening of the
tendon. Partial-thickness tear may reveal similar findings with possible anechoic
interstitial clefts. Marked hyperemia from neovascularity may also be identified with
color Doppler imaging [22]. Full-thickness tears are seen as complete tendon fiber
discontinuity and refraction shadowing at the retracted torn tendon stumps [20].

6. Hip joint

6.1 MRI protocol

MRI evaluation of the hip is performed while the patient is in the supine
position. Coronal, axial, sagittal and axial oblique planes are obtained for

11
Tendons

MR sequences of the entire pelvis and unilateral symptomatic hip. Imaging

sequences of the hip are performed with bilateral legs placed in 15° of internal
rotation. Hip MRI generally includes the following imaging sequences: non-fat
saturated T1WI, fat saturated T2WI, PD fat saturated images and inversion
recovery (IR) images [23].

6.2 Ultrasound examination technique

Examination can be divided in the following approaches [24, 25]:

1. Anterior hip: Patient lies supine with hip in neutral position. Examination starts
with the anterior synovial recess, for which the transducer is placed over the femo-
ral head in the oblique longitudinal plane. Examination continues with identifying
the anterior glenoid labrum, located cranially in this plane, and the iliofemoral
ligament that lies superficially in relation to the labrum. Next, the transducer is
placed at the interphase between the femoral head and the joint space to examine
the iliopsoas muscle and tendon. The neurovascular bundle and the iliopectineal
eminence are used as anatomical landmarks to identify these structures. Lateral to
the neurovascular bundle, the iliopsoas muscle is visualized. The iliopsoas tendon
lies deep within the bellies of the muscle and on top of the iliopectineal eminence.
The adjacent bursa is identified if there is a pathologic process present.

2. Medial hip: Patient remains in the supine position, now with abduction and
external rotation of the hip and flexion of the knee. Examination starts in the
long axis plane to scan over the insertion of the iliopsoas tendon at the lesser
trochanter of the femur. Next, the adductor muscles are evaluated in the axial
plane. The muscles of the medial hip compartment are divided in three layers.
The adductor longus is located at the lateral aspect of the superficial muscular
layer, while the gracilis is located at the medial aspect. The adductor brevis
makes up the intermediate muscular layer and the adductor magnus makes
up the deep muscular layer. Scan continues in the long axis plane with the
transducer moved along the abductor muscles to identify the abductor longus
tendon, using the pubic bone as reference landmark. The adductor longus
tendon insertion is identified as a hypoechoic triangular structure. Lastly, the
transducer is placed over the pubis in the transverse plane, from which oblique
longitudinal plane is achieved to evaluate the tendon complex formed by the
transversus abdominis and internal oblique muscles.

3. Lateral hip: The patient is moved to the lateral decubitus position, lying on
opposite hip of interest. With this examination, the following structures are
evaluated: abductor muscles, gluteus medius, gluteus minimus, and tensor fas-
cia lata. To begin, the transducer is placed over the greater trochanter. Scanning
is performed in the transverse and longitudinal planes. The gluteus medius,
seen as a curvilinear fibrillar band, lies superficial to the gluteus minimus. The
tensor fascia lata serves as an anatomical landmark to identify the gluteus mus-
cles, which is visualized as a superficial hyperechoic band in the coronal plane.

4. Posterior hip: Evaluated with the patient in the prone position. Important
structures to evaluate include: the hamstring muscles and the sciatic nerve.
Examination starts in the transverse plane with the transducer positioned at
the ischial tuberosity to identify the hamstring tendon complex, where no
distinction can be made between each individual tendon. The sciatic nerve is
a lateral flattened structure with fascicular echotexture. As the transducer is

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moved caudally, distinction between individual hamstring tendons is achieved

with the semimembranosus tendon located deep and medially in relation to
the conjoined tendon complex of the biceps femoris and semimembranosus.
Sonographic appearance of this conjoined tendon complex is a hyperechoic
line that separates the laterally located biceps femoris muscular belly from the
medially located semimembranosus muscular belly.

6.3 Gluteal tendons

The gluteus medius and gluteus minimus tendons are part of the lateral com-
partment of the hip. The gluteus medius tendon inserts at the lateral and supero-
posterior facets of the greater trochanter of the femur, while the gluteus minimus
tendon inserts at the anterior aspect of the greater trochanter. Ultrasound shows
the gluteus medius tendon as a hyperechoic structure arising from a fan shaped
hypoechoic structure that represents the gluteus medius muscle. The gluteus
medius and minimus muscles are separated by an echogenic layer of fascia and
adipose tissue [26].
The gluteus medius and minimus are the most commonly affected tendons of
the hip abductor group that cause greater trochanteric pain syndrome [28]. Gluteus
tendon abnormalities may be due to acute injury or chronic wear and tear of the hip
joint. Therefore, it typically affects women in the middle and elderly age groups.
MRI is the gold standard imaging modality for the identification of gluteus
tendon tears (Figure 6). Axial and coronal T2W fat saturated images of the hip and
coronal T1WI of the pelvis are recommended when abductor tendon pathology is
suspected [29]. MRI diagnostic criteria for tendon tears include discontinuity of the
tendon, elongation of the gluteus medius 2 cm or greater and T2 hyperintensities
superior to the level of the greater trochanter of the femur [27]. Additional MR
findings, although nonspecific, may include atrophy of the adipose tissue, changes
of the adjacent bone structures and fluid collection within the bursa.

Figure 6.
T2 fat saturated axial image shows a full thickness tear of the gluteus medius tendon as a fluid-filled defect
along the greater trochanter.

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Tendons

6.4 Iliopsoas tendon

The psoas major and iliacus muscles form the iliopsoas tendon complex. The
psoas major originates at the transverse processes of L1-L5 vertebrae; while the ilia-
cus muscle has various origins, including the superior two thirds of the iliac fossa,
the anterior sacroiliac ligaments, and the anterior sacral ala. This tendon complex
inserts at the lesser trochanter of the femur.
The iliopsoas tendon has an echogenic sonographic imaging appearance, with
anterior extension in relation to the anterior-superior acetabular labrum [28]. On
MRI sequences, the iliopsoas tendon complex is characteristically identified as two
parallel homogeneously hypointense structures, separated by a hyperintense region
that represents adipose tissue of the fascia [28].
Snapping iliopsoas tendon is characterized by an audible or palpable painful
snap with movement of the hip. Repetitive movements of the hip serve as predis-
position to develop a snapping tendon, such as those performed by young athletes
in different sports, with ballet dancers being the most commonly affected [30].
Iliopsoas tendon as the source of a snapping hip is classified as an internal cause of
the broader term snapping hip syndrome. It may get trapped during movement due
to a prominent iliopectineal eminence, an insertion site osseous projection or the
anterior inferior aspect of the iliac spine [30].
Dynamic evaluation of the hip joint with US and MRI allows the identification
of the source of snapping iliopsoas tendon. Sonographic evaluation is performed
with a high-frequency transducer (linear 5–12 MHz) placed in the transverse
oblique plane, above the hip joint and parallel to the pubis [28]. The patient is in
the supine position, with initial static evaluation performed following the iliopsoas
tendon until reaching its insertion at the lesser trochanter. Dynamic evaluation is
performed while the ipsilateral leg is moved from the “frog leg” position (exten-
sion, adduction, and internal rotation) to the neutral position (flexion, abduction,
and external rotation). The position of the iliopsoas tendon can be traced along
the anterior compartment of the hip as the leg is moved from the aforementioned
positions and snapping occurs. Regarding MRI examination for this particular
pathology, fast GRE sequence allows dynamic evaluation of the iliopsoas tendon
during movement [28]; change from “frog leg” to neutral position is also performed
during this MRI sequence.

6.5 Hamstring tendons

The hamstring tendon complex is located at the posterior compartment of the

hip, formed by three muscles groups: biceps femoris, semimembranosus and
semitendinosus. The biceps femoris is composed of a short and a long head.
Origin of the short head is at the lateral linea aspera of the posterior femur, the
lateral supracondylar line and the intermuscular septum [31]. The long head
shares origin with the semitendinosus tendon at the inferomedial facet of the
ischial tuberosity to form a conjoint tendon. Distal biceps femoris tendon inserts
at the lateral fibular head and lateral condyle of proximal tibia, while the semi-
tendinosus inserts at the anteromedial aspect of the tibia, sharing insertion with
the gracilis and sartorius muscles to form the pes anserinus tendons [32]. The
semimembranosus tendon originates at the superolateral ischial tuberosity and
has several insertion sites through tendinous arms [31]. The anterior, direct, and
inferior arms insert at the medial condyle of the tibia. The capsular arm inserts
at the posterior oblique ligament. There is also insertion into the posterior joint
capsule and arcuate ligament through the oblique popliteal ligament.

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On MRI sequences at the level of the ischial tuberosity, the hamstring tendons
are identified as well-defined round areas of low signal intensity, where the conjoint
tendon is posteromedial to the semimembranosus tendon [31].
The hamstrings are the most commonly injured muscle group in athletes, with
tendon avulsion as the most severe injury diagnosed with medical imaging, requiring
prompt surgical management. Avulsion injuries are defined as complete tear of the
tendon from its osseous insertion site and typically affect the hamstrings proximally,
particularly the conjoint tendon. This type of injury can include pulling of a bone
piece by the torn tendon, which most commonly occurs in children due to presence
of growth plates. MRI is the gold standard for examination of suspected hamstring
tendon avulsion. Evaluation approach involves identifying the affected tendon and
determining whether a partial or full thickness tear occurred. In the case of full thick-
ness tears, distal tendon retraction, degree of underlying tendinopathy, and proxim-
ity of the tear to the sciatic nerve must be included in the evaluation approach [32].

7. Ankle

7.1 MRI protocol

The ankle tendons are visualized as low signal intensity structures in all MR
sequences. The T1WI sequences are used to evaluate the anatomy and the T2W
sequences are used to assess abnormal increase in fluid, usually related to tendon
pathology [33]. Axial images are used to evaluate morphologic features of the tendons
and synovial sheath distention, longitudinal splits, fluid within the tendon sheath,
and adjacent soft tissue abnormalities, if any. For evaluating the Achilles tendon,
sagittal images prove most useful. Sagittal images also assess the proximal-to-distal
extent of tendon pathologies. Oblique coronal or short axis images at the level of the
mid- and forefoot are best for assessment of the tendons distal to the ankle [33, 34].
When the normal tendons form an angle of approximately 55° with the main
magnetic vector, it produces increased signal intensity within the tendons. This
phenomenon is called the magic angle, more commonly in sequences with echo
times less than 20 msec (T1WI, PD or GRE). This effect is particularly common
with ankle tendons because of their curvatures around the ankle joint [33, 34].
For general purposes, an ankle MRI should include at least the following: axial
T1WI or PD sequences and fat-suppressed T2WI, coronal T1WI or fat-suppressed
T2WI and IR sagittal images [34].

7.2 Ultrasound examination technique

1. Peroneal tendon: Evaluated with the patient in the supine position with the
knee semi-flexed and the ankle in internal rotation. For evaluation of the
plantar aspect of the peroneus longus tendon, the patient should be in
the prone position [35]. Both peroneal tendons are examined with linear
transducers in their short and long planes. The transducer is placed behind the
lateral malleolus over the tendons to examine their short-axis first. The trans-
ducer should be tilted along the way, to maintain the perpendicular position
of the US beam. The tendons should be evaluated upwards for approximately
5 cm and downwards into the inframalleolar region [34, 36, 37].

2. Posterior tibial tendon: Evaluated with the patient in a seated position with
internal rotation of the plantar surface of the foot. If this position cannot be

15
Tendons

achieved, the patient may lie supine with the foot slightly laterally rotated.
Placing the transducer in short-axis/transverse position behind the medial
malleolus, evaluate the posterior tibial tendon following it from its myotendi-
nous junction into its insertion [36].

3. Achilles tendon: Evaluated with the patient in prone position and the
foot hanging from the examination table. With the transducer, follow the
tendon from its myotendinous junction downward to its calcaneal inser-
tion in both the short and long planes. The size of the tendon should only
be obtained in the transverse plane [36].

7.3 Peroneal tendon

The peroneal tendons are the third most commonly injured tendons of the ankle.
Acute and chronic tears occur in young, athletic patients due to overuse or in older
patients with multifactorial degenerative wear and tear. Due to their course and
location, calcaneal fractures predispose to partial tears, entrapment and dislocation
of the peroneal tendons. Tendinopathy more commonly affects the peroneus brevis
tendon. Split peroneus brevis syndrome represents a longitudinal tear of the tendon
and the term arises from the fact that the peroneus brevis tendon is usually located
anteriorly, is embedded between the peroneus longus and fibula [33, 34, 38].

7.4 Tibialis posterior tendon

The tibialis posterior tendon is the second most commonly injured of the ankle ten-
dons [37]. It should never have more than twice the cross-sectional area of the flexor
digitorum longus tendon. Posterior tibial tendinopathy occurs because of delayed
stretching of the tendon due to chronic micro-tears, and usually occurs in older women
with progressively painful flat-foot. Systemic diseases like rheumatoid arthritis and
diabetes predispose this condition, as for other tendinopathies. On MR and ultrasound
imaging it will appear as tendon thickening with loss of normal echogenicity and
tendon sheath fluid, with increased T2 signal intensity. Imaging pitfalls include: nor-
mal tendon widening at its insertion onto the navicular bone; fluid within the tendon
sheath, mimicking enlargement on T1W sequences; and magic angle phenomenon
[33, 37, 39]. Due to its course and insertion, abnormalities of the navicular bone may
predispose to tibialis posterior tendinopathy; like the type II accessory navicular bone
or os naviculare, which is typically large and closely positioned at the medial pole of the
navicular bone by a synchondrosis, rendering insertion of the posterior tibial tendon
only on this ossicle and not extending into the cuneiforms and metatarsals [36].

7.5 Achilles tendon

The Achilles tendon is the most commonly injured tendon of the ankle (Figure 7)
[37]. It is usually hypointense on all MR sequences, although due to its fascicular
anatomy, a single line may be visible (not on T2WI), mimicking an interstitial tear.
Punctate foci of increased signal intensity may be noted in axial images of the distal
Achilles tendon, which simply are interfascicular membranes. Normal average thickness
is 6–8 mm, which may increase in male, tall and elderly patients. On axial images its
margins are concave for the majority of its course, being more convex proximally to and
at the soleus insertion. Normally, there should be subcutaneous fat between the Achilles
tendon and the skin. Branches of the posterior tibial artery supply the Achilles tendon,
but blood supply diminishes at approximately 2–6 cm proximal to its insertion site,
making this region of decreased vascularity particularly susceptible to ruptures [35, 37].

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Figure 7.
T2 fat saturated sagittal image shows disruption of the distal Achilles tendon with a fluid-filled gap.

Achilles tendinosis is common in runners and jumpers. In Achilles tendinosis

and peritendinosis, the tendon may enlarge. Acute Achilles ruptures more com-
monly occur in patients with chronic tendinopathy; runners, middle-aged women
who engage in sporadic exercise or patients with systemic diseases or chronic
steroid use, resulting in a weakened tendon. Most common site of Achilles tendon
rupture is 2–6 cm proximal to its insertion site, avascular zone, as detailed above.
Acute ruptures show a tendon gap with intermediate signal intensity on T1WI and
increased signal intensity on T2WI, consistent with edema and hemorrhage. In
chronic ruptures the gap is replaced by fat and scar tissue [33, 35, 37]. An acces-
sory soleus muscle may be mistaken with a thickened Achilles tendon, which
differ by their signal intensity on MRI. Achilles tendon thickening may occur after
surgical procedures. There is thickening also with of xanthomas (familial hyper-
lipidemia) that appear as marked tendon enlargement with heterogeneous signal
masses and linear areas of low signal intensity. Haglund’s disease results most
commonly from ill-fitting shoes that compress the distal Achilles tendon, leading
to peritendinous edema, retrocalcaneal bursitis and tendon thickening [37].

8. Conclusion

MRI and US are useful imaging modalities that allow anatomic evaluation of
tendons as well as identification of tendon pathology.

Acknowledgements

Thanks to the University of Puerto Rico School of Medicine Diagnostic

Radiology Department for allowing us to use images from its teaching file.

17
Tendons

Conflict of interest

None.

Acronyms and abbreviations

MRI magnetic resonance imaging

US ultrasound
T1WI T1-weighted image
FSE fast spin echo
T2WI T2-weighted image
PD proton density
GRE gradient echo
APL abductor pollicis longus
EPB extensor pollicis brevis
LCL lateral collateral ligament
IR inversion recovery

Author details

Stephanie C. Torres-Ayala1*, Alvaro Bravo-Martínez1, Amanda P. Marrero-González1,

Luis R. Rodriguez-Ortíz1 and Jorge A. Vidal2,3

1 University of Puerto Rico School of Medicine Diagnostic Radiology, San Juan,

Puerto Rico, USA

2 University of Puerto Rico School of Medicine, Musculoskeletal Radiology Section,

San Juan, Puerto Rico, USA

3 University of Alabama at Birmingham, Emergency Radiology Section,

Birmingham, Alabama, USA

*Address all correspondence to: [email protected]

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms
of the Creative Commons Attribution License (http://creativecommons.org/licenses/
by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.

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Imaging of Tendons
DOI: http://dx.doi.org/10.5772/intechopen.84521

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