The Use of Elastography-Ultrasound in Diagnosing Tendinopathy Related Sport Injury : A 10 Years trend Systematic Review

INTRODUCTIONS: Today, physical exercise is already become a lifestyle to majority of people around the world. In sport injury cases, tendon is one of the most frequent tissues that can be injured during physical exercises. Tendinopathy has been hypothesized as a result from inflammatory changes in the tendon, and secondary to its frequent or excessive use, assigning the label of “tendinitis” or “tendinosis” to such a presentation. For instance, de quervain tenosynovitis found in badminton athlete and professional golfer, tennis elbow as seen in tennis player and jumpers knee in soccer or basketball players. However, tendinopathies condition can also be present in general population such as new moms that can developed de quervain tenosynovitis due to frequently taking care of their baby, or kind of activities like cooking and squeezing which can raised probability of tennis elbow injury. Thus, it is very important for clinical practitioner to diagnosed this kind of injury accurately, starting from history taking, physical examination and also imaging modalities. Ultrasound (US) is one of the most important modality within medical imaging, especially for assessing soft tissues. Elastography-ultrasound (EUS), a recent advancement in ultrasound, is one of modalities that becoming a ‘rising star’ in the medical world. This modalities can be used as diagnostic tool in several organs like liver, breast, spleen, kidney, lymph node, musculoskeletal pathology including muscle, tendon, fascia, ligament, joint, and more specific cases like tumour or carpal tunnel. US has been used for musculo-skeletal diseases showing, in general, a good correlation with the clinical and ultrasound (US) examination, in agreement with the histopathological features of the lesion. It is well understood that, in some cases, it is difficult or even impossible to distinguish pathological tissues using conventional US because these tissues show the same echogenicity with the surrounding normal tissues. There are two major techniques used in musculoskeletal elastography, compressive strain elastography (CSE) and shear-wave elastography (SWE), both can be used to evaluated tendon pathology. In the situation after the operative of tendon rupture, there is an increase in tendon stiffness and according to normal healing process, probably due to the structural disorganisation of collagen fibres, with dominating of type III collagen rather of type I as physiological condition. EUS play a role on post-operative rehabilitation monitoring, as a tool to evaluate and guide ongoing treatments, as example after a surgical repair of a tendon rupture, and to predict the return to previous activities (especially in high-level athletes). OBJECTIVE: The aim of this study is to provide a systematic overview of clinical applications of EUS in normal and pathological condition of tendons. MATERIAL AND METHODS: We search PubMed and Cochrane database in 10 years range between 2009-2019, for articles in English with the search term “Tendinopathy” and “Elastography ”. A systematic research was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We excluded unidentifiable full text, all repeated articles as well as articles not in English. We do not restrict any kind of tendons cases. We also admitted different type of EUS both strain and shear-wave elastography, excluding MRI-elastography. RESULTS: A total of fifty nine articles were identified through several databases search, there were 3 articles removed after duplication screening, 38 articles excluded through title and abstract screening, 8 studies were not included after full text eligibility assessment, thus a total of 10 articles were selected for this systematic review. There is an increasing interest of EUS application for tendon pathology evaluation. Various tendons are amenable for EUS evaluation, such as the Achilles and patellar tendons, rotator cuff, common extensor tendons, rotator cuff tendons, and the plantar fascia. EUS appears to be a new wave in medical imaging that attracts clinician’s attention due to its usefullness on detecting early changes of tendon pathology, but more cost effective modality in terms for tendinopathy detection. From selected articles, shear wave elastography come out as the most frequent and reliable tool (5 articles) by cause of its quantitative result compared to strain elastography which gives qualitative and semi-quantitative outcome. There are various tendon pathology observed from 10 chosen articles, such as follows, 5 articles explain about achilles tendinopathy, 3 elbow tendon pathology, 3 patellar tendon, 1 de quervain tenosynovitis. There are 3 articles that use athlete as the study subject, and 7 use general population. The most used research method was case control study design (4 studies) followed by cross sectional study (3 studies). All of the articles showed that EUS is indeed a helpful tool for tendon pathology diagnosis. Both strain and shear-wave elastography was shown as a reliable EUS technique which give higher sensitivity, specificity and accuracy. EUS can confirms symptomatic tendinopathy, and able to detect tendinitis changes superior to B-mode conventional ultrasound. CONCLUSION: It is a common knowledge that tendinopathies is one of the most common complain at orthopaedic clinic, either related to sport activities or chronic overuse in athletes and general population. EUS can be used as the initial modality to screen any tendon pathology both in athlete and non-athlete, prior to advance imaging such as magnetic resonance imaging (MRI). EUS appears to be a very promising diagnostic tool, particularly in tendon pathology, in the other hand it provides more cost and time effective. This is a dynamic examination, demonstrate an immediate evaluation of the tissue elasticity, and useful in recognizing tendon abnormalities as well as in implementing the information available with conventional US.