Elastography

What is Elastography?

Elastography is an ultrasound procedure that makes the mechanical properties of tissue visible. Unlike classic ultrasound, which primarily images structures, elastography shows how soft or firm a tissue is. This information is helpful in musculoskeletal orthopedics (MSK) because e.g. B. pathologically altered tendons are often softer or unevenly hardened.

• Non-invasive, without radiation
• In real time at the examination bed
• Supplements conventional ultrasound with functional information
• Useful for monitoring progress and for more objective therapy planning

How does elastography work?

There are two established measurement principles in MSK diagnostics: strain elastography and shear wave elastography. Both methods rely on mechanical impulses and measure the tissue response. The difference lies in the type of stimulus and the evaluation.

• Strain elastography: The tissue is minimally compressed using gentle pressure (manual or from the transducer). The system calculates relative deformations and displays them in color (qualitative/relative measurement).
• Shear wave elastography (SWE, including ARFI): Acoustic pulses generate shear waves in the tissue. Elasticity values ​​in m/s or kPa are calculated from their propagation speed (quantitative measurement).

The measurement results are displayed as color maps and numerical values. Soft tissue usually appears different in color than hard tissue (color coding varies depending on the device). Important: Measurements depend on the direction of sound, tissue depth and relaxation of the tissue - standardized implementation is therefore crucial.

Areas of application in orthopedics

Elastography complements the clinical examination and conventional ultrasound, especially for soft tissue complaints. Typical questions:

• Tendons: Achilles tendon, patellar tendon, quadriceps tendon, plantar fascia, gluteal tendons, rotator cuff, biceps tendon
• Muscles: muscle fiber tears/strains, muscle hardening, myofascial trigger areas
• Elbow/Forearm: Epicondylitis (tennis/golfer's elbow), extensor tendons
• Shoulder: Tendinopathies, tendon changes accompanying impingement
• Knee/Thigh: Jumper’s knee, hamstring problems
• Ankle/Foot: Achillodynia, plantar fasciitis
• Scar and connective tissue: assessment of scarring, adhesions and fibrotic areas

Nerves can also be assessed elastographically in certain situations (e.g. in bottleneck syndromes). The significance depends on the indication and must always be interpreted in the context of other findings.

Advantages and limitations

• Advantages: no radiation, available at the bedside, dynamic examination (under movement/tension), quantitative/relative measurements, follow-up monitoring possible.
• Early changes: Soft tissue changes may become visible on the functional image before morphological changes are clear.
• Therapy control: Load build-up, physiotherapy and training plans can be monitored more objectively.

• Limits: dependent on examiner, device and technology; deep structures only limited; not a sole diagnosis – always in conjunction with anamnesis, examination and imaging.
• Influencing factors: tissue temperature, muscle tone, positioning, pre-stretching of the tendon, pressure of the transducer.
• Artifacts: especially at edges, with too much pressure, with restless tissue.

Examination process in our practice

Duration: depending on the region and the question, around 10-25 minutes. The examination is painless. A gel on the skin improves sound transmission. Results are available immediately and will be discussed with you.

Preparation and follow-up

• Clothing: easily accessible clothing (e.g. shorts for knees/Achilles tendon).
• Training: If possible, avoid any very unusual or intense strain on the target region 24 hours before the measurement in order to avoid temporary changes in stiffness.
• Medication/aids: Please bring relevant medication, bandages or insoles; they help with the interpretation of findings.
• After the examination: You have unrestricted mobility; Exercise is usually possible immediately, provided there is nothing medically against it.

Findings and interpretation: What do the values ​​mean?

Depending on the device, elasticities are given in m/s (shear wave velocity) or kPa (modulus of elasticity). Additionally, a color map shows relative differences. There are no universally valid limits for all tendons and situations. What is crucial are standardized measurement conditions, side comparison (right/left) and the progression over time.

• Tendinopathy: Often heterogeneous pattern; Areas with reduced or uneven stiffness may indicate a degenerative-reactive change.
• Muscle injury: Often softer in the acute phase; gradual increase in elasticity as healing progresses; Scar tissue may be locally harder.
• Plantar fascia: Thickening in ultrasound and changed stiffness support confirmation of the findings.

Important: Elastography does not replace clinical examination. Pain, function, resilience and classic imaging together form the basis of a serious diagnosis and treatment recommendation.

Elastography, ultrasound or MRI – what and when?

We usually start with anamnesis, examination and ultrasound (including Doppler). Elastography supplements this basis if functional information is helpful for the question. We consider an MRI if, for example: B. deep structures, complex injuries or intra-articular processes need to be assessed in detail - or if the results would significantly change the therapy.

• Elastography: additional functional information about tissue stiffness, useful for progression and load control.
• Ultrasound: dynamic structural imaging, very good for soft tissue and structures close to the surface.
• MRI: high resolution morphology, good for deep/complex areas; no radiation exposure, but more expensive and less dynamic.

How does elastography help guide therapy?

The objective assessment of tissue stiffness primarily supports conservative orthopedics. The aim is to recognize overload, adapt training and document healing processes - without hasty invasive measures.

• Load build-up: Adjustment of exercise dose and frequency (e.g. eccentric training for tendinopathy).
• Physiotherapy: targeted measures for muscle tension, fascia mobility and coordination.
• Return-to-Sport: Progress measurements can help reduce the risk of increasing the load too early.
• Regenerative procedures: Options such as shock wave therapy, autologous blood/PRP or infiltrations are only considered - if at all - after careful indication assessment and explanation. Elastography can document the progress before and after such measures.

Safety and contraindications

Elastography is a safe, radiation-free procedure. There are no known harmful effects when used properly. Relative limitations may exist in the case of open wounds, severe acute pain in the measurement area or immediately after recent operations when pressure on the tissue should be avoided.

• Pregnancy: Ultrasound is generally considered safe; Elastography is used carefully and according to indications.
• Implants: Prostheses or plates close to the surface can influence the propagation of sound; Measurable areas are selected accordingly.
• Children/adolescents: The method can be helpful in cases of overload caused by sports; The examination is age-appropriate and gentle.

Quality standards and technology

Meaningful elastography requires experience, standardized measurement protocols and appropriate device settings. In our practice we work with modern shear wave and strain technology and document measurement conditions, measurement window (ROI), depth and sound direction. Where appropriate, we carry out side or series comparisons to better identify individual changes.

• Standardized positioning and relaxation/tension depending on the structure
• Multiple measurements to increase reproducibility
• Combination with B-mode, Doppler and functional maneuvers
• Transparent communication of findings with clear recommendations for further action

Common findings and examples

• Achilles tendon: often inhomogeneous, sometimes reduced stiffness during the stimulus phase; Progress measurements during conservative therapy support stress control.
• Patellar tendon: changes near the insertion in jumper’s knee; additional assessment of thickness and blood flow (Doppler).
• Rotator cuff: Tendinopathies with altered stiffness; Suspected rupture requires structural clarification, possibly MRI.
• Plantar fascia: Thickening with altered elasticity supports the diagnosis of plantar fasciitis.
• Muscles: gradual increase in stiffness during the healing phase; Scar plateaus can be specifically addressed with physiotherapy.

These examples are typical, but never replace individual assessment. The clinical relevance is always compared with your complaints and goals.

Location, date and organization

You can find us in Hamburg-Winterhude, Dorotheenstraße 48, 22301 Hamburg. Elastography is part of our differentiated diagnostic offering. Appointments are scheduled in a planned manner to allow enough time for the examination and discussion.

• Please bring preliminary findings (pictures/doctor's letters) with you.
• Write down typical stresses (sports/everyday life) that trigger symptoms.
• Allow some extra time for initial introductions.

Related diagnostics in our practice

For a well-founded assessment, we combine different diagnostic modules depending on the question. These include classic ultrasound, functional diagnostics of nerves and muscles as well as laboratory analyzes if systemic factors are suspected (e.g. inflammation or metabolism).

• Ultrasound diagnostics: structural imaging and dynamic testing
• Neuro & muscle functional diagnostics: classify neuromuscular causes
• Spinal and posture diagnostics: understanding biomechanical relationships
• Laboratory diagnostics including metabolism and inflammation diagnostics, micronutrient and hormone analysis for selected questions
• Imaging supplement: e.g. B. CBCT in appropriate orthopedic indications (not for soft tissue)