https://www.um.edu.mt/library/oar/handle/123456789/5175 Thu, 04 Jun 2026 07:26:07 GMT 2026-06-04T07:26:07Z https://www.um.edu.mt/library/oar/handle/123456789/146083 Title: Supersonic shear wave elastography of human tendons is associated with in vivo tendon stiffness over small strains Authors: Mifsud, Tiziana; Chatzistergos, Panagiotis; Maganaris, Constantinos; Chockalingam, Nachiappan; Padhiar, Nat; Micallef Stafrace, Kirill; Gatt, Alfred Abstract: Supersonic shear wave (SW) elastography has emerged as a useful imaging modality offering researchers and clinicians a fast, non-invasive, quantitative assessment of tendon biomechanics. However, the exact relationship between SW speed and in vivo tendon stiffness is not intuitively obvious and needs to be verified. This study aimed to explore the validity of supersonic SW elastography against a gold standard method to measure the Achilles tendon’s in vivo tensile stiffness by combining conventional ultrasound imaging with dynamometry. Twelve healthy participants performed maximal voluntary isometric plantarflexion contractions (MVC) on a dynamometer with simultaneous ultrasonographic recording of the medial gastrocnemius musculotendinous junction for dynamometry-based measurement of stiffness. The tendon’s force–elongation relationship and stress–strain behaviour were assessed. Tendon stiffness at different levels of tension was calculated as the slope of the stress–strain graph. SW speed was measured at the midportion of the free tendon and tendon Young’s modulus was estimated. A correlation analysis between the two techniques revealed a statistically significant correlation for small strains (r(10) = 0.604, p =.038). SW-based assessments of in vivo tendon stiffness were not correlated to the gold standard method for strains in the tendon>10 % of the maximum strain during MVC. The absolute values of SW-based Young’s modulus estimations were approximately-three orders of magnitude lower than dynamometry-based measurements. Supersonic SW elastography should be only used to assess SW speed for the detection and study of differences between tissue regions, differences between people or groups of people or changes over time in tendon initial stiffness (i.e., stiffness for small strains). Sun, 01 Jan 2023 00:00:00 GMT https://www.um.edu.mt/library/oar/handle/123456789/146083 2023-01-01T00:00:00Z https://www.um.edu.mt/library/oar/handle/123456789/146054 Title: Elastography in the assessment of the Achilles tendon : a systematic review of measurement properties Authors: Mifsud, Tiziana; Gatt, Alfred; Micallef‑Stafrace, Kirill; Chockalingam, Nachiappan; Padhiar, Nat Abstract: Background: Managing and rehabilitating Achilles tendinopathy can be difficult, and the results are often unsatisfactory. Currently, clinicians use ultrasonography to diagnose the condition and predict symptom development. However, relying on subjective qualitative findings using ultrasound images alone, which are heavily influenced by the operator, may make it difficult to identify changes within the tendon. New technologies, such as elastography, offer opportunities to quantitatively investigate the mechanical and material properties of the tendon. This review aims to evaluate and synthesise the current literature on the measurement properties of elastography, which can be used to assess tendon pathologies.; Methods: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, PubMed, Cochrane, Scopus, MEDLINE Complete, and Academic Search Ultimate were searched. Studies assessing the measurement properties concerning reliability, measurement error, validity, and responsiveness of the instruments identified in healthy and patients with Achilles tendinopathy were included. Two independent reviewers assessed the methodological quality using the Consensus-based Standards for the Selection of Health Measurement Instruments methodology.; Results: Out of the 1644 articles identified, 21 were included for the qualitative analysis investigating four different modalities of elastography: axial strain elastography, shear wave elastography, continuous shear wave elastography, and 3D elastography. Axial strain elastography obtained a moderate level of evidence for both validity and reliability. Although shear wave velocity was graded as moderate to high for validity, reliability obtained a very low to moderate grading. Continuous shear wave elastography was graded as having a low level of evidence for reliability and very low for validity. Insufficient data is available to grade three-dimensional shear wave elastography. Evidence on measurement error was indeterminate so evidence could not be graded.; Conclusions: A limited number of studies explored quantitative elastography on Achilles tendinopathy as most evidence was conducted on a healthy population. Based on the identified evidence on the measurement properties of elastography, none of the different types showed superiority for its use in clinical practice. Further high-quality studies with longitudinal design are needed to investigate responsiveness. Sun, 01 Jan 2023 00:00:00 GMT https://www.um.edu.mt/library/oar/handle/123456789/146054 2023-01-01T00:00:00Z https://www.um.edu.mt/library/oar/handle/123456789/145480 Title: Foot orthoses for forefoot pressure reduction and the hypothesized role in calf muscle stretching : a systematic review highlighting an evidence gap Authors: Thiaspras, Loukas; Formosa, Cynthia; Papanas, Nikolaos; Gatt, Alfred Abstract: Background: Excessive forefoot plantar pressures are associated with pain, ulceration risk, and functional limitations in both healthy individuals and those with pathologies such as rheumatoid arthritis (RA). Limited ankle dorsiflexion, often related to gastrocnemius–soleus tightness, may contribute to forefoot overload. Although foot orthoses (FOs) are widely used to redistribute plantar loads, it remains unclear whether the existing evidence includes orthotic interventions designed to promote posterior chain flexibility.; Objective: To systematically evaluate the effectiveness of foot orthoses in reducing forefoot plantar pressure and pressure-time integral (PTI), and to identify whether current evidence addresses orthoses specifically intended to facilitate calf muscle stretching.; Methods: A systematic review was conducted in accordance with PRISMA 2020 guidelines. Five databases were searched up to December 2024. Inclusion criteria encompassed adult populations, studies reporting plantar pressure outcomes, and interventions involving foot orthoses. Methodological quality was assessed using RoB 2 and ROBINS-I tools. Due to substantial clinical and methodological heterogeneity, a meta-analysis was not undertaken and findings were synthesized narratively.; Results: Twelve studies involving 456 participants met the inclusion criteria. No eligible studies directly evaluated orthoses designed to stretch the triceps surae. All included studies reported reductions in peak plantar pressure (PPP) and/or pressure-time integral (PTI). Descriptively, PPP reductions were greater in healthy cohorts (unweighted mean 20.2%) compared to RA populations (14.5%), whereas PTI reductions were descriptively higher in RA participants (22.2% vs. 14.7%). Interventions incorporating metatarsal pads and soft contoured orthoses showed consistent reductions in forefoot loading across studies.; Conclusions: Foot orthoses appear to be consistently associated with reductions in forefoot plantar loading across populations, particularly in individuals with inflammatory or structural pathology. The absence of studies specifically evaluating posterior chain flexibility represents a clear evidence gap. Future research should explore whether orthotic designs combining forefoot offloading with mechanisms that may influence ankle dorsiflexion or posterior chain mechanics could have biomechanical relevance. Thu, 01 Jan 2026 00:00:00 GMT https://www.um.edu.mt/library/oar/handle/123456789/145480 2026-01-01T00:00:00Z https://www.um.edu.mt/library/oar/handle/123456789/145468 Title: An innovative treatment using sterile hyaluronic acid injections to reduce foot ulcer recurrence in patients with diabetes : a pilot study Authors: Hughes, Catherine; Papanas, Nikolaos; Formosa, Cynthia Abstract: To evaluate whether plantar injection of hyaluronic acid using the Curacorn® technique can reduce ulcer recurrence in high-risk patients with diabetes. This pilot study included 14 patients with type 2 diabetes and a history of recurrent healed neuropathic or Charcot-related plantar foot ulcers. All ulcers were healed for at least 4 weeks prior to inclusion. Patients underwent 3-4 treatment sessions using a sterile, cross-linked hyaluronic acid gel implanted beneath previous ulcer sites. They were followed for 6–12 months to assess ulcer recurrence. Seven patients (50%) experienced no ulcer recurrence during the follow-up period of the study. Patients without recurrence received a higher total volume of hyaluronic acid when compared with those who experienced recurrence (mean 7.4 ml vs 3.9 ml). Ulcer recurrence in the remaining patients occurred after an initial ulcer-free period of approximately six months. In this pilot cohort, hyaluronic acid injection using the Curacorn® technique was associated with a reduction in ulcer recurrence, particularly when adequate gel volumes were administered. These findings support further investigation of this minimally invasive approach as a preventive strategy in high-risk diabetic foot patients. Thu, 01 Jan 2026 00:00:00 GMT https://www.um.edu.mt/library/oar/handle/123456789/145468 2026-01-01T00:00:00Z