2016 EDIZIONI MINERVA MEDICA

Online version at http://www.minervamedica.it The Journal of Sports Medicine and Physical Fitness 2016 December;56(12):1518-25

ORIGINAL ARTICLE
S P O R T I N J U R I E S , R E H A B I L I TAT I O N

Muscle contracture diagnosis: the role of sonoelastography

Daniele BRUSCHETTA 1, Demetrio MILARDI 1, 2, Fabio TRIMARCHI 1,
Debora DI MAURO 1, Andrea VALENTI 4, Alessandro ARRIGO 1, Barbara VALENTI 3, Giuseppe SANTORO 1,
Filippo CASCIO 1, Gianluigi VACCARINO 1, Alberto CACCIOLA 1

1Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Messina, Italy; 2IRCCS Centro
Neurolesi Bonino Pulejo, Messina, Italy; 3Diagnostics Fiumara Centre, Santa Teresa Riva, Messina, Italy; 4Department of Clinical and
Experimental Medicine, University of Messina, Messina, Italy
*Corresponding author: Demetrio Milardi, Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Italy.
E-mail: dmilardi@unime.it

A B S T RAC T
BACKGROUND: Sonoelastography plays today a major role in musculoskeletal disease, showing minor muscle injuries not well appreciable in
conventional B-mode ultrasonography and integrating it in major muscle injuries diagnosis. The aim of this study was to demonstrate the ability
of elastosonography in the diagnosis of muscular contracture in football players presenting negative basic echography.
METHODS: We examined twenty-two football players using basic echography and elastosonography approximately 24-48 hours after the trau-
matic event and we subsequently re-evaluated them after two weeks.
RESULTS: Conventional echography showed, in the early stage, no muscle injuries; in twenty-two out of twenty-two patients, sonoelastography
had instead underlined a heterogeneous colorimetric map, related to decreased elasticity in the area of the muscle contracture. An evaluation
effected 1-2 weeks later showed a clear improvement of the sonoelastographic appearance.
CONCLUSIONS: This information will be useful for prognostication, post-traumatic monitoring and to detect subclinical changes in MIs even
before there are changes on the routine B-mode ultrasound.
(Cite this article as: Bruschetta D, Milardi D, Trimarchi F, Di Mauro D, Valenti A, Arrigo A, et al. Muscle contracture diagnosis: the role of sonoelas-
tography. J Sports Med Phys Fitness 2016;56:1518-25)
Key words: Ultrasonography - Contracture - Muscles - Elasticity imaging techniques.

M uscle injury (MI) is a common pathological event

in competitive sport practice, since it may be a
predictable consequence in those subjects whose prin-
ciple of training is to get higher levels of performance
and to implement muscle endurance resistance;1 whilst,
in people practicing non-competitive sport, it may be
due to inadequate general warm-up, inappropriate phys-
ical preparation and abrupt or violent movements.2 MIs
are classified in minor trauma (contractures, contusions
and elongations) and major trauma (strain of a small
contingent of fibers, partial or total breaks).3 Muscle
contracture is an involuntary, painful and persistent
contraction of one or more skeletal muscles, which rep-
resents a defensive action occurring when the muscle is
stressed beyond its physiological tolerance. The patient
feels a slight or widespread pain in the affected muscle,
involuntary increase in muscle tone and lack of muscle
elasticity during movements. Muscle fibers are overex-
tended till the limit point without muscular fibers strip-
ping, indeed conventional B-mode ultrasound examina-
tion performed in these patients was shown to have a
negative result.4, 5
However, in recent years ultrasound elastography
(USE, Sonoelastography) has assumed a key role in the
diagnosis and follow-up of MIs, allowing to identify the
precise location and extent.6

1518 The Journal of Sports Medicine and Physical Fitness December 2016
SONOELASTOGRAPHY FOR MUSCLE CONTRACTURE DIAGNOSIS BRUSCHETTA
Elastographic techniques used in addition to imaging
techniques (ultrasound, resonance magnetic or optical)
provide new clinical information on the pathological
state of soft tissues.
USE, whose development started about 20 years ago,
aims at imaging tissue stiffness, which provides addi-
tional and clinically relevant information. Initially so-
noelastography used manual compression and allowed
only for qualitative evaluation, now some methods ap-
pear to apply a non-operator dependent compression.
Images are acquired before and after soft compression
of tissues and the deformations are evaluated. Mapping
the stiffness can either be estimated from the analysis
of the strain in the tissue under a stress or by the imag-
ing of shear waves, mechanical waves, whose propaga-
tion is governed by the tissue stiffness rather than by its
bulk modulus7. USE has proven to be highly specific
in the diagnostic evaluation of lesions situated in vari-
ous organs: breast, prostate, thyroid, lymph nodes and
testes,8-17 organs mechanically stressed by either ex-
ternal or internal forces. On these bases it is possible a
qualitative or quantitative evaluation of tissues elastic
properties from the measured displacement of induced
tissue movement. It is also needed to consider several
approaches: 1) manual compression by operator using
the transducer; 2) organ compression by heartbeat or
vascular pulsations; 3) push pulse waves compression;
4) supersonic shear waves.
USE can be classified into four types: quasi-static
compression, dynamic mechanical analysis, vibration-
controlled transient elastography and hyper-frequency
viscoelastic spectroscopy.18 Our work focuses on real-
time static sonoelastography, which applies quasi-static
compression of tissue and simultaneously images it by
means of ultrasound. The vibrations and compressions
are provided physiologically by vascular pulsation and
respiratory motion. The calculation of tissue elasticity
distribution is performed in real-time and the examina-
tion results are colour-superimposed over the conven-
tional B-mode image.
Although the utility of USE in the study of the mus-
culoskeletal system has been demonstrated by several
studies on muscle stiffness,19, 20 degenerative altera-
tions of the Achilles tendon,21 neuromuscular disease 5
and lateral epicondylitis,22 to the best of our knowledge,
there are no previous reports of USE findings of muscle
contracture.
Vol. 56 - No. 12 The Journal of Sports Medicine and Physical Fitness 1519
We performed conventional echography and USE in
22 painful subjects 24-48 hours after the trauma to in-
vestigate MIs. Primary aim of this paper is to show the
diagnostic utility of USE in the identification of muscle
contractures and to suggest it as a daily technique, in-
tegrating conventional echography in post-traumatic
events.
Materials and methods
Twenty-two football players with anamnesis and
clinical diagnosis of minor traumatic MI, caused by in-
direct mechanism, underwent to our observation. Each
subject signed an informed consent and the entire study
was approved by our Ethical Committee, which con-
firmed that all examinations were in conformity with
the relevant regulatory standard and that all the proce-
dures that have been followed were in accordance with
the Helsinki declaration of 1975. Conventional echog-
raphy shown negative results, even if patients reported
persistent symptoms of localized pain.
We excluded subjects with positive conventional
echography related to muscle fibers breakdown.
The majority of the examined patients were profes-
sional football players and the traumatic event occurred
during a match. Among the rest of the examined pa-
tients, amateur players, trauma occurred during a run or
a five-a-side football game.
Traumas sites were localized in the thigh and in the
adductor region, indeed the injuries were located in cor-
respondence of the femoris quadriceps, in particular the
rectus femoris in 12 patients, the adductor in 4 patients,
the femoris biceps in 4 patients and semitendinosus in
2 patients.
All patients came to our observation about 24-48
hours after the trauma, in acute and sub-acute phase,
presenting localized, spontaneous or provoked pain,
and inability to contract the traumatized muscle. In
three patients palpable swelling was reported.
One radiologist with 15 years of conventional so-
nography and 5 years of elastosonography experience
performed the examination. Conventional echography
examination was performed by using a Siemens Acu-
son S2000 equipment with small parts probe 7-14 MHz,
integrated by assessment with a high-frequency probe
(18-7 MHz) for the study of muscular stripes and more
shallow soft tissues in thin subjects. An intermediate-
BRUSCHETTA SONOELASTOGRAPHY FOR MUSCLE CONTRACTURE DIAGNOSIS

frequency probe (9-4 MHz) was used for the study of

deep muscular structures in subjects presenting high
percentage of body fat and muscular mass. First, ultra-
sound examination was performed during muscle relax-
ation status, then in active or passive contraction phase.
Sonoelastography was performed by gently compress-
ing the heel with the hand-held transducer. The force
applied to the heel was adjusted according to the quality
factor set on the machine, which was displayed on the
screen in real time. The optimal compressive force was
indicated by a quality factor 60.23 During the examina-
tion, the elastogram appeared within a rectangular re-
gion of interest as a color-coded image superimposed A
over the B-mode image. The elastography image was
represented by color-coding. Color scale ranged from
red (elastic tissues-areas with significant deformation)
to blue (rigid elements-areas with low distortion); green
indicated intermediate degrees of elasticity. The con-
ventional B-mode ultrasound image was displayed on
the left side of the screen while the color-coded real
time sonoelastogram was depicted on the right side of
the screen. For each area of interest were recorded 4 im-
ages. In all patients, examination was also complement-
ed by eco-color-Doppler with parameters modulation
for the study of slow flows. The eco-color-Doppler was
useful to document, in some of the cases, the presence B
of reactive vascular signals, especially referred to inter-
fascial connective tissue. The integration of eco-color-
Doppler resulted therefore aspecific and less helpful to
confirm diagnosis of muscle contracture.

Results

Conventional echography resulted negative in nine-

teen patients, without visualization of muscular lesions
(Figure 1A). In three patients with palpable tumefac-
tion, during muscle contraction, a nuanced structural
diffused hypoechogenicity of muscle fibers was found,
surrounded by adjacent regions mildly hyperechogen-
ic. These areas of hypoechogenicity presented a faded
aspect of the fascia and the inter-muscular connective
tissue, with indicative traces of edema, not present con-
tralateral (Figure 1B, C). In all patients, examination
was also complemented by echo-color-Doppler with
parameters modulation for the study of slow flows and
by USE (Figure 2), which underlined a decreased elas-
ticity of the painful muscular region, corresponding to
C
Figure 1.Axial Scan of rectus femoris muscles. A) Negative ultra-
sound test; B) conventional B-mode echography of semitendinosus
muscle shows ipoechogenicity with other adjacent widespread ipere-
chogenic area, signs of edema; C) axial scan of semitendinosus muscle
fibers that documents nuanced hyperechogenicity.
the color blue in the colorimetric map (Figure 2A). The
eco-color-Doppler documented in some of the cases,
the presence of reactive vascular signals, especially
referred to inter-fascial connective tissue (Figure 2B).

1520 The Journal of Sports Medicine and Physical Fitness December 2016
SONOELASTOGRAPHY FOR MUSCLE CONTRACTURE DIAGNOSIS BRUSCHETTA
A
B
Figure 2.Axial Scan of rectus femoris muscles. A) Elastosonographi-
cal study highlights decreased elasticity of painful muscle region, cor-
responding to blue in the colorimetric map; B) eco color Doppler shows
signs of vascular reaction.
The integration of eco-color-Doppler resulted therefore
aspecific and less helpful to confirm diagnosis of mus-
cle contracture.
In twenty-two out of twenty-two patients, USE has
instead evidenced decreased elasticity in painful mus-
cular region, corresponding to a heterogeneous colori-
metric map, indicative of low elasticity and therefore
poor contractile function of the interested muscle region
(Figure 3A, 3B). The blue color is indicative of mus-
cular rigidity and contracture (Figure 3A). Color distri-
bution is graphically represented for each figure. This
color detection was not appreciable into not painful,
contiguous muscles, and even within the same muscle,
in the upstream and downstream portions of the region
affected by painful symptoms.
These findings suggest that muscle contracture is not
detectable by using conventional echography, but it can
be revealed by the expert use of USE, through which
Vol. 56 - No. 12 The Journal of Sports Medicine and Physical Fitness 1521
muscle contraction is displayed as a reduction of the
elasticity in the traumatized muscle region (Figure 4A),
compared to the contralateral one (Figure 4B). Indeed,
the contralateral pain free muscle showed signals of
good elasticity, as clearly represented by the graphical
color distribution.
USE check-up at 1-2 weeks showed a gradual nor-
malization of the colorimetric map with an increase of
the color green, as shown in (Figure 4C).
Discussion
Ultrasound examination is universally accepted as a
first level exam for the study of muscle-skeletal system,
playing a major role in the dynamic evaluation of muscle
components, which cannot be revealed by other imag-
ing techniques. Muscle ultrasound is a non-invasive and
real-time technique to visualize normal and pathological
muscular tissue (i.e. traumatisms and neuromuscular dis-
orders).24 Traumatic muscle pathology includes different
types of damage: there is contusion in case of direct trau-
ma, and contracture, stretching, tearing and breaking, in
case of indirect trauma.25 Muscle contracture is an invol-
untary, painful and persistent contraction of one or more
skeletal muscles, which appear rigid and hypertonic. The
contraction is itself a defensive reaction occurring when
the muscle tissue is stressed beyond its physiological en-
durance limit, since the overload induces the muscle to
contract. Predisposing factors can be mechanics or meta-
bolic, but their involvement is still unclear.26 The most
important biochemical finding is a marked decrease in
the ability of the sarcoplasmic reticulum to accumulate
calcium ions. The concentration of muscle phosphory-
lase is normal, but the ratio of the active form is unusu-
ally high, as well as venous-blood lactate during rest.4
Contracture frequently appears to be a consequence
of a lack of general or specific warm-up, inappropri-
ate physical preparation, excessive stress, sudden and
violent movements, joints problems, and postural and
muscular imbalances. It is therefore a very common
pathological event in sport practice, mostly affecting
lower limbs, especially quadriceps femoris muscles and
triceps surae muscles.
The lesion is characterized by metabolic intracy-
toplasmic changes of myofibrillar and mitochondrial
structures, in addition to the involvement of connective
tissue.27, 28
BRUSCHETTA SONOELASTOGRAPHY FOR MUSCLE CONTRACTURE DIAGNOSIS

Figure 3.Elastosonographic evidence of elasticity reduction of painful muscle region, shown as heterogeneous colorimetric map. The color blue
indicates muscular stiffness and contracture. Color distribution is graphically represented.

What happens is simply a permanent and involuntary
increase of the muscle tone, which is perceived quite
clearly and the athlete complains of a lack of muscle
elasticity during movements, inability to contract the
injured muscle, and modest and widespread pain.
In this situation, the conventional B-mode ultrosound
examination shows no detectable echo-structural altera-
tions.
However, since the border between contracture and
stretching is thin and it may happen that a simple hy-
pertonus hides the elongation of some muscle fibers,
the conventional investigation plays still a major role in
excluding fibers breaking.
Contraction may be followed by a marked increase
of the thickness of the interested muscle, due to the ex-
tensive edema, which is shown by conventional echog-
raphy as a nuanced hypoechogenicity of the interested
muscle, compared to the contralateral one, and with
some signals of peripheral vascular reactivity at the eco-
color-Doppler investigation. In addition, magnetic reso-
nance imaging (MRI) allows to clearly point interstitial
edema out by using fat-suppressed sequences.
It is noteworthy that diagnosis of muscle contracture
can be improved today by USE, a recently developed re-
al-time technique for in vivo imaging of the distribution
of tissue strain and elastic modulus.29 The conventional
ultrasound examination uses less than 15% of the infor-
mation contained in the native ultrasound RF signal.
USE provides information on tissue stiffness, which
is independent from the acoustic impedance and vas-
cular flow information provided by B-mode and Dop-
pler imaging, since it originates from the deformations
induced by the operators hand (slight compression or
vibration).30 The only technique currently able to com-
pete with USE is the Magnetic Resonance elastography,
which is not limited by the presence of bone or gas, is
sensitive to the omnidirectional movement with volu-
metric acquisitions at high speed, can be performed by
relatively inexperienced staff and gives a clear inter-
pretability of data. However, USE is relatively fast and
more accurate and precise; access to equipment is easier
for the operator and for the patient and overall costs for
investigation are much lower;31 it is used for several pa-
thologies with good results: prostate cancer,32 thyroid

1522 The Journal of Sports Medicine and Physical Fitness December 2016
SONOELASTOGRAPHY FOR MUSCLE CONTRACTURE DIAGNOSIS BRUSCHETTA

Figure 4.Elastosonographic evidence of elasticity reduction of the painful muscle (A), compared to the contralateral one (B). The latter shows an
intermediate signal of good elasticity. Colorimetric distribution is graphically represented; C) elastosonographic examination after 1-2 weeks shows
a gradual normalization of the colorimetric map with an increase level of the color green in painful muscle.

cancer,33 azoospermia,34 breast lesions 35 and neuromus-
cular disorders.36, 37
USE image is represented on the monitor by a color
window overlapped to the B-mode image, associated
with an elastogram, in which blue is used for econding
hard tissues, red for soft tissues, and yellow/green for
tissue of intermediate stiffness. The colorimetric repre-
sentation better depicts information provided by tradi-
tional examination but not perceptible in its entirety by
the human eye: B-mode ultrasound provides a different
representation of the various tones of gray, closely re-
lated to the refractive power of the ultrasound beam by
the tissues, which can be just partially discriminated.
The elasticity of a material describes its tendency to
deform itself and to resume its original size and shape
after being subjected to a deforming force (stress). The
resulting difference in size or shape is known as strain
and expressed as ratio (e.g. change in length per unit
length).30 In particular, muscle elasticity corresponds to
the ability to stretch through its contractile elastic ele-
ments.
In painful patients with muscle contracture, the in-

Vol. 56 - No. 12 The Journal of Sports Medicine and Physical Fitness 1523
BRUSCHETTA SONOELASTOGRAPHY FOR MUSCLE CONTRACTURE DIAGNOSIS
elastic area of contracture can interest just one portion
of the muscle, with preserved regular elasticity of the
muscle tissue located upstream and downstream of the
region concerned. In muscle ruptures, ultrasound exam-
ination shows the presence of structural inhomogeneity
and hemorrhage zones, appearing in muscular trauma as
homogeneous areas, very soft on elastographic image.
In addition, USE is proving to be useful in dynamic
for evolution of MIs, showing perilesional irregular
areas of different elasticity, which bi-dimensional ul-
trasound could reveal as normal. Indeed, lesions with
favorable evolution are usually characterized by a soft
elastic ribbed appearance, whilst fibrosis causes a wide
range perilesional predominantly stiff appearance (blue
image elastography) in which soft areas (red image elas-
tography) could be present, depending on lesion length.
In this study, we found a correspondence between the
muscle painful region and the elastic area of USE. This
finding confirmed the hypothesis of muscle contracture
and directed us to a favorable prognosis. Indeed, about
1-2 weeks later we noted the complete regression of the
pain symptomatology and of the partial loss of muscle
function. In addition, USE showed a regular elasticity
of the muscle fibers involved.
Limitations of the study
However, this study has several limitations. First, it
is noteworthy that several artifacts can be encountered
during the USE examination of skeletal muscles, such
as red lines appearing at the interfaces between adjacent
muscles, due to tissue shifting; fluctuation at the edges
of the elastogram and at the medial and lateral borders
of thin structures due to out-of-plane movement of the
transducer.38, 39 These artefacts have been minimized by
aligning the transducer head and the area of interest par-
allel to the floor during tissue compression and by over-
lapping elastograms so that the results of the borders
can be excluded from the elastogram analysis.
Second, axial-strain sonoelastography technique
suffers from operator dependency, which represents a
technical obstacle to reproduce the sonoelastographic
images. However, the system allows a stable evaluation
of stiffness/elasticity, as shown by the color distribution
within the area of interest.
Third, this technique is not able to provide quantifica-
tion of sonoelastography data.
1524 The Journal of Sports Medicine and Physical Fitness December 2016
Finally, this is a preliminary study on a limited num-
ber of muscle injured subjects, although it is meaningful
as a novel way for diagnosis and also for rehabilitation
in muscular traumas.
The strength of this method is that sonoelastography
may be used as a routine practice during sonographic
examination for MI, since it is low-cost, it allows fast
scan time and it may increase the diagnostic accuracy
of conventional US by supplying information about the
elasticity of muscle tissue.40, 41 However, future longi-
tudinal studies including a wider sample of patients are
needed to improve our findings.
USE can provide valuable information for patients
with MIs and appropriate treatments thus ameliorating
elasticity properties of the injured muscles.
Conclusions
USE is a useful imaging technique that produces
muscle elasticity maps, and its use as a diagnostic pro-
cedure is based on the premise that pathological pro-
cesses as MIs alter the physical characteristics of the
involved tissue.
All these evidences suggest that the muscle-skeletal
USE completes the conventional B-mode ultrasonog-
raphy, and it is able to provide functional information
about muscle and tendineous tissues, being able to re-
veal minors traumatic pathologies (i.e. elongation and
muscle contracture).
This information will be useful for prognostication,
post-traumatic monitoring and to detect subclinical
changes in MIs even before there are changes on the
routine B-mode ultrasound.
It is likely that USE may help to clear many diagnosis
doubt and facilitate follow-up evaluation as a relatively
accurate, non-traumatic and non-expensive technique.
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