Estimation of the Achilles tendon twist in vivo by individual triceps surae muscle stimulation

The Achilles tendon (AT) is comprised of three distinct subtendons, each arising from the one of the three heads of the triceps surae muscles: gastrocnemius medialis (GM), gastrocnemius lateralis (GL) and soleus (SOL). These subtendons exhibit a twisted structure, classified as low (Type I), medium (Type II), and high (Type III) twist, based on cadaveric studies. Nevertheless, the in-vivo investigation of AT twist is notably scarce, resulting in a limited understanding of its functional significance. The aim of this study was to give insights into the complex 3D AT structure in vivo. 30 healthy participants underwent individual stimulation of each of the triceps surae muscles at rest with the foot attached to the pedal of an isokinetic dynamometer. Ultrasound images were captured to concomitantly examine the displacement of the superficial, middle and deep AT layers. SOL stimulation resulted in the highest AT displacement followed by GM and GL stimulation. Independent of the muscle stimulated, non-uniformity within the AT was observed with the deep layer exhibiting more displacement compared to the middle and superficial layers, hence important inter-individual differences in AT displacement were noticeable. By leveraging these individual displacement patterns during targeted stimulations in conjunction with cadaveric twist classifications providing insights into the area of each specific subtendon, our classification identified 19 subjects with a low and 11 subjects with a high AT twist. More research is needed to understand the complexity of the AT twisted structure in vivo to further understand its effect on AT properties and behaviour.