Ultrasonographic measurements of the achilles tendon and talar condylar cartilage thickness in paraplegics and healthy controls

Ultrasonographic measurements of the achilles tendon and talar condylar cartilage thickness in paraplegics and healthy controls | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Ultrasonographic measurements of the achilles tendon and talar condylar cartilage thickness in paraplegics and healthy controls Serdar Kılınç, Burak Öztürk, Elif Bahadır This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8263278/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Study Design: The study was a cross-sectional study. Objectives The aim of the study is to ultrasonographically measure the ankle talar cartilage and achilles tendon thicknesses in paraplegics and to compare them with the healthy population. Setting: Clinical evaluations were conducted in the physical therapy and rehabilitation department. Methods Twenty-four paraplegics and twenty-four healthy controls with similar demographic characteristics were included in the study. The age, gender, body mass index, educational status, and the talus cartilage and achilles tendon thicknesses measured by ultrasonography of all participants were recorded. Results The mean right talar cartilage thickness was 0.97 (0.23) mm in paraplegics > 24 months, whereas it was 1.1 (0.44) mm in paraplegics 24 months (p < 0.05). The mean right proximal Achilles tendon thickness was 4.90 mm ± 1.13 in paraplegics 24 months. In comparisons with the control group, while the right proximal Achilles tendon thickness was significantly thicker in paraplegics with a paraplegia duration of less than 24 months (p 0.05). Conclusions The detection of thinning in the talar cartilage in patients with a paraplegia duration of > 24 months may be helpful for the early recognition of long-term talar cartilage degeneration or the possible development of ankle joint problems. The study was registered with the number NCT05483764. Health sciences/Neurology/Neurological disorders/Spinal cord diseases Health sciences/Anatomy/Musculoskeletal system/Cartilage Health sciences/Anatomy/Musculoskeletal system/Tendons Paraplegia talar cartilage thickness achilles tendon thickness ultrasonographic measurements the American Spinal Injury Association scale Figures Figure 1 Figure 2 Figure 3 Introduction Spinal cord injury (SCI) is one of the most devastating conditions affecting an individual's quality of life. Approximately 40 million people worldwide experience a spinal cord injury each year [ 1 ]. After SCI, contractures, periarticular osteoporosis, heterotopic ossification, osteoarthritis, and changes in the periarticular soft tissue are observed due to long-term immobility [ 2 ]. When the effects of immobilization on muscle and tendon structure are examined, it is well known that it leads to a rapid loss in muscle volume and muscle strength, and that this negatively affects muscle function [ 3 ]. However, the studies conducted on its effect on tendon structure are limited and their results are contradictory [ 4 – 6 ]. The matrix components required for the preservation of the natural morphological and biomechanical properties of the articular cartilage are synthesized by chondrocytes. For chondrocytes to produce matrix, repeated mechanical loading on the joint is required. When loading is eliminated with immobilization, it is thought that cartilage degradation increases and degeneration accelerates [ 7 ]. Musculoskeletal ultrasonography (US) has become increasingly important in the examination of articular cartilage due to its easy accessibility, low cost, ability to provide dynamic evaluation, and ability to allow bilateral comparison [ 8 ]. In the studies available in the literature, talus cartilage thickness has been measured in healthy individuals, in hemiplegic patients, in individuals with poliomyelitis, in patients with cerebral palsy, in the contralateral extremities of amputee patients, and in some rheumatological diseases [ 9 – 13 ]. One of these studies was conducted in patients with diplegic cerebral palsy, and in the evaluations, the talar cartilage thickness was found to be thinner compared to the healthy control group [ 11 ]. However, the small number of studies in the literature and the fact that their results differ from one another draw attention. For this reason, it is seen that studies investigating the effects of diseases causing immobility on joint cartilage and tendon structures are needed. Considering that one of the main goals in the rehabilitation of the paraplegics is to increase mobilization, we think that knowing the tendon and cartilage characteristics of load-bearing joints such as the ankle will contribute to the conduct of the rehabilitation process. To the best of our knowledge, ultrasonographic measurements of talus cartilage and Achilles tendon thickness in paraplegics have not been performed before. We established our hypothesis in the direction that there would be a difference between paraplegic and control group patients in terms of talar cartilage and Achilles tendon thicknesses. Therefore, we aimed to investigate whether the immobilization that develops in paraplegics after spinal cord injury has an effect on talus cartilage and achilles tendon thicknesses. Methods Participants and Demographic Characteristics The study was designed as a cross-sectional study. It was conducted in accordance with the Ethical Principles of the Declaration of Helsinki. It was approved by the …… University Clinical Research Ethics Committee (2022/184). The study was registered with the number NCT05483764. In the study, the sample size was calculated based on the study titled “Ultrasonographic Measurement of Talar Cartilage Thickness in Patients With Cerebral Palsy,” conducted by Aras et al. in 2020 [ 11 ] using the mean (SD) values of talar cartilage thickness in both groups in that study [Group 1, mean (SD): 0.88 (0.04), Group 2, mean (SD): 0.80 (0.03)]. In this study, using the G*Power 3.1 program, the effect size was found to be 2.26. According to the program, it was calculated that there should be a total of 8 participants, with 4 patients and 4 controls in each group [ 14 – 15 ]. Since we planned a cross-sectional study, in order to reach the maximum sample size that could be achieved, it was planned to include a total of 48 participants, with 24 patients and 24 controls in each group. Accordingly, in our study, the alpha error was planned as 0.05 and the power of the study was planned as 80%. After obtaining ethics committee approval, between August 2022 and August 2024, 24 paraplegic patients who presented to the physical therapy and rehabilitation outpatient clinic and who received outpatient/inpatient treatments in our unit were included in the study. The patients were selected using the simple sampling method. Twenty-four healthy individuals matched to the paraplegics in terms of age, gender, and body mass index (BMI) were included in the control group. The inclusion criteria for paraplegics were: having a traumatic etiology, being between 18 and 75 years of age, having grade A, B, C, or D according to the American Spinal Injury Association (ASIA) scale, and having a neurological injury level at or below thoracic 2. The exclusion criteria were: a history of trauma, infection, arthritis, or surgery in the ankle; having severe spasticity (Grade 4) or contracture; having a history of ankle injection within the last 3 months; having received lower extremity botulinum toxin injection treatment within the last 6 months; and having acquired foot and ankle anomalies. Informed written consent forms were obtained from the patients who participated in the study and from the individuals in the control group. Evaluations Evaluations and ultrasonographic measurements were performed by a physical medicine and rehabilitation specialist experienced in ultrasonographic evaluation of the musculoskeletal system and rehabilitation of patients with spinal cord injury. The demographic data such as age, gender, BMI, and educational status of the individuals in the patient and control groups were recorded. The paraplegics were examined, and their sensory, motor, and neurological levels were noted and classified according to the ASIA scale. The time elapsed after the spinal cord injury was recorded. ASIA scale: ASIA-A:Complete loss of motor and sensory functions, ASIA-B: No motor function but some sensory function is preserved, ASIA-C and ASIA-D: Motor and sensory functions are partially preserved, ASIA-E: Motor and sensory functions are normal. If more than half of the muscles below the neurological level have a muscle strength 3/5, it is classified as ASIA-D [ 16 ]. The patients were evaluated in terms of walking ability using the Walking Index for Spinal Cord Injury (WISCI-II). WISCI-II is a 20-item scale that scores walking ability between 0 and 20 according to the amount of support the person receives while walking and the assistive devices used. A higher score indicates more proper and independent walking [ 17 ]. The Modified Ashworth Scale (MAS) was used in the evaluation of spasticity. In the MAS scale, (0) indicates no increase in muscle tone; (1) indicates a slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected parts are moved in flexion or extension; (1+) indicates a slight increase in muscle tone, manifested by a catch followed by minimal resistance throughout the remainder (less than half) of the range of motion; (2) indicates a more marked increase in muscle tone through most of the range of motion, but the affected parts are still easily moved; (3) indicates a considerable increase in muscle tone, with passive movement being difficult; and (4) indicates that the affected parts are rigid in flexion or extension [ 18 ]. The Barthel Index was used to evaluate activities of daily living. In the Barthel Index, physical independence in activities of daily living such as feeding, bathing, personal care, dressing and undressing, bowel care, bladder care, toilet use, mobility, and going up and down stairs is assessed. It consists of a total of 10 questions scored between 0 and 100 [ 19 ]. Ultrasonographic Measurements Ultrasonographic evaluations were performed by the same physical medicine and rehabilitation specialist in accordance with the criteria of the European Musculoskeletal Ultrasound Study Group (EURO-MUSCULUS), using an 8 MHz linear probe (B-K Medical Ultrasound Scanner Class I Type B). For the measurement of talus cartilage thickness, the patient was placed in the supine position, the knees were brought into 90° flexion, and the foot was positioned flat on the ground. The linear US probe was placed longitudinally just medial to the tibialis anterior tendon. Talus cartilage thickness was determined by measuring the distance between the sharp hyperechoic line at the bone cortex–cartilage interface and the thin hyperechoic line at the fat tissue interface on the obtained image. The cartilage thickness was measured from the tibio-talar joint. Three measurements were taken and the mean value was used (Fig. 1 ). For the measurement of Achilles tendon thickness, the patient was placed in the prone position, with the feet hanging off the examination table, the knees in full extension, and the ankle in the neutral position. The linear US probe was placed horizontally over the Achilles tendon, and the attachment site of the Achilles tendon to the calcaneus was defined as the measurement site for distal Achilles tendon thickness, while the point 3 cm proximal to this site was defined as the measurement site for proximal Achilles tendon thickness. Achilles tendon thicknesses were measured from these regions (Fig. 2 ). The measurements were recorded in millimeters. Standardized data collection procedures were applied and all participants were assessed with the same measurement tools and under the same conditions. Statistical Analysis SPSS software was used for the evaluation and statistical analysis of the data obtained. Descriptive statistics such as mean, standard deviation, median, and frequency were recorded. The Shapiro–Wilk test was used to assess the normality distribution of the variables. Comparative analyses were conducted between the patient and control groups. Subgroups based on disease duration, namely < 24 months and ≥ 24 months, were also analyzed comparatively with the control group. The chi-square test was used to evaluate the relationship between variables; the Mann–Whitney U test was used to determine the difference between the medians of continuous variables belonging to two groups that did not show normal distribution; and the independent t-test was used to determine the difference between the means of variables that met parametric conditions. Quantitative variables were expressed with mean and standard deviation, and qualitative variables were expressed with frequency and percentage. A p-value < 0.05 was considered statistically significant. Results Thirty-five paraplegics were screened for the study. Twenty-four patients met the inclusion criteria (Fig. 3 ). The mean age of the paraplegics was 48 (16) years, and that of the control group was 48 (17) years. In the paraplegic group, 6 were female (25%) and 18 were male (75%); in the control group, 8 were female (33%) and 16 were male (66%). The BMI of the paraplegics was 27 (4.4), whereas that of the control group was 26 (4.4). There was no significant difference between the two groups in terms of age, sex, or BMI (p > 0.05). There was a significant difference between the two groups regarding educational status (p < 0.05). The disease duration of the paraplegics had a mean of 64 (79) months and ranged from 8 to 300 months (Table 1). Table 1: Demographic Characteristics Paraplegia (n = 24) Control (n = 24) p-value Age (years)* Mean (SD) 48 (16) 48 (17) 0.986 BMI (kg/m2)** Mean (SD) 27 (4.4) 26 (4.4) 0.918 Sex*** n (%) Female 6 (%25) 8 (%33) 0.525 Male 18 (%75) 16 (%66) Education*** Illiterate 1 (%4) 0 (%0) 0.014 n (%) Primary school 14 (%58) 7 (%29) Middle school 0 (%0) 1 (%4) High school 9 (%37) 10 (%41) University 0 (%0) 6 (%25) Duration of paraplegia (months) Mean (SD) 64 (79) - - min-max 8-300 - SD : Standard Deviation, Min : Minimum Value, Max : Maximum Value, BMI : Body Mass Index, n : number of participants *Independent Samples t-test, **MannWhitney-U test, ***Chi-square tests p-value < 0.05 was considered statistically significant Spasticity was evaluated according to the Modified Ashworth Scale. The levels of spasticity in the right and left hip flexors, knee extensors, and ankle plantar flexors are shown in Table 2 . Table 2 Modified Ashworth Scale, ASIA Classification, Barthel Index, and WISCI-II Scores of Paraplegics Paraplegics (n = 24) Modified Ashworth Scale Right HF n(%) Left HF n(%) Right KE n(%) Left KE n(%) Right Foot PF n(%) Left Foot PF n(%) 0 10 (%41.7) 8 (%33.3) 9 (%37.5) 8 (%33.3) 6 (%25) 5 (%20.8) 1 8 (%33.3) 9 (37.5) 8 (%33.3) 8 (%33.3) 7 (%29.2) 8 (%33.3) 2 3 (%12.5) 4 (%16.7) 5 (%20.8) 6 (%25) 3 (%12.5) 3 (%12.5) 3 3(%12.5) 3 (%12.5) 2 (%8.3) 2 (%8.3) 8 (%33.3) 8 (%33.3) ASIA scale A 0 (%0) B 3(%12) C 15 (%62) D 6 (%25) E 0 (%0) Barthel Index Mean (SD) 70 (22) WISCI-II scores Mean (SD) 9.4 (5.8) HF :Hip flexor, KE :Knee extensor, PF :Plantar flexor, n : number of participants, SD : standard deviation, ASIA : American Spinal Injury Association, WISCI : Walking Index for Spinal Cord Injury According to the ASIA classification, 3 patients (12%) in the paraplegic group were ASIA-B, 15 patients (68%) were ASIA-C, and 6 patients (25%) were ASIA-D. In the paraplegic group, the Barthel Index score was 70 (22), and the WISCI-II score was 9.4 (5.8) (Table 2 ). In the ultrasonographic evaluations of all paraplegics, no statistically significant difference was observed in the right and left talar cartilage thicknesses compared to the control group (p > 0.05). In the ultrasonographic evaluations of all paraplegics, the right proximal Achilles tendon thickness was significantly greater compared to the control group (p 0.05) (Table 3 ). Table 3 Ultrasonographic Measurements of Talar Cartilage and Achilles Tendon Thickness (mm) Paraplegia Mean (SD) Control Mean (SD) p-value r Right talar cartilage thickness* 1 (0.35) 1.1 (0.18) 0.467 Left talar cartilage thickness* 0.98 (0.28) 1 (0.15) 0.417 Right proximal Achilles tendon thickness* 4.7 (1) 4.2 (0.39) 0.033 0.306 Left proximal Achilles tendon thickness* 4.4 (1) 4.3 (0.56) 0.630 Right distal Achilles tendon thickness** 4.8 (0.73) 4.5 (0.58) 0.123 Left distal Achilles tendon thickness* 4.8 (0.77) 4.5 (0.66) 0.170 SD : Standard Deviation, mm : millimeter, *Independent samples t-test, **MannWhitney-U test p < 0.05 was considered statistically significant. r: Effect size When two subgroups were formed and examined according to the duration of the disease, the mean right talar cartilage thickness was 0.97 (0.23) mm in paraplegics with a duration of > 24 months, whereas it was 1.1 (0.44) mm in those with a duration of 24 months (p < 0.05) (Table 4 ). When two subgroups were formed and examined according to the duration of the disease, the mean right proximal Achilles tendon thickness was 4.9 (1.1) mm in paraplegics with a duration of 24 months. In comparisons with the control group, the right proximal Achilles tendon thickness was significantly greater in paraplegics with a duration of less than 24 months (p 0.05) (Table 4 ). Table 4 Ultrasonographic Measurements of paraplegics 24 Months and the Control Group (mm) Paraplegics <24 Months, and the Control Group (mm) < 24 Months Paraplegics (n = 11) Control (n = 24) p-value r Mean ( SD) Mean ( SD) Right talar cartilage thickness 1.1 (0.44) 1.1 (0.18) 0.778 Left talar cartilage thickness 1 (0.25) 1 (0.15) 0.636 Right Achilles tendon proximal thickness 4.9 (1.1) 4.2 (0.39) 0.012 0.399 Left Achilles tendon proximal thickness 4.3 (1.1) 4.3 (0.56) 0.880 Right Achilles tendon distal thickness 4.7 (0.85) 4.5 (0.58) 0.442 Left Achilles tendon distal thickness 4.9 (0.96) 4.5 (0.66) 0.185 Paraplegics > 24 Months and the control group (mm) > 24 Months Paraplegics (n = 13) Control (n = 24) p-value r Mean ( SD) Mean ( SD) Right talar cartilage thickness 0.97 (0.23) 1.1 (0.18) 0.047 -0.341 Left talar cartilage thickness 0.97 (0.30) 1 (0.15) 0.451 Right Achilles tendon proximal thickness 4.5 (0.99) 4.2 (0.39) 0.219 Left Achilles tendon proximal thickness 4.4 (1) 4.3 (0.56) 0.489 Right Achilles tendon distal thickness 4.9 (0.62) 4.5 (0.58) 0.066 Left Achilles tendon distal thickness 4.7 (0.59) 4.5 (0.66) 0.337 SD: standard deviation, mm: millimeter p < 0.05 was considered statistically significant. r: Effect size Discussion We established our hypothesis based on the expectation that there would be differences in talar cartilage and Achilles tendon thicknesses between paraplegics and healthy individuals comprising the control group. The comparison results demonstrated that paraplegics had a significant increase in the thickness of the right proximal Achilles tendon. However, this was not the case for the other tendon regions or for talar cartilage thicknesses. Additionally, the patients were divided into two subgroups according to the duration of spinal cord injury and were compared with the control group. With respect to talar cartilage thickness, no significant difference was found between healthy individuals and paraplegics with a duration of less than 24 months, whereas paraplegics lasting longer than 24 months demonstrated significantly thinner right talar cartilage. In terms of tendon thicknesses, the right proximal Achilles tendon was found to be thicker in patients with a duration of less than 24 months. Paraplegia resulting from spinal cord injury fundamentally leads to immobility due to lower-extremity weakness. Movement and mechanical loading are essential for preserving the structural and functional integrity of the musculoskeletal system, including joints, surrounding soft tissues, and cartilage [ 3 , 20 , 21 ]. When we examined the literature, we observed that the effects of immobilization on joint cartilage have been investigated, with particular emphasis on the evaluation of distal femoral cartilage. In several studies, it has been reported that cartilage thickness decreases with immobilization [ 8 , 22 – 24 ]. In some studies, however, it has been determined that immobilization does not have a significant effect on cartilage thickness. Yalçın et al. evaluated talar cartilage thickness using ultrasonography in hemiplegic patients with a mean disease duration of 12.7 months and reported that there was no statistically significant difference between the paretic and non-paretic sides [ 9 ]. In our study, however, we detected a marked thinning of the talar cartilage in paraplegics with a duration longer than 24 months. The unique immobilization-related problems that arise in paraplegic and hemiplegic patients, as well as differences in disease duration among the patient populations included in various studies, may have contributed to this situation. Yilmaz et al., in their study evaluating distal femoral cartilage thickness in paraplegics, reported that cartilage thickness was reduced in paraplegics compared with the control group and that this difference was statistically significant [ 20 ]. Vanwanseele et al. examined nine patients with spinal cord injury based on magnetic resonance imaging (MRI) findings and reported that patellar cartilage, the medial and lateral condyles of the distal femoral cartilage, and tibial cartilage thickness were significantly lower compared with the control group. In addition, they demonstrated that cartilage thickness loss increased markedly at the 12th and 24th months following the injury [ 22 ]. In our study, we preferred ultrasonography (US) because of its practical applicability, cost-effectiveness, and easy accessibility. In the evaluation performed with US, we found that the right talar cartilage thickness in paraplegics with a duration longer than 24 months was significantly thinner compared with the control group. Kara et al., on the other hand, measured distal femoral cartilage thickness using US in 46 patients with spinal cord injury and reported that, compared with healthy controls, cartilage was significantly thicker bilaterally in the intercondylar regions and over the left medial femoral condyle in patients with spinal cord injury. In addition, they reported a negative correlation between femoral cartilage thickness and both disease duration and severity. As the reason for the increased thickness of the femoral cartilage, they stated that since patients with spinal cord injury spend long periods sitting in a wheelchair with their knees in a flexed position, the loading pattern of the knee joint changes, and cartilage thickness may increase in the non–weight-bearing regions while decreasing in the weight-bearing regions. In that study, the mean duration of the disease was reported to be 26.5 months [ 25 ]. However, in another study conducted in paraplegics with a longer duration of disease, femoral cartilage thickness was shown to be reduced compared with the control group [ 20 ]. In our study, when we compared patients with a paraplegia duration of less than 24 months with the control group, we observed that talar cartilage thickness was of similar thickness. However, we found that talar cartilage thickness was significantly thinner in patients with a paraplegia duration longer than 24 months, 87% of whom had right lower-extremity dominance, compared with the control group. This situation suggested to us that a longer duration of the disease may have an effect on the talar cartilage in the form of thinning. It is observed that, in the studies being compared, the majority of the patients were classified as ASIA A–B and their WISCI-II scores were low. In our study, however, the majority of the patients consisted of those classified as ASIA C–D, and their WISCI-II scores were higher. These methodological differences may have an effect on the results. There are several studies that have examined immobilization-related changes in tendon structure. When we reviewed the literature, we observed that, alongside studies reporting that tendon thickness decreases with immobilization [ 5 , 26 ], there are also publications indicating that there is no statistically significant difference [ 6 , 26 , 27 ]. Liang et al. measured Achilles tendon thickness in chronic hemiplegic patients at the proximal, distal, and mid-portion. As a result, they reported that there was no significant difference between the paretic and non-paretic sides in the proximal and mid-portion; however, in the distal portion, Achilles tendon thickness was decreased on the paretic side compared with the non-paretic side [ 26 ]. Zhou et al., in their study conducted on rabbits, investigated the effect of immobilization on Achilles tendon thickness and did not detect a statistically significant difference [ 27 ]. Aufwerber et al. reported that, between two groups in whom immediate weight-bearing and ankle joint mobilization were allowed after Achilles tendon rupture surgery and those who were immobilized with a cast for two weeks, no significant difference was observed in terms of Achilles tendon thickness [ 6 ]. In present study, in the general analysis of the paraplegic group, we found that the right proximal Achilles tendon thickness was significantly greater. However, while this difference persisted in patients with a paraplegia duration of less than 24 months, it was not observed in patients with a duration longer than 24 months. When we reviewed the literature, we did not encounter any study demonstrating an association between immobilization and an increase in tendon thickness. We believe that the increase in right proximal Achilles tendon thickness may be due to the lower extremity becoming more vulnerable to mechanical trauma and degenerative changes as a result of decreased muscle strength, reduced sensory and proprioceptive input, and increased degree of spasticity. This situation may arise as a consequence of improper or excessive use. When we reviewed the literature, we could not identify any study evaluating talar cartilage thickness and Achilles tendon thickness in paraplegics. From this perspective, the present study is important as it is the first to determine baseline values for Achilles tendon thickness and talar cartilage thickness in paraplegics and to assess their changes with immobilization. In particular, we observed that in paraplegics lasting longer than 24 months, the talar cartilage thickness of the dominant right lower extremity was significantly thinner. Based on this result, we believe that paraplegics may be at risk for developing osteoarthritis and degeneration in the ankle joint, and early diagnosis and treatment are important for their protection. We think that ultrasonography, as a non-invasive method in early diagnosis, provides valuable information about both cartilage thickness and tendon structure and morphology. A relative limitation of this study is that we measured tendon thickness in cross-section and did not measure the cross-sectional area. The relatively small sample size and the fact that talar cartilage evaluation was performed using cross-sectional thickness measurement, without any volumetric or histological assessment, are additional limitations. Conclusion The detection of talar cartilage thinning in patients with a paraplegia duration longer than 24 months may help in the early identification of long-term talar cartilage degeneration or the development of possible ankle joint problems. We believe that, in the future, comparative evaluations of tendon and cartilage morphology in spinal cord–injured patients with different ASIA impairment levels will contribute to our knowledge on this subject. Declarations Acknowledgements None. Ethical approval and consent to participate The study was conducted in accordance with the principles of the Declaration of Helsinki. Approval was obtained from the ….. University Clinical Research Ethics Committee (Approval No: 2022/184). The study was registered in the ClinicalTrials.gov database with the number NCT05483764. Funding The authors received no financial support for the research, authorship, and/or publication of this article. Declaration of conflicting interests The authors declare that they have no conflicts of interest regarding the conduct of this study, the preparation of the manuscript, or its publication. 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Ultrasonographic measurement of femoral cartilage thickness in patients with spinal cord injury. J Rehabil Med. 2013;45:145–148. Liang JN, Ho KY. Altered Achilles tendon morphology in individuals with chronic post-stroke hemiparesis: a case report. BMC Med Imaging. 2020;20:34. Zhou J, Koike Y, Uhthoff HK, Trudel G. Quantitative histology and ultrastructure fail to explain weakness of immobilized rabbit Achilles' tendons. Arch Phys Med Rehabil. 2007;88:1177–1184. Additional Declarations There is no duality of interest Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 09 Jan, 2026 Editor assigned by journal 09 Dec, 2025 Submission checks completed at journal 09 Dec, 2025 First submitted to journal 07 Dec, 2025 Unknown event 05 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":1726058,"visible":true,"origin":"","legend":"\u003cp\u003eMeasurement of talar cartilage thickness.\u003c/p\u003e\n\u003cp\u003e*: Talar cartilage\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8263278/v1/791c0a0d8474614ea1864103.png"},{"id":100388657,"identity":"8b66dcb6-6fc5-41c4-928f-2a66f3599526","added_by":"auto","created_at":"2026-01-16 11:17:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1690391,"visible":true,"origin":"","legend":"\u003cp\u003eMeasurement of Achilles tendon thickness\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8263278/v1/cf29aee5b98bbe947c6c2258.png"},{"id":100388502,"identity":"5c676193-ac7a-432b-b7ee-82f7ab343b7d","added_by":"auto","created_at":"2026-01-16 11:17:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":773596,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8263278/v1/e2089bd5f72af827dbd82465.png"},{"id":100421693,"identity":"45e0bda4-4df6-434b-bf1f-f38b296e72d0","added_by":"auto","created_at":"2026-01-16 13:44:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6320341,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8263278/v1/c869cfa6-ac79-4880-9dc2-825417ea7115.pdf"}],"financialInterests":"There is no duality of interest","formattedTitle":"Ultrasonographic measurements of the achilles tendon and talar condylar cartilage thickness in paraplegics and healthy controls","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSpinal cord injury (SCI) is one of the most devastating conditions affecting an individual's quality of life. Approximately 40\u0026nbsp;million people worldwide experience a spinal cord injury each year [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. After SCI, contractures, periarticular osteoporosis, heterotopic ossification, osteoarthritis, and changes in the periarticular soft tissue are observed due to long-term immobility [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. When the effects of immobilization on muscle and tendon structure are examined, it is well known that it leads to a rapid loss in muscle volume and muscle strength, and that this negatively affects muscle function [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, the studies conducted on its effect on tendon structure are limited and their results are contradictory [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The matrix components required for the preservation of the natural morphological and biomechanical properties of the articular cartilage are synthesized by chondrocytes. For chondrocytes to produce matrix, repeated mechanical loading on the joint is required. When loading is eliminated with immobilization, it is thought that cartilage degradation increases and degeneration accelerates [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMusculoskeletal ultrasonography (US) has become increasingly important in the examination of articular cartilage due to its easy accessibility, low cost, ability to provide dynamic evaluation, and ability to allow bilateral comparison [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the studies available in the literature, talus cartilage thickness has been measured in healthy individuals, in hemiplegic patients, in individuals with poliomyelitis, in patients with cerebral palsy, in the contralateral extremities of amputee patients, and in some rheumatological diseases [\u003cspan additionalcitationids=\"CR10 CR11 CR12\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. One of these studies was conducted in patients with diplegic cerebral palsy, and in the evaluations, the talar cartilage thickness was found to be thinner compared to the healthy control group [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, the small number of studies in the literature and the fact that their results differ from one another draw attention. For this reason, it is seen that studies investigating the effects of diseases causing immobility on joint cartilage and tendon structures are needed. Considering that one of the main goals in the rehabilitation of the paraplegics is to increase mobilization, we think that knowing the tendon and cartilage characteristics of load-bearing joints such as the ankle will contribute to the conduct of the rehabilitation process.\u003c/p\u003e\u003cp\u003eTo the best of our knowledge, ultrasonographic measurements of talus cartilage and Achilles tendon thickness in paraplegics have not been performed before. We established our hypothesis in the direction that there would be a difference between paraplegic and control group patients in terms of talar cartilage and Achilles tendon thicknesses. Therefore, we aimed to investigate whether the immobilization that develops in paraplegics after spinal cord injury has an effect on talus cartilage and achilles tendon thicknesses.\u003c/p\u003e"},{"header":"Methods","content":"\n\u003ch3\u003eParticipants and Demographic Characteristics\u003c/h3\u003e\n\u003cp\u003eThe study was designed as a cross-sectional study. It was conducted in accordance with the Ethical Principles of the Declaration of Helsinki. It was approved by the \u0026hellip;\u0026hellip; University Clinical Research Ethics Committee (2022/184). The study was registered with the number NCT05483764. In the study, the sample size was calculated based on the study titled \u0026ldquo;Ultrasonographic Measurement of Talar Cartilage Thickness in Patients With Cerebral Palsy,\u0026rdquo; conducted by Aras et al. in 2020 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] using the mean (SD) values of talar cartilage thickness in both groups in that study [Group 1, mean (SD): 0.88 (0.04), Group 2, mean (SD): 0.80 (0.03)]. In this study, using the G*Power 3.1 program, the effect size was found to be 2.26. According to the program, it was calculated that there should be a total of 8 participants, with 4 patients and 4 controls in each group [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Since we planned a cross-sectional study, in order to reach the maximum sample size that could be achieved, it was planned to include a total of 48 participants, with 24 patients and 24 controls in each group. Accordingly, in our study, the alpha error was planned as 0.05 and the power of the study was planned as 80%. After obtaining ethics committee approval, between August 2022 and August 2024, 24 paraplegic patients who presented to the physical therapy and rehabilitation outpatient clinic and who received outpatient/inpatient treatments in our unit were included in the study. The patients were selected using the simple sampling method. Twenty-four healthy individuals matched to the paraplegics in terms of age, gender, and body mass index (BMI) were included in the control group.\u003c/p\u003e\u003cp\u003eThe inclusion criteria for paraplegics were: having a traumatic etiology, being between 18 and 75 years of age, having grade A, B, C, or D according to the American Spinal Injury Association (ASIA) scale, and having a neurological injury level at or below thoracic 2. The exclusion criteria were: a history of trauma, infection, arthritis, or surgery in the ankle; having severe spasticity (Grade 4) or contracture; having a history of ankle injection within the last 3 months; having received lower extremity botulinum toxin injection treatment within the last 6 months; and having acquired foot and ankle anomalies. Informed written consent forms were obtained from the patients who participated in the study and from the individuals in the control group.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eEvaluations\u003c/h2\u003e\u003cp\u003eEvaluations and ultrasonographic measurements were performed by a physical medicine and rehabilitation specialist experienced in ultrasonographic evaluation of the musculoskeletal system and rehabilitation of patients with spinal cord injury.\u003c/p\u003e\u003cp\u003eThe demographic data such as age, gender, BMI, and educational status of the individuals in the patient and control groups were recorded. The paraplegics were examined, and their sensory, motor, and neurological levels were noted and classified according to the ASIA scale. The time elapsed after the spinal cord injury was recorded.\u003c/p\u003e\u003cp\u003eASIA scale: ASIA-A:Complete loss of motor and sensory functions, ASIA-B: No motor function but some sensory function is preserved, ASIA-C and ASIA-D: Motor and sensory functions are partially preserved, ASIA-E: Motor and sensory functions are normal.\u003c/p\u003e\u003cp\u003eIf more than half of the muscles below the neurological level have a muscle strength\u0026thinsp;\u0026lt;\u0026thinsp;3/5, it is classified as ASIA-C; if\u0026thinsp;\u0026gt;\u0026thinsp;3/5, it is classified as ASIA-D [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe patients were evaluated in terms of walking ability using the Walking Index for Spinal Cord Injury (WISCI-II). WISCI-II is a 20-item scale that scores walking ability between 0 and 20 according to the amount of support the person receives while walking and the assistive devices used. A higher score indicates more proper and independent walking [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe Modified Ashworth Scale (MAS) was used in the evaluation of spasticity. In the MAS scale, (0) indicates no increase in muscle tone; (1) indicates a slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected parts are moved in flexion or extension; (1+) indicates a slight increase in muscle tone, manifested by a catch followed by minimal resistance throughout the remainder (less than half) of the range of motion; (2) indicates a more marked increase in muscle tone through most of the range of motion, but the affected parts are still easily moved; (3) indicates a considerable increase in muscle tone, with passive movement being difficult; and (4) indicates that the affected parts are rigid in flexion or extension [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe Barthel Index was used to evaluate activities of daily living. In the Barthel Index, physical independence in activities of daily living such as feeding, bathing, personal care, dressing and undressing, bowel care, bladder care, toilet use, mobility, and going up and down stairs is assessed. It consists of a total of 10 questions scored between 0 and 100 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eUltrasonographic Measurements\u003c/h3\u003e\n\u003cp\u003eUltrasonographic evaluations were performed by the same physical medicine and rehabilitation specialist in accordance with the criteria of the European Musculoskeletal Ultrasound Study Group (EURO-MUSCULUS), using an 8 MHz linear probe (B-K Medical Ultrasound Scanner Class I Type B).\u003c/p\u003e\u003cp\u003eFor the measurement of talus cartilage thickness, the patient was placed in the supine position, the knees were brought into 90\u0026deg; flexion, and the foot was positioned flat on the ground. The linear US probe was placed longitudinally just medial to the tibialis anterior tendon. Talus cartilage thickness was determined by measuring the distance between the sharp hyperechoic line at the bone cortex\u0026ndash;cartilage interface and the thin hyperechoic line at the fat tissue interface on the obtained image. The cartilage thickness was measured from the tibio-talar joint. Three measurements were taken and the mean value was used (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFor the measurement of Achilles tendon thickness, the patient was placed in the prone position, with the feet hanging off the examination table, the knees in full extension, and the ankle in the neutral position. The linear US probe was placed horizontally over the Achilles tendon, and the attachment site of the Achilles tendon to the calcaneus was defined as the measurement site for distal Achilles tendon thickness, while the point 3 cm proximal to this site was defined as the measurement site for proximal Achilles tendon thickness. Achilles tendon thicknesses were measured from these regions (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The measurements were recorded in millimeters.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eStandardized data collection procedures were applied and all participants were assessed with the same measurement tools and under the same conditions.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eSPSS software was used for the evaluation and statistical analysis of the data obtained. Descriptive statistics such as mean, standard deviation, median, and frequency were recorded. The Shapiro\u0026ndash;Wilk test was used to assess the normality distribution of the variables. Comparative analyses were conducted between the patient and control groups. Subgroups based on disease duration, namely\u0026thinsp;\u0026lt;\u0026thinsp;24 months and \u0026ge;\u0026thinsp;24 months, were also analyzed comparatively with the control group. The chi-square test was used to evaluate the relationship between variables; the Mann\u0026ndash;Whitney U test was used to determine the difference between the medians of continuous variables belonging to two groups that did not show normal distribution; and the independent t-test was used to determine the difference between the means of variables that met parametric conditions. Quantitative variables were expressed with mean and standard deviation, and qualitative variables were expressed with frequency and percentage. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThirty-five paraplegics were screened for the study. Twenty-four patients met the inclusion criteria (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe mean age of the paraplegics was 48 (16) years, and that of the control group was 48 (17) years. In the paraplegic group, 6 were female (25%) and 18 were male (75%); in the control group, 8 were female (33%) and 16 were male (66%). The BMI of the paraplegics was 27 (4.4), whereas that of the control group was 26 (4.4). There was no significant difference between the two groups in terms of age, sex, or BMI (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). There was a significant difference between the two groups regarding educational status (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The disease duration of the paraplegics had a mean of 64 (79) months and ranged from 8 to 300 months (Table\u0026nbsp;1).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eTable\u0026nbsp;1: Demographic Characteristics\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eParaplegia (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48 (16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48 (17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.986\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m2)**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (4.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26 (4.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.918\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex*** n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (%25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (%33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.525\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (%75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16 (%66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIlliterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (%4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (%0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"1\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (%58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (%29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (%0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (%4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (%37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (%41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUniversity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (%0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (%25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of paraplegia (months)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64 (79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003emin-max\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8-300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eSD\u003c/b\u003e: Standard Deviation, \u003cb\u003eMin\u003c/b\u003e: Minimum Value, \u003cb\u003eMax\u003c/b\u003e: Maximum Value,\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eBMI\u003c/b\u003e: Body Mass Index, \u003cb\u003en\u003c/b\u003e: number of participants\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Independent Samples t-test, **MannWhitney-U test, ***Chi-square tests\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003ep-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSpasticity was evaluated according to the Modified Ashworth Scale. The levels of spasticity in the right and left hip flexors, knee extensors, and ankle plantar flexors are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eModified Ashworth Scale, ASIA Classification, Barthel Index, and WISCI-II Scores of Paraplegics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003eParaplegics (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModified Ashworth Scale\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRight HF\u003c/p\u003e\u003cp\u003en(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eLeft HF\u003c/p\u003e\u003cp\u003en(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eRight KE\u003c/p\u003e\u003cp\u003en(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLeft KE\u003c/p\u003e\u003cp\u003en(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eRight Foot PF n(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eLeft Foot PF n(%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (%41.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e8 (%33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e9 (%37.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8 (%33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6 (%25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e5 (%20.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (%33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e9 (37.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e8 (%33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8 (%33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e7 (%29.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e8 (%33.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (%12.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e4 (%16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e5 (%20.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6 (%25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3 (%12.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e3 (%12.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(%12.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e3 (%12.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e2 (%8.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2 (%8.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e8 (%33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e8 (%33.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eASIA scale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003e0 (%0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003e3(%12)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003e15 (%62)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003e6 (%25)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003e0 (%0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBarthel Index\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003e70 (22)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWISCI-II scores\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003e9.4 (5.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cb\u003eHF\u003c/b\u003e:Hip flexor, \u003cb\u003eKE\u003c/b\u003e:Knee extensor, \u003cb\u003ePF\u003c/b\u003e:Plantar flexor, \u003cb\u003en\u003c/b\u003e: number of participants, \u003cb\u003eSD\u003c/b\u003e: standard deviation, \u003cb\u003eASIA\u003c/b\u003e: American Spinal Injury Association, \u003cb\u003eWISCI\u003c/b\u003e: Walking Index for Spinal Cord Injury\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAccording to the ASIA classification, 3 patients (12%) in the paraplegic group were ASIA-B, 15 patients (68%) were ASIA-C, and 6 patients (25%) were ASIA-D. In the paraplegic group, the Barthel Index score was 70 (22), and the WISCI-II score was 9.4 (5.8) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the ultrasonographic evaluations of all paraplegics, no statistically significant difference was observed in the right and left talar cartilage thicknesses compared to the control group (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In the ultrasonographic evaluations of all paraplegics, the right proximal Achilles tendon thickness was significantly greater compared to the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), whereas no significant difference was observed between the other Achilles tendon measurements (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eUltrasonographic Measurements of Talar Cartilage and Achilles Tendon Thickness (mm)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParaplegia\u003c/p\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRight talar cartilage thickness*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0.35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.1 (0.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.467\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLeft talar cartilage thickness*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.98 (0.28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (0.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.417\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRight proximal Achilles tendon thickness*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.7 (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.2 (0.39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.306\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLeft proximal Achilles tendon thickness*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.4 (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.3 (0.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.630\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRight distal Achilles tendon thickness**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.8 (0.73)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.5 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.123\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLeft distal Achilles tendon thickness*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.8 (0.77)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.5 (0.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.170\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eSD\u003c/b\u003e: Standard Deviation, \u003cb\u003emm\u003c/b\u003e: millimeter,\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Independent samples t-test, **MannWhitney-U test\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. r: Effect size\u003c/p\u003e\u003cp\u003eWhen two subgroups were formed and examined according to the duration of the disease, the mean right talar cartilage thickness was 0.97 (0.23) mm in paraplegics with a duration of \u0026gt;\u0026thinsp;24 months, whereas it was 1.1 (0.44) mm in those with a duration of \u0026lt;\u0026thinsp;24 months. When compared with the control group, the right talar cartilage thickness was significantly thinner in paraplegics with a duration of \u0026gt;\u0026thinsp;24 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhen two subgroups were formed and examined according to the duration of the disease, the mean right proximal Achilles tendon thickness was 4.9 (1.1) mm in paraplegics with a duration of \u0026lt;\u0026thinsp;24 months, whereas it was 4.5 (0.99) mm in those with a duration of \u0026gt;\u0026thinsp;24 months. In comparisons with the control group, the right proximal Achilles tendon thickness was significantly greater in paraplegics with a duration of less than 24 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while no difference was detected in patients with a duration longer than 24 months (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eUltrasonographic Measurements of paraplegics\u0026thinsp;\u0026lt;\u0026thinsp;24 Months, \u0026gt;\u0026thinsp;24 Months and the Control Group (mm)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003eParaplegics \u0026lt;24 Months, and the Control Group (mm)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;24 Months Paraplegics (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c7\" namest=\"c6\" rowspan=\"2\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMean (\u003c/b\u003eSD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u003cb\u003eMean (\u003c/b\u003eSD)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight talar cartilage thickness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e1.1 (0.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e1.1 (0.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.778\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft talar cartilage thickness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e1 (0.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e1 (0.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.636\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight Achilles tendon proximal thickness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e4.9 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e4.2 (0.39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.399\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft Achilles tendon proximal thickness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e4.3 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e4.3 (0.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.880\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight Achilles tendon distal thickness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e4.7 (0.85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e4.5 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.442\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft Achilles tendon distal thickness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e4.9 (0.96)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e4.5 (0.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.185\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParaplegics\u0026thinsp;\u0026gt;\u0026thinsp;24 Months and the control group (mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e\u003cb\u003e\u0026gt;\u0026thinsp;24 Months Paraplegics (n\u0026thinsp;=\u0026thinsp;13)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e\u003cb\u003eControl\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003er\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e\u003cb\u003eMean (\u003c/b\u003eSD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e\u003cb\u003eMean (\u003c/b\u003eSD)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eRight talar cartilage thickness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.97 (0.23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e1.1 (0.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.047\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.341\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eLeft talar cartilage thickness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.97 (0.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e1 (0.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.451\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eRight Achilles tendon proximal thickness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e4.5 (0.99)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e4.2 (0.39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.219\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eLeft Achilles tendon proximal thickness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e4.4 (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e4.3 (0.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.489\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eRight Achilles tendon distal thickness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e4.9 (0.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e4.5 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.066\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eLeft Achilles tendon distal thickness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e4.7 (0.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e4.5 (0.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.337\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eSD: standard deviation, mm: millimeter\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. r: Effect size\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe established our hypothesis based on the expectation that there would be differences in talar cartilage and Achilles tendon thicknesses between paraplegics and healthy individuals comprising the control group. The comparison results demonstrated that paraplegics had a significant increase in the thickness of the right proximal Achilles tendon. However, this was not the case for the other tendon regions or for talar cartilage thicknesses. Additionally, the patients were divided into two subgroups according to the duration of spinal cord injury and were compared with the control group. With respect to talar cartilage thickness, no significant difference was found between healthy individuals and paraplegics with a duration of less than 24 months, whereas paraplegics lasting longer than 24 months demonstrated significantly thinner right talar cartilage. In terms of tendon thicknesses, the right proximal Achilles tendon was found to be thicker in patients with a duration of less than 24 months.\u003c/p\u003e\u003cp\u003eParaplegia resulting from spinal cord injury fundamentally leads to immobility due to lower-extremity weakness. Movement and mechanical loading are essential for preserving the structural and functional integrity of the musculoskeletal system, including joints, surrounding soft tissues, and cartilage [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhen we examined the literature, we observed that the effects of immobilization on joint cartilage have been investigated, with particular emphasis on the evaluation of distal femoral cartilage. In several studies, it has been reported that cartilage thickness decreases with immobilization [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In some studies, however, it has been determined that immobilization does not have a significant effect on cartilage thickness. Yal\u0026ccedil;ın et al. evaluated talar cartilage thickness using ultrasonography in hemiplegic patients with a mean disease duration of 12.7 months and reported that there was no statistically significant difference between the paretic and non-paretic sides [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In our study, however, we detected a marked thinning of the talar cartilage in paraplegics with a duration longer than 24 months. The unique immobilization-related problems that arise in paraplegic and hemiplegic patients, as well as differences in disease duration among the patient populations included in various studies, may have contributed to this situation. Yilmaz et al., in their study evaluating distal femoral cartilage thickness in paraplegics, reported that cartilage thickness was reduced in paraplegics compared with the control group and that this difference was statistically significant [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Vanwanseele et al. examined nine patients with spinal cord injury based on magnetic resonance imaging (MRI) findings and reported that patellar cartilage, the medial and lateral condyles of the distal femoral cartilage, and tibial cartilage thickness were significantly lower compared with the control group. In addition, they demonstrated that cartilage thickness loss increased markedly at the 12th and 24th months following the injury [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In our study, we preferred ultrasonography (US) because of its practical applicability, cost-effectiveness, and easy accessibility. In the evaluation performed with US, we found that the right talar cartilage thickness in paraplegics with a duration longer than 24 months was significantly thinner compared with the control group. Kara et al., on the other hand, measured distal femoral cartilage thickness using US in 46 patients with spinal cord injury and reported that, compared with healthy controls, cartilage was significantly thicker bilaterally in the intercondylar regions and over the left medial femoral condyle in patients with spinal cord injury. In addition, they reported a negative correlation between femoral cartilage thickness and both disease duration and severity. As the reason for the increased thickness of the femoral cartilage, they stated that since patients with spinal cord injury spend long periods sitting in a wheelchair with their knees in a flexed position, the loading pattern of the knee joint changes, and cartilage thickness may increase in the non\u0026ndash;weight-bearing regions while decreasing in the weight-bearing regions. In that study, the mean duration of the disease was reported to be 26.5 months [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, in another study conducted in paraplegics with a longer duration of disease, femoral cartilage thickness was shown to be reduced compared with the control group [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In our study, when we compared patients with a paraplegia duration of less than 24 months with the control group, we observed that talar cartilage thickness was of similar thickness. However, we found that talar cartilage thickness was significantly thinner in patients with a paraplegia duration longer than 24 months, 87% of whom had right lower-extremity dominance, compared with the control group. This situation suggested to us that a longer duration of the disease may have an effect on the talar cartilage in the form of thinning. It is observed that, in the studies being compared, the majority of the patients were classified as ASIA A\u0026ndash;B and their WISCI-II scores were low. In our study, however, the majority of the patients consisted of those classified as ASIA C\u0026ndash;D, and their WISCI-II scores were higher. These methodological differences may have an effect on the results.\u003c/p\u003e\u003cp\u003eThere are several studies that have examined immobilization-related changes in tendon structure. When we reviewed the literature, we observed that, alongside studies reporting that tendon thickness decreases with immobilization [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], there are also publications indicating that there is no statistically significant difference [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Liang et al. measured Achilles tendon thickness in chronic hemiplegic patients at the proximal, distal, and mid-portion. As a result, they reported that there was no significant difference between the paretic and non-paretic sides in the proximal and mid-portion; however, in the distal portion, Achilles tendon thickness was decreased on the paretic side compared with the non-paretic side [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Zhou et al., in their study conducted on rabbits, investigated the effect of immobilization on Achilles tendon thickness and did not detect a statistically significant difference [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAufwerber et al. reported that, between two groups in whom immediate weight-bearing and ankle joint mobilization were allowed after Achilles tendon rupture surgery and those who were immobilized with a cast for two weeks, no significant difference was observed in terms of Achilles tendon thickness [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn present study, in the general analysis of the paraplegic group, we found that the right proximal Achilles tendon thickness was significantly greater. However, while this difference persisted in patients with a paraplegia duration of less than 24 months, it was not observed in patients with a duration longer than 24 months. When we reviewed the literature, we did not encounter any study demonstrating an association between immobilization and an increase in tendon thickness. We believe that the increase in right proximal Achilles tendon thickness may be due to the lower extremity becoming more vulnerable to mechanical trauma and degenerative changes as a result of decreased muscle strength, reduced sensory and proprioceptive input, and increased degree of spasticity. This situation may arise as a consequence of improper or excessive use.\u003c/p\u003e\u003cp\u003eWhen we reviewed the literature, we could not identify any study evaluating talar cartilage thickness and Achilles tendon thickness in paraplegics. From this perspective, the present study is important as it is the first to determine baseline values for Achilles tendon thickness and talar cartilage thickness in paraplegics and to assess their changes with immobilization. In particular, we observed that in paraplegics lasting longer than 24 months, the talar cartilage thickness of the dominant right lower extremity was significantly thinner. Based on this result, we believe that paraplegics may be at risk for developing osteoarthritis and degeneration in the ankle joint, and early diagnosis and treatment are important for their protection. We think that ultrasonography, as a non-invasive method in early diagnosis, provides valuable information about both cartilage thickness and tendon structure and morphology.\u003c/p\u003e\u003cp\u003eA relative limitation of this study is that we measured tendon thickness in cross-section and did not measure the cross-sectional area. The relatively small sample size and the fact that talar cartilage evaluation was performed using cross-sectional thickness measurement, without any volumetric or histological assessment, are additional limitations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe detection of talar cartilage thinning in patients with a paraplegia duration longer than 24 months may help in the early identification of long-term talar cartilage degeneration or the development of possible ankle joint problems. We believe that, in the future, comparative evaluations of tendon and cartilage morphology in spinal cord\u0026ndash;injured patients with different ASIA impairment levels will contribute to our knowledge on this subject.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the principles of the Declaration of Helsinki. Approval was obtained from the ….. University Clinical Research Ethics Committee (Approval No: 2022/184). The study was registered in the ClinicalTrials.gov database with the number NCT05483764.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of conflicting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest regarding the conduct of this study, the preparation of the manuscript, or its publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants included in the study prior to the initiation of the research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNas K, Yazmalar L, Aydın A, \u0026Ouml;neş K. 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J Anat. 2015;226:447\u0026ndash;457.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKara M, Tiftik T, \u0026Ouml;ken \u0026Ouml;, Akkaya N, Tunc H, \u0026Ouml;z\u0026ccedil;akar L. Ultrasonographic measurement of femoral cartilage thickness in patients with spinal cord injury. J Rehabil Med. 2013;45:145\u0026ndash;148.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiang JN, Ho KY. Altered Achilles tendon morphology in individuals with chronic post-stroke hemiparesis: a case report. BMC Med Imaging. 2020;20:34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhou J, Koike Y, Uhthoff HK, Trudel G. Quantitative histology and ultrastructure fail to explain weakness of immobilized rabbit Achilles' tendons. Arch Phys Med Rehabil. 2007;88:1177\u0026ndash;1184.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"spinal-cord","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"sc","sideBox":"Learn more about [Spinal Cord](http://www.nature.com/sc/)","snPcode":"41393","submissionUrl":"https://mts-sc.nature.com/cgi-bin/main.plex","title":"Spinal Cord","twitterHandle":"@journalsci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Paraplegia, talar cartilage thickness, achilles tendon thickness, ultrasonographic measurements, the American Spinal Injury Association scale","lastPublishedDoi":"10.21203/rs.3.rs-8263278/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8263278/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eStudy Design:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was a cross-sectional study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe aim of the study is to ultrasonographically measure the ankle talar cartilage and achilles tendon thicknesses in paraplegics and to compare them with the healthy population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical evaluations were conducted in the physical therapy and rehabilitation department.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwenty-four paraplegics and twenty-four healthy controls with similar demographic characteristics were included in the study. The age, gender, body mass index, educational status, and the talus cartilage and achilles tendon thicknesses measured by ultrasonography of all participants were recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean right talar cartilage thickness was 0.97 (0.23) mm in paraplegics \u0026gt; 24 months, whereas it was 1.1 (0.44) mm in paraplegics \u0026lt; 24 months. When the right talar cartilage thickness was compared with the control group, it was significantly thinner in paraplegics \u0026gt; 24 months (p \u0026lt; 0.05). The mean right proximal Achilles tendon thickness was 4.90 mm ± 1.13 in paraplegics \u0026lt; 24 months, whereas it was 4.5 (0.99) mm in paraplegics \u0026gt; 24 months. In comparisons with the control group, while the right proximal Achilles tendon thickness was significantly thicker in paraplegics with a paraplegia duration of less than 24 months (p \u0026lt; 0,05), no difference was detected in paraplegics with a paraplegia duration longer than 24 months (p \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe detection of thinning in the talar cartilage in patients with a paraplegia duration of \u0026gt; 24 months may be helpful for the early recognition of long-term talar cartilage degeneration or the possible development of ankle joint problems.\u003c/p\u003e\n\u003cp\u003eThe study was registered with the number NCT05483764.\u003c/p\u003e","manuscriptTitle":"Ultrasonographic measurements of the achilles tendon and talar condylar cartilage thickness in paraplegics and healthy controls","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 06:26:10","doi":"10.21203/rs.3.rs-8263278/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-01-09T06:40:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-09T16:35:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-09T16:33:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"Spinal Cord","date":"2025-12-07T18:35:22+00:00","index":"","fulltext":""},{"type":"checksFailed","content":"","date":"2025-12-05T12:33:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"spinal-cord","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"sc","sideBox":"Learn more about [Spinal Cord](http://www.nature.com/sc/)","snPcode":"41393","submissionUrl":"https://mts-sc.nature.com/cgi-bin/main.plex","title":"Spinal Cord","twitterHandle":"@journalsci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4a77901d-1427-4fde-bc49-db45e7e42462","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":60857476,"name":"Health sciences/Neurology/Neurological disorders/Spinal cord diseases"},{"id":60857477,"name":"Health sciences/Anatomy/Musculoskeletal system/Cartilage"},{"id":60857478,"name":"Health sciences/Anatomy/Musculoskeletal system/Tendons"}],"tags":[],"updatedAt":"2026-01-16T06:26:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 06:26:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8263278","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8263278","identity":"rs-8263278","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}