# Calcaneal Ultrasound Attenuation: Does the Region of Interest and Loading Influence the Repeatability of Measurement?

## TL;DR

This study examines how the region of interest and lower limb loading affect the repeatability of calcaneal ultrasound measurements.

## Contribution

The study shows that weightbearing improves the repeatability of ultrasound attenuation measurements in the calcaneus.

## Key findings

- Repeatability of ultrasound FDA depends on the region of interest and improves with weightbearing.
- SEM and 95% tolerance limits show better consistency during weightbearing conditions.
- Mean FDA values varied between 58.0 and 77.2 dB/MHz across different conditions.

## Abstract

Current calcaneal quantitative ultrasound systems assess different regions of interest (ROI), under different levels of lower limb loading, yield different parameter values, and are likely prone to different levels of error. This study evaluated the repeatability of measures of frequency-dependent attenuation (FDA, 0.3–0.8 MHz) at three calcaneal ROI, Brooke–Wavell (BW), Jaworski (JA), and foot gauge (FG), under four loading conditions (non-weightbearing, semi-weightbearing, bipedal stance, and unipedal stance). FDA in the calcaneus was assessed in 20 healthy participants (mean (± SD) age, 41.7 ± 19.6 years; height, 1.70 ± 0.16 m; and weight, 70.1 ± 23.0 kg) using a custom-built transmission-mode ultrasound system. Reliability was evaluated using the standard error of measurement (SEM) and limits of agreement (LA) and tolerance (95%TL). Differences in mean FDA values between ROI, loading, and measurement occasions were assessed using a repeated measures ANOVA (α = .05). Mean FDA values ranged between 58.0 ± 32.0 and 77.2 ± 27.6 dB/MHz across all conditions. Repeatability of FDA was dependent on the ROI examined and tended to improve with weightbearing. The narrowest limits for 95%TL ranged between ± 15.1 dB/MHz (JA SWB) and ± 62.7 dB/MHz (BW NWB) across sites. The SEM was approximately 10 dB/MHz for both FG and JA during non-weightbearing and was reduced to around 5 dB/MHz with full weightbearing. This study demonstrates that, although measures of ultrasound FDA are dependent on the ROI, lower limb loading may be a useful method to improve the repeatability of FDA measurements.