What Contributes to Tendon Thickness After Stroke–A Commentary

By Dr. Jennifaye V. Brown

April, August, and December are months reserved to address comments made to articles written for “A Foot Forward for Optimum Health”. However, I did not have any comments from May, June and July and I wanted to make some comments and pose clinical questions from the article titled, “Changes in Lower Extremity Tendon Thickness After Stroke Rehab (Balance and Outcomes)” in the series “From The Literature” for June 2026.

Ultrasound has been used in the past to assess muscle thickness post-stroke;^1-6 however, just because a muscle is thicker in girth does not automatically mean there is an increase in strength isometrically, eccentrically and concentrically needed for functional mobility. Therefore, it is imperative to train a muscle and load it with resistance in the functional pattern of use, despite increase tendon thickness.

After reading the article,⁷ I was concerned that there was no description of the paretic lower extremity long-term typical resting position or during weightbearing such as standing. If the knee is extended and the ankle is in plantarflexion from an extensor synergy pattern or increase tone in the quadriceps and posterior leg compartment muscles or weakness in the tibialis anterior, these impairments may perhaps cause an increase in tendon thickness due to the shortening of the muscle and tension applied to the musculotendinous junction.

Ultrasound assessments were done in a non-weight-bearing position and specifically for the quadriceps tendon, the knee was flexed to 30˚ in supine and for the Achilles tendon, 0˚ or neutral dorsiflexion in prone. Of the 20 sessions of therapy, I would like to have known the percentage of activities in non-weight bearing versus weight bearing. The musculoskeletal system adapts to load after a stroke.^8-9

My last comment is the use of the Berg Balance Scale (BBS) to assess balance. It has been known that stroke survivors over rely on the less-affected lower extremity for stability during testing often driving up test scores and masking the risk of falls.^10-11 The crucial “…finding was a within-patient increase in quadriceps tendon thickness over the 4-week inpatient period,”⁷⁽⁰⁵⁾ may be attributed to the inability to bend the knee using the hamstrings or increased tone in the quadriceps. However, one has to judge how the stroke survivor was achieving balance and stability during the BBS to state that there is “modest” association of balance improvement as thickness increased in the quadriceps tendon.

Based on clinical knowledge, skill and insights, it is imperative that we scrutinize the research for its applicability to patient/client rehabilitation care. I know a lot of “strong” stroke survivors with a 5 out of 5 on the manual muscle test for the quadriceps (knee extensors), but they cannot navigate stairs step over step up or down.¹² Go figure…it out!?!

Jennifaye V. Brown, PT, MSPT, PhD, NCS, CAPS is an American Physical Therapy Association 4-time 10-year board certified neurologic physical therapist in Charleston, South Carolina, specializing in stroke rehabilitation, specifically gait analysis and treatment, AFO design, and the redesign of lived spaces allowing individuals with disAbilities to age in place. She is the author of the book, Brace Yourself: Everything You Need to Know About AFOs After Stroke. Visit her YouTube channel @jvbneuropt for more information regarding stroke rehabilitation.