ORIGINAL RESEARCH
Ultrasound Imaging Is Reliable for
Tibialis Posterior Size Measurements
A. Wayne Johnson, PT, PhD , Dustin A. Bruening, PhD , Victoria A. Violette, BS, Keisha V. Perkins, BS,
Christopher L. Thompson, BS, Sarah T. Ridge, PhD
Received January 16, 2020, from the Depart-
ment of Exercise Sciences (A.W.J., D.A.B.,
V.A.V., K.V.P., C.L.T., S.T.R.). Manuscript
accepted for publication April 26, 2020.
All of the authors of this article have
reported no disclosures.
Address correspondence to Aaron
Wayne Johnson, PT, PhD, Department of Exer-
cise Sciences, Brigham Young University,
106 Smith Fieldhouse, Provo, UT 84602, USA.
E-mail: wayne_johnson@byu.edu
Abbreviations
CSA, cross-sectional area; ICC, intraclass
correlation coefficient; LoA, limits of
agreement; MRI, magnetic resonance
imaging; SEM, standard error of the mea-
surement; TP, tibialis posterior; US,
ultrasound
doi:10.1002/jum.15340
© 2020 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2020; 00:1–8 | 0278-4297 | www.aium.org
Objectives—The tibialis posterior (TP) is a vital muscle for controlling the
medial longitudinal arch of the foot during weight-bearing activities. Dysfunction
of this muscle is associated with a variety of pathologic conditions; thus, it is
important to reliably assess its morphologic characteristics. Ultrasound (US) has
been used to assess characteristics of TP tendons but not the muscle cross-
sectional area (CSA). The purpose of this study was to establish a reliable US
technique to measure the TP CSA and thickness.
Methods—Twenty-three healthy volunteers participated. We evaluated the CSA
and thickness at 4 measurement locations (anterior and posterior views at both
30% and 50% of the shank length).
Results—The participants included 12 female and 11 male volunteers (mean
age  SD, 31.23  14.93 years). Excellent reliability was seen for the CSA and
thickness at all locations (intraclass correlation coefficients, 0.988–0.998). Limits
of agreement (LoA) and standard errors of the measurement (SEMs) were
slightly lower at the 30% locations (LoA at 30%, 4.6–9.2; LoA at 50%, 6.4–9.7;
SEM at 30%, 0.03–0.05; SEM at 50%, 0.04–0.07). Strong correlations were seen
between anterior and posterior measurements of the CSA (30%, r = 0.99;
P < .0001; 50%, r = 0.94; P < .0001) and thickness (30%, r = 0.98; P < .0001;
50%, r = 0.95; P = .0001).
Conclusions—Based on these results, the TP can be measured accurately with
US at any of the tested locations. Due to the ease of collection and the quality of
the data, we recommend the anterior view at 30% of the shank length to mea-
sure the CSA. The ability to assess muscle size of the TP will aid in a variety of
medical and research applications.
Key Words—medial longitudinal arch; morphology; musculoskeletal imaging
protocol; posterior tibial tendon dysfunction
T he tibialis posterior (TP) is a key muscle in controlling the
medial longitudinal arch of the foot during static and
dynamic loading, including walking,1–6 jumping, and
running7,8 as it controls inversion and plantar flexion of the
foot/ankle.8 It is a clinically important muscle to consider with
regards to various pathologic conditions and rehabilitation
programs.1–6 Measuring the TP muscle size may help with
diagnosis, monitoring disease progression, and tracking interven-
tion outcomes.
Magnetic resonance imaging (MRI) has been used to measure
the TP muscle size; however, there are a number of clinical limita-
tions that may be overcome by using ultrasound (US) imaging.
Magnetic resonance imaging has been used to image the resting
TP muscle thickness, cross-sectional area (CSA), and volume9 as
Johnson et al—Tibialis Posterior Size via Ultrasound

well as structures associated with its tendon.10,11 tip of the malleolus.14,26,29 Other locations have been
Although MRI may result in excellent image quality, used for tibialis anterior (20% of fibular length)28 and
it is expensive, is often not readily available to clini- medial gastrocnemius (30% of tibial length) measure-
cians, and does not allow a dynamic assessment.11–13 ment.27 We previously measured the TP at 30% of the
Ultrasound has a growing place in musculoskeletal shank length because its muscle belly is proximal to the
rehabilitation. It has been used to evaluate the other muscles of that compartment.25
morphologic characteristics of muscles (thickness, The purpose of this study was to establish a reliable
CSA, and volume)14–17 and tendons,18 assess muscle technique to assess the TP CSA using US. Specifically,
activation,19 measure rehabilitation or exercise inter- we evaluated 4 measurement locations: anterior and
vention outcomes,20–22 dynamically evaluate patho- posterior views at both 30% and 50% of the shank
logic conditions,13,23 and provide biofeedback.23,24 length. The ability to assess the muscle size of the TP
Although the TP is an important muscle func- will aid in a variety of medical and research applications.
tionally, its muscle size is typically not assessed in US
studies. This is due to its position deep within the leg
and origin on the interosseous membrane, leading to Materials and Methods
measurement challenges in assessing the muscular
portion of the TP. Advancements in the processing Twenty-three individuals completed this study. All
power of US machines and in musculoskeletal US participants were volunteers, ages 18 years or older,
techniques are now making it possible to use US to who did not have a lower extremity injury within the
record the contraction of the TP and directly measure last 1 month or leg/foot surgery within the last year.
its size. Currently, there are techniques to directly Each participant read and signed an informed consent
assess the TP tendon with US18 but not the CSA of form approved by the university Institutional Review
the muscle belly itself. We previously used US to Board (study protocol, x18445). All images for each
measure the thickness of the TP from an anterior
position at 30% of the distance between the knee
joint line and lateral malleolus (shank length).25 We Figure 1. Thickness measurement (centimeters) of the TP from an
also applied the same procedure to track TP changes anterior view at 30% of the shank length. A line is drawn between
throughout an 8-week intervention.20 Although the tibia and fibula along the interosseous membrane, then at the 50%
point on this line, a vertical line is drawn from the interosseous
CSA may better represent muscle size, we previously membrane to the posterior border of the TP.
focused on thickness based on instrumentation limita-
tions. Measuring the TP CSA is challenging because
of the deep, central location of the TP and its poten-
tial to be obscured by either the tibia or fibula, partic-
ularly from an anterior view. A posterior approach is
possible but would require scanning through both the
gastrocnemius and soleus, increasing the measure-
ment depth. Advances in US technology may now
allow for CSA measurement of the TP.
Ultrasound imaging of superficial leg and foot mus-
cles may provide the foundation for a robust TP mea-
surement technique. Several studies have shown good
to excellent reliability (intraclass correlation coefficients
[ICCs], 0.57–0.99) of US imaging in many of the lower
leg muscles, including tibialis anterior, flexor digitorum
longus, flexor hallucis longus, fibularis longus, fibularis
brevis, and medial gastrocnemius.14,26–30 Most of these
studies measured the CSA of lower leg muscles at 50%
of the distance from the knee joint line to the inferior

2 J Ultrasound Med 2020; 00:1–8

 Johnson et al—Tibialis Posterior Size via Ultrasound

participant were captured within a single 60-minute
data collection section.
Ultrasound Measurement
A researcher with 10 years of musculoskeletal US
imaging experience gathered images obtained in this
study. Participants sat in a relaxed position on a
treatment table with an upright, inclined back and
had their thigh supported by a bolster so that their
calf was uncompressed and that images could be
recorded from both anterior and posterior views.
The anterior and posterior views of the TP of both
legs of each participant were imaged via US
(LOGIQ S8; GE Healthcare, Chicago, IL) using an
ML6-15-D matrix linear transducer. Frequencies
ranged between 8 and 12 MHz as determined by the
scanner to enhance image clarity. Adjustments to
depth, frequency, focal position, and time-gain-
compensation were performed as needed to enhance
the clarity of the image. Additionally, the Virtual
Convex setting was occasionally used to enhance the
field of view during scanning. Both the CSA and
thicknesses of the muscle were recorded. To mea-
sure the CSA and thickness of the TP, the linear dis-
tance from the lateral knee joint line to the inferior
point of the lateral malleolus was measured. From
this measurement, the 30% and 50% distances were
determined and marked with a soft-tipped marker.
Participants were then asked to invert their foot and
then return to rest. Cine loops, or video clips, were
recorded of the contraction cycle to help visualize
the fascial borders of the TP and the conformational

Figure 2. A, Cross-sectional area measurement (square centimeters) of the TP from the anterior view at 30% of the shank length. B, Poste-
rior view of the measurement of the TP CSA at 30% of the shank length.

Table 1. Comparison of TP Muscle CSA Mean (SD), ICC, SEM, and Bland–Altman LoA From Anterior and Posterior Views at 30% and 50%
of the Shank Length

SEM 95% CI LoA 95% CI

Parameter Mean (SD) ICC SEM Lower Upper Lower Upper LoA, %

50% TP anterior CSA, cm 2

3.43 (1.09) 0.997 0.060 3.315 3.549 −0.2194 0.2202 6.4
50% TP posterior CSA, cm2 3.55 (1.09) 0.996 0.069 3.419 3.690 −0.23658 0.2922 7.4
30% TP anterior CSA, cm2 3.96 (1.05) 0.998 0.047 3.868 4.052 −0.210 0.171 4.8
30% TP posterior CSA, cm2 4.00 (1.06) 0.998 0.047 3.905 4.090 −0.19265 0.175246 4.6

CI indicates confidence interval.

J Ultrasound Med 2020 3

Johnson et al—Tibialis Posterior Size via Ultrasound

changes within the muscle. This allowed the muscle
to be distinguished from the adjacent muscles and
other leg structures. Two separate recordings of the
contraction cycle were taken with the transducer ori-
ented transversely at each of the 4 locations (ante-
rior, 30%; posterior, 30%; anterior, 50%; and
posterior, 50%). The transducer was removed from
the leg between trials.
Image Processing
The thickness and CSA were measured from a single
frame within each cine loop when the muscle was at rest.
The TP thickness was measured between the inter-
osseous membrane and the posterior border of the mus-
cle. This was accomplished by first drawing a reference
line along the interosseus membrane from the tibia to
the fibula. The thickness measurement was taken

Table 2. Comparison of TP Muscle Thickness Mean (SD), ICC, SEM, and Bland–Altman LoA From Anterior and Posterior Views at 30% and
50% of the shank Length

SEM 95% CI LoA 95% CI

Parameter Mean (SD) ICC SEM Lower Upper Lower Upper % LoA
50% TP anterior thickness, cm 1.72 (0.39) 0.991 0.037 1.6456 1.792 −0.1434 0.1576 8.6
50% TP posterior thickness, cm 1.69 (0.40) 0.989 0.041 1.6094 1.7721 −0.1672 0.1596 9.7
30% TP anterior thickness, cm 1.78 (0.36) 0.995 0.030 1.733 1.832 −0.1097 0.0979 5.8
30% TP posterior thickness, cm 1.80 (0.35) 0.988 0.040 1.718 1.889 −0.1437 0.1886 9.2

CI indicates confidence interval.

Figure 3. Correlations between TP CSA measurements (square centimeters) with anterior and posterior US transducer placements at 30%
and 50% of the shank length and Bland–Altman plots of the comparison between anterior and posterior transducer placements.

4 J Ultrasound Med 2020; 00:1–8


perpendicular to this line at its midpoint (Figure 1).
Measurements of the CSA were obtained by tracing just
inside the visualized muscle borders (Figure 2). A feature
of the US machine allows for the tracing to remain on
the screen while viewing the muscle contraction.
Data Analysis
Averages of both measurements were calculated for
each of the 4 views of the muscle for both the
CSA and thickness. Reliability was determined by
comparing these measurements using the ICC3,k
model (random participants and fixed operators) for
absolute agreement. Measurements of the 23 partici-
pants’ right and left legs were used in the data analy-
sis, providing 46 data points for each comparison.
An ICC of greater than 0.8 was considered moder-
ate, and an ICC of greater than 0.9 was considered
excellent.31 The 95% confidence intervals for the
ICCs were also calculated. The standard error of
the measurement (SEM)32 and Bland–Altman plots
Figure 4. Correlations between TP thickness measurements (centimeters) with anterior and posterior US transducer placements at 30%
and 50% of the shank length and Bland–Altman plots of the comparison between anterior and posterior transducer placements.
J Ultrasound Med 2020
Johnson et al—Tibialis Posterior Size via Ultrasound
with limits of agreement (LoA)33 were then calcu-
lated and used to further characterize reliability. A
Pearson product correlation (α = .05) was per-
formed to compare the average anterior-to-posterior
measurements at each location. We used SPSS ver-
sion 25.0 statistical software (IBM Corporation,
Armonk, NY).
Results
The 23 participants included 12 female and 11 male
volunteers (mean age  SD, 31.23  14.93 years;
height, 1.76  0.11 m; weight, 75.70  17.90 kg).
Excellent reliability was seen when comparing repeated
measurements of the CSA (Table 1) and thickness
(Table 2) for anterior and posterior views at the 30%
and 50% points. For all measurements, LoA for CSAs
and thicknesses ranged from 4.6% to 7.4% and 5.8% to
9.7%, respectively, and SEMs ranged from 0.03 to
5
Johnson et al—Tibialis Posterior Size via Ultrasound
0.07. A strong correlation was seen between anterior
and posterior CSA measurements at the 30% mark
(r = 0.99; P < .0001) and 50% mark (r = 0.94;
P < .0001; Figure 3). There was also a strong correla-
tion for thickness measurements between anterior and
posterior views (30% mark, r = 0.98; P < .0001; 50%
mark, r = 0.95; P = .0001; Figure 4).
Discussion
The primary purpose of this study was to establish a
reliable method for measuring the CSA and thickness
of the TP using US imaging. As far as we know, this
is the first study to report a reliable method for mea-
suring the TP CSA using US. Our ICC scores were
similar to or higher than those reported for other
lower extremity muscles, which ranged from 0.57 to
0.99.15,26,29,30,34–36 The SEM and LoA were also com-
parable to or lower than those seen in other stud-
ies.26,29,30 For thickness measurements, our LoA
ranged from 5.8% to 9.7%, whereas other researchers
saw a range of 9% to 18% for foot and leg mus-
cles.26,29 For the CSA, we saw even lower LoA
(4.6%–7.4%), which were lower than the 8% to 30%
found in previous studies.26,29 Only a couple of previ-
ous studies presented SEMs: one was in weight-
bearing intrinsic foot muscles, showing scores ranging
from 0.03 to 0.17,30 and the other was performed in
our research group.25 Our range of 0.03 to 0.07 com-
pares favorably. Thus, it appears that our method of
measuring the TP CSA and thickness provides reli-
able measurements with low error rates, potentially
due to the use of cine loops.25
Although the sizes of most of the lower leg mus-
cles have been measured at 50% of the shank length,
we chose to measure at 30% of the shank length
for more proximally located muscles. Although ICCs
at both locations were excellent, lower LoA and SEM
values were found at the 30% mark. At the 30%
location, the position and size of the muscle appears
more conducive to visualization. In this study, the
average CSA at the 30% distance was approximately
14% larger than at the more distal point (3.98 versus
3.49 cm2) and was more representative of the maxi-
mal CSA of the muscle. Previous MRI studies
have extracted the maximum TP CSA from multislice
images with comparable magnitudes (4.3 cm2 [n = 8]
6 J Ultrasound Med 2020; 00:1–8
in middle-aged adults9 and 4.7 cm2 [n = 19] in young
athletic men37). In addition, as the distance increases
from the knee joint line toward the foot, the muscle
belly of the TP from an anterior view has a greater
potential to be obscured by the tibia or fibula bone
shadow. This is further influenced by the fact that as
you near the ankle joint, the flexor digitorum longus
and the TP cross over one another. This is a problem
even in MRI,9 which reinforces the potential utility of
US. In future research, it may be beneficial to com-
pare measurement of the TP via US and MRI in the
same individuals.
We saw a very strong correlation between mea-
surements of the TP taken from the anterior and pos-
terior views at both 30% and 50% of the shank
length. This suggests that both views provide an ade-
quate way of measuring its CSA and thickness. Each
view presents advantages and disadvantages from
both collection and processing standpoints. The ante-
rior view of the TP may be preferred for image
recording because of easier transducer placement and
accessibility, only imaging through a single superficial
muscle (tibialis anterior). In contrast, placing the
transducer posterior on the calf requires imaging
through the bulk of the gastrocnemius and soleus,
making it more difficult to distinguish the deep ante-
rior borders of the TP, particularly its border on the
interosseous membrane. The entirety of the muscle
and the borders can be measured from a posterior
view with a skilled operator using a sufficiently power-
ful US unit and holding the transducer with an appro-
priate angle and pressure. For novice operators, it
may be easier to use an anterior transducer place-
ment, which requires less signal depth. The operator
needs to consider the frequency, depth setting,
focal point position, and use of the time-gain com-
pensation feature of the US machine to enhance the
image quality. If a skilled operator has obtained a
high-quality image, key posteriorly located landmarks,
such as blood vessels, posterior fascial borders, and
hyperechoic cortical bone lines, may be more easily
seen from the posterior view. However, the difficulty
of differentiating the TP from other structures when
using the anterior view is decreased with the use of
cine loops.25 Considering the aforementioned factors,
we recommend an anterior transducer placement
with the use of cine loops to identify key landmarks
and muscle borders.

Limitations
There are several study design limitations inherent
when using US imaging. For example, the US opera-
tor could not be blinded to the placement, location,
or position of the US transducer. Although the loca-
tion of 30% or 50% was blinded at the time of mea-
surement, the anterior/posterior view was apparent
because of differences in the tissues adjacent to the
TP. Anecdotally, we noted that it was more difficult
to image and measure the TP of older individuals
because of high echogenicity within the TP. Assessing
muscles of older adults or less-active adults may be
more prone to complications related to fatty infiltra-
tion. Although MRI allows for direct measurement of
the fatty infiltration within the muscle, an evaluation
of the US echo intensity can provide insight into fatty
infiltration or fibrosis of the muscle.38
Clinical Implications
Clinically, the TP is the most important muscle for
maintaining the integrity of the medial longitudinal
arch and influences the mechanics of the weight-
bearing kinetic chain during activities such as walking
and running.1–6,8 Dysfunction of the TP is the leading
contributor to adult acquired flatfoot deformities,
which affect 20% to 30% of the population.39 Other
clinical applications in which assessment of the TP
would be beneficial include the evaluation and moni-
toring of pathologic conditions (eg, posterior shin
splints) and training interventions (eg, clinical
strengthening programs). The proper analysis of this
muscle through US imaging will allow clinicians to
evaluate not only the tendon of the TP but the mus-
cle characteristics as well, such as size,20 quality,38,40
and functional activation.19,41 Clinical application of
this measurement technique could be strengthened
by investigating the correlation between a clinical
functional strength test, such as the single-leg plantar
flexion test, and TP morphologic characteristics, the
percentage of activation, and muscle quality.38
Conclusions
Repeated measurements showed excellent reliability.
At the 30% point, the anterior and posterior measure-
ments were highly correlated; thus, either position
could be used to image the TP. The anterior view at
the 50% location should generally not be used
because portions of the TP are often hidden behind
J Ultrasound Med 2020
Johnson et al—Tibialis Posterior Size via Ultrasound
bone, which increases the difficulty of the measure-
ment. Due to the ease of collection and the quality of
the data, we recommend measuring the CSA of the
TP using the anterior view at 30% of the shank
length.
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