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. 2025 Jul 23:16:1639270.
doi: 10.3389/fendo.2025.1639270. eCollection 2025.

Assessment of extensor hallucis brevis stiffness and microcirculation in diabetes: shear wave elastography and contrast-enhanced ultrasound

Fuqiang Yan #  1 , Mingli Cai #  1 , Meirong Li #  2 , Shanshan Huang  1 , Jingyi Guo  1 , Jinmiao Lin  1 , Guorong Lyu  3
Affiliations

Assessment of extensor hallucis brevis stiffness and microcirculation in diabetes: shear wave elastography and contrast-enhanced ultrasound

Fuqiang Yan et al. Front Endocrinol (Lausanne). .

Abstract

Background: Diabetic foot complications, driven by microvascular dysfunction, remain a leading cause of morbidity and amputations. Early detection of microcirculatory and biomechanical alterations in vulnerable muscles, such as the extensor hallucis brevis (EHB), may contribute to risk stratification. However, noninvasive tools for quantifying these changes are lacking.

Methods: This cross-sectional study enrolled 90 participants stratified into healthy controls, uncomplicated type 2 diabetes (T2DM), and T2DM with microvascular complications (MC). Shear wave elastography (SWE) measured EHB stiffness (mean Young's modulus, Emean), while contrast-enhanced ultrasound (CEUS) assessed perfusion dynamics (transcapillary transit time [ΔAT], net enhancement intensity [ΔPI]). Diagnostic accuracy and reproducibility were evaluated via ROC analysis and intra-class correlation coefficients (ICC).

Results: Emean increased progressively across groups (control: 11.88 kPa; T2DM: 15.78 kPa; T2DM+MC: 18.57 kPa; P < 0.01). T2DM+MC exhibited prolonged ΔAT (89.5 s vs. 50.5 s in controls) and reduced ΔPI (5.0 dB vs. 7.0 dB; P < 0.01). ROC analysis demonstrated high diagnostic accuracy for ΔAT (AUC = 0.970), Emean (AUC = 0.947), and ΔPI (AUC = 0.931) in detecting MC. Both SWE and CEUS showed excellent reproducibility (ICC > 0.80).

Conclusion: SWE and CEUS provide robust, noninvasive biomarkers for early diabetic microvascular complications. The EHB's unique susceptibility to stiffness and perfusion deficits highlights its clinical value, which may facilitate diabetic foot risk assessment and guide timely interventions to mitigate ulceration and amputations.

Keywords: diabetes; elasticity; microcirculation; skeletal muscle; ultrasound diagnosis.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Shear Wave Elastography (SWE) Images of the Extensor Hallucis Brevis Muscle Across Groups. (A) Normal group: Mean Young’s modulus (Emean) = 11.88 kPa. (B) DM group: Emean = 15.78 kPa. (C) DM+MC group: Emean = 18.57 kPa. DM, Type 2 diabetes; DM+MC, DM with microvascular complications. SWE measurements reflect increasing muscle stiffness with disease progression.
Figure 2
Figure 2
Time-Intensity Curves (TICs) of Contrast-Enhanced Ultrasound (CEUS) for the Extensor Hallucis Brevis Muscle. (A) Normal group: Arrival time (AT) = 50.5 s, peak intensity (PI) = 7.0 db. (B) DM group: AT = 51.6 s, PI = 6.7 db. (C) DM+MC group: AT = 89.5 s, PI = 5.0 db. CEUS parameters demonstrate delayed contrast arrival (AT) and reduced perfusion (PI) in the DM+MC group.
Figure 3
Figure 3
ROC curve chart comparing five diagnostic parameters: Emean, PI, API, AT, and AAT. Sensitivity is on the y-axis, and 1-specificity on the x-axis. A diagonal reference line indicates random chance. Curves demonstrate high diagnostic accuracy for AAT (AUC=0.970), Emean (AUC=0.947), and API (AUC=0.931) in detecting diabetic microvascular complications.
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