EP4604845A2 - Procédés permettant de déterminer la taille d'une lésion et la capacité physique d'un tissu - Google Patents

Procédés permettant de déterminer la taille d'une lésion et la capacité physique d'un tissu

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Publication number
EP4604845A2
EP4604845A2 EP23832786.0A EP23832786A EP4604845A2 EP 4604845 A2 EP4604845 A2 EP 4604845A2 EP 23832786 A EP23832786 A EP 23832786A EP 4604845 A2 EP4604845 A2 EP 4604845A2
Authority
EP
European Patent Office
Prior art keywords
connective tissue
tissue
interest
determining
injury
Prior art date
Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
Pending
Application number
EP23832786.0A
Other languages
German (de)
English (en)
Inventor
Mohamed Hamza NOORDEEN
Andrew Ting
Current Assignee (The listed assignees may be inaccurate. Google has not performed a legal analysis and makes no representation or warranty as to the accuracy of the list.)
Regenall Ltd
Original Assignee
Regenall Ltd
Priority date (The priority date is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the date listed.)
Filing date
Publication date
Priority claimed from GBGB2215448.8A external-priority patent/GB202215448D0/en
Priority claimed from GBGB2217225.8A external-priority patent/GB202217225D0/en
Priority claimed from GBGB2217228.2A external-priority patent/GB202217228D0/en
Application filed by Regenall Ltd filed Critical Regenall Ltd
Publication of EP4604845A2 publication Critical patent/EP4604845A2/fr
Pending legal-status Critical Current

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Classifications

    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B8/00—Diagnosis using ultrasonic, sonic or infrasonic waves
    • A61B8/08—Clinical applications
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B8/00—Diagnosis using ultrasonic, sonic or infrasonic waves
    • A61B8/08—Clinical applications
    • A61B8/0833—Clinical applications involving detecting or locating foreign bodies or organic structures
    • A61B8/085—Clinical applications involving detecting or locating foreign bodies or organic structures for locating body or organic structures, e.g. tumours, calculi, blood vessels, nodules
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B8/00—Diagnosis using ultrasonic, sonic or infrasonic waves
    • A61B8/08—Clinical applications
    • A61B8/0858—Clinical applications involving measuring tissue layers, e.g. skin, interfaces
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B8/00—Diagnosis using ultrasonic, sonic or infrasonic waves
    • A61B8/08—Clinical applications
    • A61B8/0883—Clinical applications for diagnosis of the heart
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B8/00—Diagnosis using ultrasonic, sonic or infrasonic waves
    • A61B8/52—Devices using data or image processing specially adapted for diagnosis using ultrasonic, sonic or infrasonic waves
    • A61B8/5207—Devices using data or image processing specially adapted for diagnosis using ultrasonic, sonic or infrasonic waves involving processing of raw data to produce diagnostic data, e.g. for generating an image
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B8/00—Diagnosis using ultrasonic, sonic or infrasonic waves
    • A61B8/52—Devices using data or image processing specially adapted for diagnosis using ultrasonic, sonic or infrasonic waves
    • A61B8/5215—Devices using data or image processing specially adapted for diagnosis using ultrasonic, sonic or infrasonic waves involving processing of medical diagnostic data
    • A61B8/5223—Devices using data or image processing specially adapted for diagnosis using ultrasonic, sonic or infrasonic waves involving processing of medical diagnostic data for extracting a diagnostic or physiological parameter from medical diagnostic data

Definitions

  • This invention relates to methods for determining the size of a lesion in a tissue (in particular, a connective tissue or a muscle tissue) in a subject, and to methods for determining a change in the size of a lesion in a subject, for example a tendon or ligament in a horse, or a tendon or ligament in a human, or a muscle, such as a cardiac muscle (for example, in a human).
  • the methods may be computer implemented.
  • This invention also relates to methods for determining fitness potential of a tissue (in particular, a connective tissue or a muscle tissue) in a subject, and to methods for determining a change in the fitness potential of a tissue (in particular a connective tissue or a muscle tissue) in a subject, for example a tendon or a ligament in a horse, or a tendon or a ligament in a human, or a muscle, such as a cardiac muscle (for example, in a human).
  • the methods may be computer implemented.
  • the equine limb contains several tendons and even more ligaments (see Figure 21 ). Tendons attach muscles to bones, while ligaments attach bones to bones. Tendons are often named for their function. For example the superficial digital flexor tendon (SDFT) runs along the back of the limb extending from the knee to where it attaches on the pastern bones. It has many functions, but one of them is to flex the lower limb. The extensor tendons are on the front of the limb and they extend the limb. The suspensory ligament is one of the most important ligaments in the limb. It extends from the back of the knee or hock to the sesamoid bones, which are located in the back of the fetlock joint. Many ligaments are quite short, such as the collateral ligaments, which act to help stabilize almost every joint.
  • SDFT superficial digital flexor tendon
  • ACL anterior cruciate ligament
  • Tendons and ligaments are complex structures. They are made up of thousands of complex structures called collagen fibrils. The collagen fibrils are connected to other fibrils to make a collagen fibre. Fibres are bound together to make a fascicle. Small fascicles are bound together to make ever-larger groups of fascicles to form a tendon. This very structured internal organization is what gives a tendon its unique strength and function. Collagen is the most common molecule in tendons, but they also contain other molecules such as proteoglycans. The collagen and proteoglycans make up the scaffold of the tendon. Seventy percent of the weight of a tendon is water. Most of a tendon’s ability to stretch comes from sliding of fascicles past one another.
  • a small amount of a tendon’s ability to stretch comes from the collagen molecules themselves stretching.
  • the course of a tendon is not always straight.
  • the deep digital flexor tendon starts just behind the knee and then makes its way around the back of the fetlock before attaching to the foot.
  • tendons cross a bony prominence, such as a joint, they are usually encased within a tendon sheath.
  • the tendon sheath contains synovial fluid, which is almost identical to the fluid contained within joints. This helps ease friction as the tendon slides over the bone point or over a joint.
  • the digital flexor tendon sheath on the back of the fetlock joint helps ease the passage of the deep digital flexor tendon past the fetlock joint.
  • Tendons and ligaments have a variety of functions. They transmit forces to enable movement, support the lower limb, store energy, and provide support to joints. Tendons are viscoelastic, meaning that they have different material properties as different forces are applied to them. As force is first applied to a tendon it stretches quite a bit as the fascicles themselves stretch out. As more force is applied to the tendon, the fascicles start to slide past each other and the amount of stretch per unit of force is less than it was initially. Thus, the tendon is stiffer. This predictable relationship of increased force resulting in increased tendon stretch occurs until the load becomes too great and the tendon structures start to break down. This is called the yield point. Once this occurs there is irreparable damage done to the tendon and a tendon injury occurs.
  • tendon and ligament injuries There are two main types of tendon and ligament injuries; external injuries and overstrain injuries. External injuries include kicks, overreaching injuries, and lacerations. Overstrain injuries occur in two main ways. One is a sudden large overload of a tendon that was previously normal. The second type of injury is more common. With this type of injury there is a chronic, gradual build-up of tendon degradation or microtrauma. This damage builds up silently with no outward signs until the damage is too much and the tendon suddenly fails resulting in a significant injury.
  • Tendon and ligament injuries result in disruption of the highly organized internal organization of these structures. Initially there is haemorrhage or bleeding within the tendon or ligament. This is followed by a period of significant inflammation. Blood flow increases to the area, oedema or swelling occurs, and white blood cells congregate in the injury site. This is seen externally as an enlarged, hot, and painful tendon or ligament. This is the first stage of tendon or ligament repair and is designed to remove dead tendon fibres and cells, however the inflammation can get out of hand and result in even more damage. Treatment during this phase is directed at reducing the inflammation by doing things such as icing or cold hosing or administering anti-inflammatory drugs such as phenylbutazone.
  • the inflammatory phase is short, lasting several days and overlaps with the next stage of tendon healing, which is the reparative phase.
  • This phase new tissue is laid down within the tendon.
  • This scar tissue has a different composition than normal tendon tissue.
  • One of the largest differences is the type of collagen. Normal uninjured tendon has a predominance of Type I collagen.
  • the new tissue laid down after an injury has a predominance of Type III collagen and is essentially scar tendon tissue.
  • These different collagens have different structural properties meaning that the new tendon is not a strong as the old tendon.
  • the next phase of tendon healing can last up to 18 months after injury.
  • the amount of Type I collagen gradually increases, but never returns to its original concentration.
  • the body is able to repair the injury, but the scar tissue is never the same as the original tendon tissue. It is stiffer than normal tendon (does not stretch as much when loaded) and is more prone to re-injury.
  • the deep digital flexor tendon arises from three locations in the upper forelimb: the humerus, radius, and ulna. It then courses down the carpal canal (the depression running down the back of the knee) and crosses over the navicular bone before inserting at the back of the coffin bone, lying deep beneath the SOFT and just over the suspensory ligament.
  • the DDFT originates from two areas of the tibia and also inserts into the coffin bone. This tendon plays a role in the knee and forefoot flexion, forelimb elbow joint extension, and hock and hindfoot flexion and extension. Horse tendon injury occurs most frequently within the hoof capsule and the sheath around the tendon, likely from repetitive excessive loading.
  • lesions appear in the body or borders of the tendon at the fetlock joint level and are more common in the hind than forelimbs.
  • the four most common DDFT lesions are tendon enlargements or changes in shape, focal core lesions, mineralizations, and marginal tears.
  • Suspensory ligaments originate from the back of the fore and hind cannon bones.
  • the SL’s main function is to prevent the fetlock joint from overextending.
  • proximal (upper) suspensory desmitis PSD
  • PSD suspensory desmitis
  • Lameness is typically mild to moderate.
  • hind-limb PSD occurs in horses of all ages and disciplines, it is especially common in high-level dressage horses. Nerve blocks and ultrasonography are used to diagnose this injury. Prognosis for hind-limb PSD following conservative therapy alone is poor, with only 14% of horses resuming full work without lameness for more than a year.
  • the ACL In humans, the ACL and Achilles tendon are commonly injured. The ACL does not heal when torn, and surgical reconstruction is the standard treatment in the field of sports medicine.
  • the ACL is divided into two parts, the anteromedial bundle (AMB) and the posterolateral bundle (PLB), which attach the femur to the tibia.
  • the AMB is functional (tight) at knee flexion, and is moderately lax at the extended knee.
  • the PLB is functional at the extended knee, and lax at flexion. In this way, the AMB and PLB cooperate to control knee dynamics, particularly in rotation and tibia translation (preventing tibial overtranslation).
  • the Achilles tendon is susceptible to damage with repetitive use or overload, typically during sports.
  • the tendon provides distal attachment sites for the calf muscle and soleus muscles, and inserts onto the posterior surface of the heel (calcaneus) bone.
  • the plantaris tendon also fuses with the medial side of the Achilles tendon proximal to its attachment site.
  • Ultrasound is currently used to diagnose and monitor tendon and ligament injuries in horses (Leshaw, The Horse, 13 October 2021 : “Ultrasonography’s Role in Equine Lameness Cases”), and is sometimes used to demonstrate connective tissue damage in humans, especially in athletes and sportsmen and sportswomen.
  • Ultrasound uses high-frequency sound waves to produce images in real time. The user holds a sound-wave-emitting probe against the skin toward the structure being evaluated. When the waves meet structures or interfaces between structures, they reflect back to the probe like a ship’s sonar. The more abrupt the interface or dense the structure, the more waves reflected. The more sound waves received, the brighter the structure looks on-screen. The brightness is described in terms of echogenicity. For example, bone appears bright (echogenic), normal fluid is dark (nonechogenic), and all other structures show up somewhere between.
  • tendon or ligaments When tendons or ligaments are strained, their fibres can tear. The extent of tendon or ligament damage can be evaluated by its size, echogenicity, and fibre pattern. Tendon or ligament injuries result in an increase in size of the structure, quantified as an increase in cross-sectional area. In cases of significant disruption, changes in echogenicity and fibre pattern are observed.
  • the “echotexture” or patterning of a tendon or ligament is homogenous (even throughout); a perpendicular view of a normal tendon shows a round or ovoid structure with uniform shading. A damaged tendon might appear round and bright (normal fibres) with a dark area within it. Dark regions represent fibre disruption, or voids, where no sounds waves reflect.
  • Whist ultrasound is extremely useful for diagnosing and monitoring tendon, ligament, and muscle injuries, determining the size of a lesion is time-consuming and requires human input. As such, many medical practitioners do not determine the size of a lesion as a matter of normal practice.
  • echocardiograms are not currently used to accurately determine the presence or size of a lesion in cardiac tissue in a subject. Echocardiograms are routinely used to show how the blood moves through the heart and heart valves.
  • Current diagnostic technology used to detect for cardiac tissue damage includes electrocardiography. This process produces an electrocardiogram (ECG), a recording of the heart’s electrical activity through repeated cardiac cycles. An electrogram of the heart is produced, which shows a graph of voltage versus time of the electrical activity of the heart using electrodes placed on the skin. These electrodes detect the small electrical changes that are a consequence of cardiac muscle depolarization followed by repolarization during each cardiac cycle (heartbeat).
  • cardiac rhythm disturbances such as atrial fibrillation and ventricular tachycardia
  • inadequate coronary artery blood flow such as myocardial ischemia and myocardial infarction
  • electrolyte disturbances such as hypokalemia and hyperkalemia.
  • an ECG can be used to measure the rate and rhythm of heartbeats, the size and position of the heart chambers, the presence of any damage to the heart’s muscle cells or conduction system, the effects of heart drugs, and the function of implanted pacemakers.
  • an ECG cannot be used to accurately determine the size of a lesion in cardiac tissue, or to determine a change in the size of a lesion in the tissue.
  • the Applicant has recognised that computer implemented methods provide rapid information on the size of a tissue lesion, allowing for quick and accurate diagnosis and monitoring of tissue injuries. Such methods enable appropriate treatment of the lesion to be administered soon after diagnosis, facilitating healing and functional recovery of the tissue. Such methods are suitable for use with connective tissues, such as ligaments and tendons, and muscle tissue, such as cardiac tissue.
  • a second aspect of the invention relates to methods for determining fitness potential of tissue in a subject, and to methods for determining a change in the fitness potential of tissue in a subject.
  • the invention relates to methods for determining the fitness potential, and change in fitness potential, of connective tissue, such as a tendon or a ligament in a horse, or a tendon or a ligament in a human.
  • the invention also particularly relates to methods for determining fitness potential, and change in fitness potential, of muscle tissue, such as cardiac tissue (for example, in a human).
  • the methods may be computer implemented.
  • whist ultrasound is extremely useful for diagnosing and monitoring tendon and ligament injuries
  • minor changes in settings of the equipment, or operator method can result in inconsistencies of image quality. This can make accurate diagnosis and monitoring of such injuries more difficult.
  • manually performing diagnostics on the captured images is time-consuming and requires human input. As such, many medical practitioners do not determine the fitness potential of a connective tissue as a matter of normal practice.
  • the Applicant has recognised that computer implemented methods provide rapid information on the echogenicity of a tissue, allowing for quick and accurate diagnosis and monitoring of tissue injuries. Such methods enable appropriate treatment of a lesion to be administered soon after diagnosis, facilitating healing and functional recovery of the tissue. Such methods are suitable for use with connective tissues, such as ligaments and tendons, and muscle tissue, such as cardiac tissue.
  • a method for determining a size of a lesion in a connective tissue which comprises: i) determining an area of the lesion from an ultrasonogram of an ultrasound scan carried out on the connective tissue, and determining a total area of the connective tissue from the ultrasonogram; and ii) determining the area of the lesion as a proportion of the total area of the connective tissue.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • a computerized method for determining a size of a lesion in a connective tissue comprising: i) determining an area of the lesion from an ultrasonogram of an ultrasound scan carried out on the connective tissue, and determining a total area of the connective tissue from the ultrasonogram; and ii) determining the area of the lesion as a proportion of the total area of the connective tissue.
  • Methods of the invention are advantageous because real-time information is provided regarding the severity of the lesion. This allows for rapid diagnosis and monitoring of the lesion at any one time point, and over the course of a period. Such methods enable appropriate treatment of the lesion to begin soon after diagnosis, which can be tailored to the severity of the lesion. In doing so, the tissue can heal and functionally recover quickly.
  • Determining the area of the lesion as a proportion of the total area of the connective tissue allows for normalisation of the size of the lesion across different connective tissues. As one can imagine, different connective tissues occupy different total areas, depending on location and function. Thus, the size of a lesion will have different severities depending on the total area of the connective tissue. For example, a large lesion will be more severe if it is contained in a small connective tissue than a larger connective tissue. Determining the area of the lesion as a proportion of the total area of the connective tissue allows direct comparison of the lesion size across different connective tissues. For instance, methods of the invention can be used to compare a particular treatment for connective tissue injury across multiple subjects and multiple connective tissues. The proportionality output provides a proxy for the determination of efficacy of said treatment, when the area of the lesion as a proportion of the total area of the connective tissue is determined over a period of treatment.
  • Determining the area of the lesion as a proportion of the total area of the connective tissue also minimises differences in measurements for the area of the lesion due to changes in settings of the equipment used to determine the echogenicity values, or to differences in operator method.
  • Determination of the area of the lesion or total area of the connective tissue is carried out by determining the cross-sectional area of the lesion or cross-sectional area of the connective tissue. As such, the respective areas can be determined from one ultrasound scan of the tissue.
  • Methods of the invention can also be carried out for multiple ultrasound scans of the tissue, wherein an ultrasound scan is taken at multiple points along the depth of the lesion and the connective tissue. This provides a rudimentary indication of the volume of the lesion and connective tissue.
  • Determination of the area of the lesion as a proportion of the total area of the connective tissue can be calculated by dividing the area of the lesion by the total area of the connective tissue. The resultant figure may also be multiplied by 100 to provide a percentage of total area of the connective tissue comprising the lesion.
  • the area of the lesion comprises: i) 0-15% of the total area of the connective tissue, determining that the lesion is mild; ii) 16-25% of the total area of the connective tissue, determining that the lesion is moderate; or iii) >25% of the total area of the connective tissue, determining that the lesion is severe.
  • the determination of the severity of the lesion above incorporates the cross-sectional area of the lesion as a proportion of the total area of the connective tissue occupied by the lesion.
  • the figure may also incorporate the proportion of the volume of the lesion as compared with the total volume of the connective tissue.
  • a treatment program is initiated for the subject which is appropriate for the size and/or severity of the lesion.
  • Said treatment program may comprise administering to the subject anti-inflammatory medication, dietary supplementation, or stem-cell treatment, and/or cold therapy, rest, confinement, surgery, or a loading/working training regime.
  • the subject may need to reduce the amount of force applied to the connective tissue, by reducing exercise applied to the connective tissue for a period of time.
  • the lesion is determined to be moderate, the subject may need to rest the connective tissue, apply cold therapy, and/or administer anti-inflammatory medication.
  • the lesion is determined to be severe, the subject may require surgery.
  • a method of the invention further comprises repeating steps (i) and (ii) after a period to determine whether there is a change in the area of the lesion as a proportion of the total area of the connective tissue.
  • the period is at least one day, at least a week, at least two weeks, at least a month, at least six months, or at least twelve months.
  • the treatment program may be amended such that it is more suitable for the lesion after healing. For instance, the subject may no longer need to rest the connective tissue, but continue to be administered anti-inflammatory medication.
  • the treatment program may be amended such that it is more suitable for the lesion after progression.
  • the subject may require surgery.
  • a method for monitoring a change in a size of a lesion in a connective tissue which comprises: i) determining an area of the lesion from an ultrasonogram of an ultrasound scan carried out on the connective tissue, and determining a total area of the connective tissue from the ultrasonogram; ii) determining the area of the lesion as a proportion of the total area of the connective tissue; iii) repeating steps (i) and (ii) after a period; and iv) determining whether the area of the lesion as a proportion of the total area of the connective tissue has changed.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • a computerized method for monitoring a change in a size of a lesion in a connective tissue comprising: i) determining an area of the lesion from an ultrasonogram of an ultrasound scan carried out on the connective tissue, and determining a total area of the connective tissue from the ultrasonogram; ii) determining the area of the lesion as a proportion of the total area of the connective tissue; iii) repeating steps (i) and (ii) after a period; and iv) determining whether the area of the lesion as a proportion of the total area of the connective tissue has changed.
  • step (iii) determining that the lesion size has decreased over the period. This may indicate that the lesion is healing.
  • the treatment program may be amended such that it is more suitable for the lesion after healing. For instance, the subject may no longer need to rest the connective tissue, but continue to be administered anti-inflammatory medication.
  • step (iii) determining that the lesion size has increased over the period. This may indicate that the lesion is progressing.
  • the treatment program may be amended such that it is more suitable for the lesion after progression.
  • the subject may require surgery.
  • step (iii) determining that the lesion size has remained the same over the period. This may indicate that the lesion is stable, or that a treatment program isn’t effective.
  • the treatment program may be continued unamended, until the area of the lesion decreases as a proportion of the total area of the connective tissue.
  • the period is at least one day, at least a week, at least two weeks, at least a month, at least six months, or at least twelve months.
  • a method of the invention further comprises carrying out the ultrasound scan of the connective tissue, and providing an ultrasonogram from the ultrasound scan.
  • the ultrasonogram is a cross-sectional ultrasonogram.
  • the ultrasonogram is a longitudinal ultrasonogram.
  • the area of the lesion is determined by grey scale analysis of the ultrasonograms.
  • the area of the connective tissue which does not form a part of the area of the lesion is healthy connective tissue.
  • the connective tissue is a tendon or ligament tissue.
  • the lesion is the result of an injury to the subject.
  • the injury is an acute injury.
  • the injury is a traumatic injury.
  • the injury is an overload injury.
  • the injury is a chronic injury.
  • the chronic injury is caused by long-term micro-trauma or degradation of the connective tissue.
  • the chronic injury is a caused by chronic inflammation about the tissue.
  • the subject is a horse.
  • the subject is a polo horse.
  • the polo horse takes a right forelimb lead.
  • the subject is a racehorse.
  • the racehorse takes a right or a left forelimb lead.
  • the connective tissue comprises a flexor tendon or an extensor tendon.
  • the flexor tendon is a superficial digital flexor tendon (SDFT), or a deep digital flexor tendon (DDFT).
  • SDFT superficial digital flexor tendon
  • DDFT deep digital flexor tendon
  • the extensor tendon is a lateral digital extensor tendon (LDET), or a common digital extensor tendon (CDET).
  • LDET lateral digital extensor tendon
  • CDET common digital extensor tendon
  • the subject is a non-human subject.
  • the subject is a human subject.
  • the human subject is an athlete, a sportsman, or a sports woman.
  • the human subject is a professional athlete, sportsman, or sports woman.
  • athlete is used herein to include a person (male or female) who is trained or skilled in exercises, sports, or games requiring physical strength, agility, or stamina.
  • Examples of athletes include sprinters (including runners of track races of 100 metres, 200 metres, and 400 metres), middle distance runners (including runners of track races of 500 metres to less than 3,000 metres, including 800 metres, 1500 metres), long distance runners (including runners of at least 3000 metres, including 3000 metres, 5000 metres, 10,000 metres), hurdles (including runners of track races of 100 metre hurdles, 110 metre hurdles, 400 metre hurdles) relays (4x100 metres, 4x400 metres).
  • Examples of sports include association football (often referred to as simply “football” or “soccer”), rugby football (including rugby union or rugby league), American football, basketball, baseball (including Major League Baseball).
  • the connective tissue comprises an anterior cruciate ligament (ACL).
  • ACL anterior cruciate ligament
  • the connective tissue comprises an Achilles tendon.
  • the connective tissue comprises a flexor tendon.
  • the connective tissue comprises a tibial tendon.
  • the connective tissue comprises a peroneal tendon.
  • a method for determining a size of a lesion in a muscle tissue which comprises determining an area of the lesion from an ultrasonogram of an ultrasound scan carried out on the muscle tissue.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • a computerized method for determining a size of a lesion in a muscle tissue comprising determining an area of the lesion from an ultrasonogram of an ultrasound scan carried out on the muscle tissue.
  • the method further comprises determining the area of the lesion as a proportion of the total area of the muscle tissue.
  • a treatment program is initiated for the subject which is appropriate for the size and/or severity of the lesion.
  • the treatment program comprises administering to the subject anti-inflammatory medication, dietary supplementation, or stem-cell treatment, and/or cold therapy, rest, confinement, surgery, or a loading/working training regime.
  • the method is repeated after a period to determine whether there is a change in the area of the lesion.
  • a method for monitoring a change in a size of a lesion in a muscle tissue which comprises: i) determining an area of the lesion from an ultrasonogram of an ultrasound scan carried out on the muscle tissue; ii) repeating step (i) after a period; and iii) determining whether the area of the lesion has changed.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • a computerized method for monitoring a change in a size of a lesion in a muscle tissue comprising: i) determining an area of the lesion from an ultrasonogram of an ultrasound scan carried out on the muscle tissue; ii) repeating step (i) after a period; and iii) determining whether the area of the lesion has changed.
  • step (iii) If it is determined that the area of the lesion obtained in step (iii) is less than that obtained in step (ii), it is determined that the lesion size has decreased over the period. This indicates that the lesion is healing.
  • step (iii) If it is determined that the area of the lesion obtained in step (iii) is greater than that obtained in step (ii), it is determined that the lesion size has increased over the period. This indicates that the lesion is progressing.
  • the period is at least one day, at least a week, at least two weeks, at least a month, at least six months, or at least twelve months.
  • the ultrasonogram is a cross-sectional ultrasonogram.
  • the ultrasonogram is a longitudinal ultrasonogram.
  • the area of the lesion is determined by grey scale analysis of the ultrasonograms.
  • an area of the muscle tissue which does not form a part of the area of the lesion is healthy muscle tissue.
  • the muscle tissue is cardiac tissue.
  • the injury is an acute injury.
  • the muscle tissue is cardiac muscle tissue, and the injury is caused by decreased or complete cessation of blood flow to the cardiac tissue.
  • the muscle is cardiac muscle and the injury is caused by blunt cardiac injury.
  • the injury is an overload injury.
  • the injury is caused by long-term disruption of blood flow to the tissue.
  • the tissue is cardiac tissue and the injury is caused by atherosclerosis.
  • the chronic injury is caused by long-term micro-trauma or degradation of the muscle tissue.
  • the chronic injury is caused by chronic inflammation about the tissue.
  • the muscle tissue is human muscle tissue.
  • the subject is a human subject.
  • An advantage of methods of the invention is that they can provide real-time information on lesion size.
  • the methods also provide information on the change in the size and severity of the lesion over a period. This allows for rapid diagnosis and monitoring of a connective tissue lesion.
  • Such methods enable appropriate treatment of the lesion to be administered soon after diagnosis, and for the treatment to be modified over a period of time depending on changes in the state of the lesion.
  • methods of the invention facilitate healing and functional recovery of the tissue.
  • a method for determining the fitness potential of a connective tissue of interest in a subject comprising: i) determining an echogenicity value of a first connective tissue in a limb of the subject, and an echogenicity value of a second connective tissue in the same limb of the subject, wherein the connective tissue of interest is the first connective tissue; and ii) determining a ratio of the echogenicity value of the first connective tissue to the echogenicity value of the second tissue.
  • a method for determining the fitness potential of a connective tissue of interest in a subject comprising: i) determining an echogenicity value of a first connective tissue in a limb of the subject, and an echogenicity value of a second connective tissue in the same limb of the subject, wherein the connective tissue of interest is the first connective tissue; ii) determining a ratio of the echogenicity value of the first connective tissue to the echogenicity value of the second tissue; and iii) if the ratio determined in step (ii) is: a. less than one, determining that the fitness potential of the connective tissue of interest is lower than the fitness potential of the second connective tissue; or b. greater than one, determining that the fitness potential of the connective tissue of interest is higher than the fitness potential of the second connective tissue; or c. one, determining that the fitness potential of the connective tissue of interest is the same as the fitness potential of the second connective tissue.
  • a method for determining the fitness potential of a connective tissue of interest in a subject comprising: i) determining an echogenicity value of a first connective tissue in a limb of the subject, and an echogenicity value of a second connective tissue in the same limb of the subject, wherein the connective tissue of interest is the first connective tissue; ii) determining a ratio of the echogenicity value of the first connective tissue to the echogenicity value of the second tissue; and iii) if the ratio determined in step (ii) is: a. less than one, determining that the fitness potential of the connective tissue of interest is lower than the fitness potential of the second connective tissue; or b. greater than one, determining that the fitness potential of the connective tissue of interest is higher than the fitness potential of the second connective tissue.
  • Methods of the invention are advantageous because the ratio of the echogenicity value of the first connective tissue to the echogenicity value of the second connective tissue determined in step (ii) provides a normalisation of the echogenicity value of the first connective tissue. This minimises differences in echogenicity values obtained due to changes in settings of the equipment used to determine the echogenicity values, or to differences in operator method.
  • Methods of the invention allow, for example, more accurate determination of the fitness potential of the connective tissue of interest.
  • the ratio determined at one time can also be compared with the ratio determined at a different time. This allows, for example, more accurate monitoring of changes in fitness potential of the connective tissue of interest.
  • fit potential is used herein to refer to a measure of the integrity or condition of the connective tissue of interest. It can be used, for example, to provide a diagnosis or an assessment of an injury to the connective tissue of interest, or of the state of recovery or healing of an injury to the connective tissue of interest, or of the susceptibility of the connective tissue of interest to injury. It can also provide a measure of the strength of the connective tissue of interest, for example to monitor improvements to already healthy connective tissue during or after a training program.
  • the second connective tissue is healthy connective tissue, it is expected that the echogenicity value of that tissue will remain relatively constant, so any change in the ratio over time will be due to a change in echogenicity of the connective tissue of interest.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • a computerized method for determining the fitness potential of a connective tissue of interest in a subject comprising: i) determining an echogenicity value of a first connective tissue in a limb of the subject, and an echogenicity value of a second connective tissue in the same limb of the subject, wherein the connective tissue of interest is the first connective tissue; ii) determining a ratio of the echogenicity value of the first connective tissue to the echogenicity value of the second tissue; and iii) if the ratio determined in step (ii) is: a) less than one, determining that the fitness potential of the connective tissue of interest is lower than the fitness potential of the second connective tissue; or b) greater than one, determining that the fitness potential of the connective tissue of interest is higher than the fitness potential of the second connective tissue; or c) one, determining that the fitness potential of the connective tissue of interest is the same as the fitness potential of the second connective tissue.
  • the second connective tissue is healthy connective tissue, and in step (iii), if the ratio determined in step (ii) is: a. less than one, determining that the connective tissue of interest has a low fitness potential; or b. greater than one, determining that the connective tissue of interest has a high fitness potential; or c. one, determining that the connective tissue of interest is healthy.
  • the connective tissue of interest has a high fitness potential, this may indicate, for example, that the connective tissue of interest is strong, or has a lower risk of injury.
  • a method of the invention further comprises repeating steps (i) to (iii) after a period to determine whether there is a change in the fitness potential of the connective tissue of interest.
  • the period is at least one day, at least a week, at least two weeks, or at least a month.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • a computerized method for determining a change in the fitness potential of a connective tissue of interest in a subject comprising: i) determining an echogenicity value of a first connective tissue in a limb of the subject, and an echogenicity value of a healthy second connective tissue in the same limb of the subject, wherein the connective tissue of interest is the first connective tissue; ii) determining a ratio of the echogenicity value of the first connective tissue to the echogenicity value of the second tissue; and iii) repeating steps (i) and (ii) after a period; and iv) if the ratio obtained in step (iii) is: a.
  • step (ii) determines that the fitness potential of the connective tissue of interest has increased; or b. similar to the ratio obtained in step (ii), determining that the fitness potential of the connective tissue of interest has remained the same; or c. lower than the ratio obtained in step (ii), determining that the fitness potential of the connective tissue of interest has reduced.
  • the period is at least one day, at least a week, at least two weeks, or at least a month.
  • the connective tissue of interest in a method for determining a change in the fitness potential of a connective tissue of interest in a subject, is an injured connective tissue, and if the ratio obtained in step (iii) is higher than the ratio obtained in step (ii), it is determined that the injury to the connective tissue of interest is healing.
  • the connective tissue of interest in a method for determining a change in the fitness potential of a connective tissue of interest in a subject, is a healthy connective tissue, and if the ratio obtained in step (iii) is lower than the ratio obtained in step (ii), it is determined that the connective tissue of interest is at risk of injury (or has a higher risk of injury).
  • the first connective tissue is in a forelimb of the subject.
  • the first connective tissue is in a left forelimb of the subject.
  • the first connective tissue is in a right forelimb of the subject.
  • the first connective tissue is in a hindlimb of the subject.
  • the first connective tissue is in a left hindlimb of the subject.
  • the first connective tissue is in a right hindlimb of the subject.
  • a ratio of the echogenicity value of the second connective tissue to the echogenicity value of the first connective tissue can instead be determined.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • a method for determining the fitness potential of a connective tissue of interest in a subject comprising: i) determining an echogenicity value of a first connective tissue in a limb of the subject, and an echogenicity value of a second connective tissue in the same limb of the subject, wherein the connective tissue of interest is the first connective tissue; ii) determining a ratio of the echogenicity value of the second connective tissue to the echogenicity value of the first connective tissue; and iii) if the ratio determined in step (ii) is: a.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • a method for determining a change in the fitness potential of a connective tissue of interest in a subject comprising: i) determining an echogenicity value of a first connective tissue in a limb of the subject, and an echogenicity value of a healthy second connective tissue in the same limb of the subject, wherein the connective tissue of interest is the first connective tissue; ii) determining a ratio of the echogenicity value of the second connective tissue to the echogenicity value of the first connective tissue; and iii) repeating steps (i) and (ii) after a period; and iv) if the ratio obtained in step (iii) is: a.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • step (iii) determining that the fitness potential of the connective tissue of interest is lower than the fitness potential of the first connective tissue in the compared limb; or b. similar to the compared relative difference in step (iii), determining that the fitness potential of the connective tissue of interest is similar to the fitness potential of the first connective tissue in the compared limb; or c. higher than the compared relative difference in step (iii), determining that the fitness potential of the connective tissue of interest is higher than the fitness potential of the first connective tissue in the compared limb.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • the compared limb in step (iii) is a different limb of the same subject.
  • the compared limb in step (iii) is the same limb of a different subject.
  • the compared limb in step (iii) is a different limb of a different subject.
  • the corresponding relative difference obtained for first and second connective tissue of the compared limb in step (iii) is a predetermined corresponding relative difference previously obtained for the first and second connective tissues of the compared limb.
  • the corresponding relative difference obtained for first and second connective tissue in step (iii) is a predetermined corresponding relative difference previously obtained for the first and second connective tissues in the same limb of the same subject.
  • the predetermined corresponding relative difference was obtained when the connective tissue of interest was healthy.
  • the echogenicity value of the connective tissue of interest obtained in step (i) is obtained after an injury to the first connective tissue.
  • the predetermined corresponding relative difference was obtained after an injury to the connective tissue of interest.
  • the echogenicity value of the connective tissue of interest obtained in step (i) is obtained while the injury to the first connective tissue is healing.
  • the period is at least one day, at least a week, at least two weeks, or at least a month.
  • step (iv) determining that the fitness potential of the connective tissue of interest has improved; or b. similar to the compared relative difference obtained in step (iv), determining that the fitness potential of the connective tissue of interest has remained the same; or c. lower than the compared relative difference obtained in step (iv), determining that the fitness potential of the connective tissue of interest has reduced.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • the period is at least one day, at least a week, at least two weeks, or at least a month.
  • the second connective tissue, in step (i) of a method for determining a change in the fitness potential of a connective tissue of interest in a subject is healthy connective tissue, and the first and second connective tissue in step (iii) is healthy connective tissue.
  • the connective tissue of interest in a method for determining a change in the fitness potential of a connective tissue of interest in a subject, is an injured connective tissue, and if the compared relative difference obtained in step (iii) is higher than the compared relative difference obtained in step (iv), it is determined that the injury to the connective tissue of interest is healing.
  • the connective tissue of interest in a method for determining a change in the fitness potential of a connective tissue of interest in a subject, is a healthy connective tissue, and if the compared relative difference obtained in step (iii) is lower than the compared relative difference obtained in step (iv), it is determined that the connective tissue of interest is at risk of injury.
  • the connective tissue is tendon or ligament tissue.
  • the echogenicity values are determined quantitatively.
  • the echogenicity values are determined by ultrasonography.
  • the echogenicity values are determined by quantifying the echogenicity of ultrasonographic images.
  • the echogenicity is quantified by grey scale analysis of ultrasonographic images.
  • the grey scale analysis of ultrasonographic images includes analysis of cross- sectional ultrasonographic images taken of the connective tissues.
  • the grey scale analysis of ultrasonographic images includes analysis of longitudinal ultrasonographic images taken of the connective tissues.
  • a mean echogenicity value is determined for each connective tissue in each limb.
  • a quantitative measure of echogenicity of the connective tissue of interest and the second connective tissue is computed from an ultrasound image (an ultrasonograph) of each tissue.
  • This can be performed by grey scale analysis using any suitable software, for example open-source image processing software, lmageJ2 (version 2.3.0/1 .53f).
  • a mean grey scale (MGS) value for each tissue is determined.
  • Each tissue has a value between 0 (black) and 255 (white), representing the mean echogenicity value of the tissue.
  • a ratio of the resultant values is determined for each limb (for example, an SDFT/DDFT ratio). The ratio of mean echogenicity of the injured tendon to that of the healthy tendon is determined to assess the extent of damage/healing at a lesion.
  • the connective tissue of interest comprises damaged tissue.
  • a mean echogenicity value is determined for a lesion in the damaged tissue.
  • a mean echogenicity value is determined for tissue excluding a lesion in the damaged tissue.
  • the damage tissue is the result of an injury to the subject.
  • the injury is an acute injury.
  • the injury is a traumatic injury.
  • the injury is an overload injury.
  • the injury is a chronic injury.
  • the chronic injury is caused by long-term micro-trauma or degradation of the connective tissue.
  • the chronic injury is caused by chronic inflammation about the tissue.
  • the first connective tissue is in a forelimb, or an upper limb, of the subject.
  • the first connective tissue is in a hindlimb, or a lower limb, of the subject.
  • the subject is a horse.
  • the polo horse takes a right forelimb lead.
  • the racehorse takes a right or a left forelimb lead.
  • the connective tissue comprises a flexor tendon or an extensor tendon.
  • the flexor tendon is a superficial digital flexor tendon (SDFT), or a deep digital flexor tendon (DDFT).
  • SDFT superficial digital flexor tendon
  • DDFT deep digital flexor tendon
  • the first connective tissue is a SDFT and the second connective tissue is a DDFT.
  • the first connective tissue is a LDET and the second connective tissue is a CDET.
  • the first connective tissue comprises a suspensory ligament, or a check ligament.
  • the first connective tissue is a suspensory ligament and the second connective tissue is a check ligament.
  • the first connective tissue is a check ligament and the second connective tissue is a suspensory ligament.
  • the first connective tissue is a healthy connective tissue (i.e. does not comprise an injury).
  • the subject is a horse, wherein the first connective tissue is a healthy connective tissue (i.e. does not comprise an injury).
  • the first connective tissue is not a SDFT of a horse.
  • the first connective tissue is not a left fore SDFT of a horse.
  • the first connective tissue is not a check ligament of a horse.
  • the first connective tissue is not a left fore check ligament of a horse.
  • the subject is a horse, excluding a polo horse.
  • the subject is a human subject.
  • the human subject is a professional athlete, sportsman, or sports woman.
  • athlete is used herein to include a person (male or female) who is trained or skilled in exercises, sports, or games requiring physical strength, agility, or stamina.
  • Examples of athletes include sprinters (including runners of track races of 100 metres, 200 metres, and 400 metres), middle distance runners (including runners of track races of 500 metres to less than 3,000 metres, including 800 metres, 1500 metres), long distance runners (including runners of at least 3000 metres, including 3000 metres, 5000 metres, 10,000 metres), hurdles (including runners of track races of 100 metre hurdles, 110 metre hurdles, 400 metre hurdles) relays (4x100 metres, 4x400 metres).
  • Examples of sports include association football (often referred to as simply “football” or “soccer”), rugby football (including rugby union or rugby league), American football, basketball, baseball (including Major League Baseball).
  • the first connective tissue is in an upper limb of the subject.
  • the first connective tissue is a tendon in a finger in a hand of the subject
  • the second connective tissue is a tendon in a different finger in the same hand of the subject.
  • the first connective tissue is in a lower limb of the subject.
  • the first connective tissue is a tendon in a toe in a foot of the subject
  • the second connective tissue is a tendon in a different toe in the same foot of the subject.
  • the first connective tissue comprises a tendon in a foot of the subject, wherein the tendon is selected from a tibial tendon, an Achilles tendon, or a peroneal tendon
  • the second connective tissue comprises a different tendon in the same foot of the subject, wherein the tendon is selected from a tibial tendon, an Achilles tendon, or a peroneal tendon.
  • the first connective tissue comprises a posterior tibial tendon
  • the second connective tissue comprises an anterior tibial tendon
  • the first connective tissue comprises an anterior tibial tendon
  • the second connective tissue is a posterior tibial tendon
  • the second connective tissue is an equivalent connective tissue to the first connective tissue.
  • An equivalent connective tissue may be in the same limb as the connective tissue of interest.
  • equivalent connective tissue is used herein to refer to a connective tissue which has the same or a similar structure and/or function as the connective tissue of interest.
  • the skilled person will appreciate that it is advantageous for an equivalent connective tissue to have the same or a similar tissue structure and composition to the connective tissue of interest, such that its echogenicity can be used as a suitable comparison to the echogenicity of the connective tissue of interest.
  • the equivalent connective tissue can be used, for example, to provide a comparative connective tissue for the determination of the fitness potential of the connective tissue of interest.
  • the equivalent connective tissue can be used for determination of a ratio of the echogenicity value of the connective tissue of interest to the echogenicity value of the equivalent connective tissue.
  • the echogenicity value of the equivalent connective tissue can be used to determine the change in fitness potential of the connective tissue of interest over time.
  • the echogenicity value of the equivalent connective tissue may provide a relatively fixed value such that the change in echogenicity value of the connective tissue of interest can be deduced. This in turn can be used to determine the amount and rate of healing of a damaged connective tissue, or the propensity for a connective tissue to become damaged over time. It can also provide a means to determine the strength of the connective tissue of interest, for example to monitor improvements to already healthy connective tissue during or after a training program.
  • a connective tissue of interest may be in an upper limb or a forelimb of the subject, or in a lower limb or a hindlimb of the subject.
  • a connective tissue of interest may, for example, be in a shoulder, arm, upper arm, lower arm, elbow, wrist, hand, or finger, a hip, leg, upper leg, lower leg, knee, ankle, foot, or toe of the subject.
  • the connective tissue of interest may be in a finger of one hand, and an equivalent connective tissue may be in a different finger (for example, an adjacent finger) of the same hand.
  • the connective tissue of interest may be in a toe of one foot, and an equivalent connective tissue may be in a different toe (for example, an adjacent toe) of the same foot.
  • the connective tissue of interest may be the tibialias posterior, Achilles Tendon or the peroneal tendon, in humans.
  • the equivalent tendon may, for example, be one of these tendons in the same foot.
  • the equivalent connective tissue may perform a similar function as the connective tissue of interest.
  • the connective tissue of intertest may be a flexor tendon, and the equivalent connective tissue may also be a flexor tendon.
  • the connective tissue of intertest may be an extensor tendon, and the equivalent connective tissue may also be an extensor tendon.
  • the connective tissue of interest may be a flexor tendon (for example, a flexor tendon of a finger), and the equivalent connective tissue may also be a flexor tendon (for example, a flexor tendon of a different finger in the same hand, such as an adjacent finger), rather than an extensor tendon.
  • a method for determining the fitness potential of a connective tissue of interest in a subject comprising: i) determining an echogenicity value of the connective tissue of interest in a first limb of the subject; ii) determining an echogenicity value of an equivalent connective tissue in a second limb of the subject; iii) determining a ratio of the echogenicity value of the connective tissue of interest in the first limb to the echogenicity value of the equivalent connective tissue in the second limb; and iv) if the ratio determined in step (iii) is: a) less than one, determining that the fitness potential of the connective tissue of interest in the first limb is lower than the fitness potential of the equivalent connective tissue in the second limb; or b) greater than one, determining that the fitness potential of the connective tissue of interest in the first limb is higher than the fitness potential of the equivalent connective tissue in the second limb; or c) one, determining that the fitness potential of the
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • steps (i) to (iii) are repeated after a period to determine whether there is a change in the fitness potential of the connective tissue of interest.
  • the period is at least one day, at least a week, at least two weeks, or at least a month.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • the connective tissue of interest is a healthy connective tissue, and if the ratio obtained in step (iv) is lower than the ratio obtained in step (iii), it is determined that the connective tissue of interest is at risk of injury.
  • the second limb is a different limb of the same subject.
  • An equivalent connective tissue may be in the opposite limb to the connective tissue of interest.
  • the connective tissue of interest may be in a finger of one hand (such as an index finger), and an equivalent connective tissue may be in the corresponding finger (such as an index finger) of the opposite hand.
  • the connective tissue of interest may be in a toe of one foot, and an equivalent connective tissue may be in a corresponding toe of the opposite foot.
  • the connective tissue of interest may be a tendon in an arm of the subject, and the equivalent connective tissue may be the corresponding tendon in the opposite arm of the subject.
  • the connective tissue of interest may be the tibialias posterior tendon, Achilles Tendon or peroneal tendon, in humans.
  • the equivalent tendon may, for example, be the corresponding tendon in the opposite foot.
  • the equivalent connective tissue may perform a similar function as the connective tissue of interest.
  • the connective tissue of intertest may be a flexor tendon, and the equivalent connective tissue may also be a flexor tendon.
  • the connective tissue of intertest may be an extensor tendon, and the equivalent connective tissue may also be an extensor tendon.
  • the connective tissue of interest may be a flexor tendon (for example, a flexor tendon of a finger), and the equivalent connective tissue may also be a flexor tendon (for example, a flexor tendon in the corresponding finger of the opposite hand), rather than an extensor tendon.
  • a flexor tendon for example, a flexor tendon of a finger
  • the equivalent connective tissue may also be a flexor tendon (for example, a flexor tendon in the corresponding finger of the opposite hand), rather than an extensor tendon.
  • a ratio of the echogenicity value of the connective tissue of interest in the first limb to the echogenicity value of the connective tissue in the second limb in step (ii) can instead be determined.
  • a method for determining the fitness potential of a connective tissue of interest in a subject comprising: i) determining an echogenicity value of the connective tissue of interest in a first limb of the subject; ii) determining an echogenicity value of an equivalent connective tissue in a second limb of the subject; iii) determining a ratio of the echogenicity value of the connective tissue in the second limb to the echogenicity value of the equivalent connective tissue of interest in the first limb; and iv) if the ratio determined in step (iii) is: a) greater than one, determining that the fitness potential of the connective tissue of interest in the first limb is lower than the fitness potential of the equivalent connective tissue in the second limb; or b) less than one, determining that the fitness potential of the connective tissue of interest in the first limb is higher than the fitness potential of the equivalent connective tissue in the second limb; or c) one, determining that the fitness potential of the
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • the connective tissue in the second limb is healthy, and if the ratio determined in step (iii) is: a) greater than one, determining that the connective tissue of interest is injured or at risk of injury; or b) less than one, determining that the connective tissue of interest has a high fitness potential; or c) one, determining that the connective tissue of interest is healthy.
  • steps (i) to (iii) are repeated after a period to determine whether there is a change in the fitness potential of the connective tissue of interest.
  • the period is at least one day, at least a week, at least two weeks, or at least a month.
  • a method for determining a change in the fitness potential of a connective tissue of interest in a subject comprising: i) determining an echogenicity value of a connective tissue of interest in a first limb of the subject; ii) determining an echogenicity value of an equivalent connective tissue in a second limb of the subject; iii) determining a ratio of the echogenicity value of the connective tissue in the second limb to the echogenicity value of the connective tissue of interest in the first limb; iv) repeating steps (i) to (iii) after a period; and v) if the ratio obtained in step (iv) is: a) lower than the ratio obtained in step (iii), determining that the fitness potential of the connective tissue of interest has increased; or b) the same as the ratio obtained in step (iii), determining that the fitness potential of the connective tissue of interest has remained the same; or c) higher than the ratio obtained in step
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • the connective tissue of interest is an injured connective tissue, and if the ratio obtained in step (iv) is lower than the ratio obtained in step (iii), it is determined that the injury to the connective tissue of interest is healing.
  • the connective tissue of interest is a healthy connective tissue, and if the ratio obtained in step (iv) is higher than the ratio obtained in step (iii), it is determined that the connective tissue of interest is at risk of injury.
  • the echogenicity value of the equivalent connective tissue in the second limb determined in step (ii) is a predetermined echogenicity value previously obtained for the connective tissue of the compared limb.
  • the predetermined echogenicity value was obtained when the connective tissue of the compared limb was healthy.
  • the echogenicity value of the connective tissue of interest obtained in step (i) is obtained after an injury to the connective tissue of interest.
  • the echogenicity value of the connective tissue of interest obtained in step (i) is obtained while the injury to the connective tissue of interest is healing.
  • the subject is a non-human subject.
  • the connective tissue of interest is in a forelimb, or an upper limb, of the subject, and the equivalent connective tissue is in the opposite forelimb, or opposite upper limb, of the subject.
  • the connective tissue of interest is in a hindlimb, or a lower limb, of the subject, and the equivalent connective tissue is in the opposite hindlimb, or opposite lower limb, of the subject.
  • the subject is a human subject.
  • the connective tissue of interest is in an upper limb of the subject, and the equivalent connective tissue is in the opposite upper limb of the subject.
  • the connective tissue of interest is in a lower limb of the subject, and the equivalent connective tissue is in the opposite lower limb of the subject.
  • the connective tissue is tendon or ligament tissue.
  • the connective tissue is a flexor tendon or an extensor tendon.
  • the first connective tissue is a tendon in a finger in a hand of the subject
  • the second connective tissue is a tendon in a corresponding finger in the opposite hand of the subject.
  • the first connective tissue is a tendon in a toe in a foot of the subject
  • the second connective tissue is a tendon in a corresponding toe in the opposite foot of the subject.
  • the first connective tissue comprises a tendon in a foot of the subject, wherein the tendon is selected from a tibial tendon, an Achilles tendon, or a peroneal tendon, and the second connective tissue comprises a corresponding tendon in the opposite foot of the subject.
  • the echogenicity values are determined quantitatively.
  • the echogenicity values are determined by ultrasonography.
  • the echogenicity values are determined by quantifying the echogenicity of ultrasonographic images.
  • the echogenicity is quantified by grey scale analysis of ultrasonographic images.
  • Optionally quantification by grey scale analysis of ultrasonographic images includes analysis of cross-sectional ultrasonographic images taken of the connective tissues.
  • Optionally quantification by grey scale analysis of ultrasonographic images includes analysis of longitudinal ultrasonographic images taken of the connective tissues.
  • a mean echogenicity value is determined for the connective tissue in the first limb, and a mean echogenicity value is determined for the connective tissue in the second limb.
  • the connective tissue of interest comprises damaged tissue.
  • a mean echogenicity value is determined for a lesion in the damaged tissue.
  • a mean echogenicity value is determined for tissue excluding a lesion in the damaged tissue.
  • tissue damage is the result of an injury to the subject.
  • the injury is an acute injury.
  • the injury is a chronic injury.
  • the chronic injury is caused by long-term micro-trauma or degradation of the connective tissue.
  • the chronic injury is a caused by chronic inflammation about the tissue.
  • the second connective tissue comprises ligament tissue.
  • first connective tissue comprises tendon tissue
  • second connective tissue comprises ligament tissue
  • the first connective tissue comprises ligament tissue.
  • the second connective tissue comprises tendon tissue.
  • the first connective tissue comprises ligament tissue
  • the second connective tissue comprises tendon tissue.
  • a method for determining the fitness potential of an area of interest in a tissue of a subject comprising: i) determining an echogenicity value of a first area of the tissue, and an echogenicity value of a second area of the same tissue spatially distant from the first area, wherein the area of interest is the first area; ii) determining a relative difference of the echogenicity value of the first area to the echogenicity value of the second area; and iii) if the relative difference determined in step (ii) is: a) less than one, determining that the fitness potential of the area of interest is lower than the fitness potential of the second area; b) greater than one, determining that the fitness potential of the area of interest is higher than the fitness potential of the second area; or c) one, determining that the fitness potential of the area of interest is the same as the fitness potential of the second area.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • the second area is healthy tissue
  • the method comprises, if the relative difference determined in step (ii) is: a) less than one, determining that the area of interest is injured or at risk of injury; or b) greater than one, determining that the area of interest has a high fitness potential; or c) one, determining that the area of interest is healthy.
  • the method further comprises repeating steps (i) to (iii) after a period to determine whether there is a change in the fitness potential of the area of interest.
  • the period is at least one day, at least a week, at least two weeks, or at least a month.
  • a method for determining a change in the fitness potential of an area of interest in tissue in a subject comprising: i) determining an echogenicity value of a first area of the tissue, and an echogenicity value of a second area of the same tissue spatially distant from the first area, wherein the area of interest is the first area of the tissue; ii) determining a relative difference of the echogenicity value of the first area to the echogenicity value of the second area;
  • step (iii) is: a) higher than the relative difference obtained in step (ii), determining that the fitness potential of the area of interest has increased; or b) similar to the relative difference obtained in step (ii), determining that the fitness potential of the area of interest has remained the same; or c) lower than the relative difference obtained in step (ii), determining that the fitness potential of the area of interest has reduced.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • the period is at least one day, at least a week, at least two weeks, or at least a month.
  • the area of interest comprises injured tissue, and if the relative difference obtained in step (iii) is higher than the relative difference obtained in step (ii), it is determined that the injury to the area of interest is healing.
  • the area of interest is healthy tissue, and if the relative difference obtained in step (iii) is lower than the relative difference obtained in step (ii), it is determined that the area of interest is at risk of injury.
  • a method of the invention further comprises: a) comparing the relative difference obtained in step (ii) with a relative difference obtained for a corresponding first and second area for tissue of the same type as for the relative difference obtained in step (ii) but at the same or a different site for the same subject, or at the same or a different site for a different subject; and b) if the relative difference obtained in step (ii) is: lower than the relative difference obtained in step (a), determining that the fitness potential of the area of interest is lower than the fitness potential of the corresponding first area of tissue in the compared tissue; or similar to the relative difference obtained in step (a), determining that the fitness potential of the area of interest is similar to the fitness potential of the corresponding first area of tissue in the compared tissue; or higher than the relative difference obtained in step (a), determining that the fitness potential of the area of interest is higher than the fitness potential of the corresponding first area of tissue in the compared tissue.
  • step (a) is at the same site for a different subject.
  • step (a) is at a different site for a different subject.
  • step (a) is at a same site for the same subject.
  • step (a) is at a different site for the same subject.
  • the relative difference obtained for the corresponding first and second area of the compared tissue in step (a) is a predetermined relative difference previously obtained for the first and second area of the compared tissue.
  • the predetermined relative difference was obtained when the area of interest was healthy.
  • the echogenicity value of the area of interest obtained in step (i) is obtained after an injury to the area of interest.
  • the predetermined relative difference was obtained after an injury to the area of interest.
  • the echogenicity value of the area of interest obtained in step (i) is obtained while the injury to the area of interest is healing.
  • the second area of tissue in step (i) is healthy tissue
  • the first and second area of tissue in step (a) is healthy tissue
  • the relative difference obtained in step (ii) is: a) lower than the compared relative difference in step (a), determining that the area of interest is injured or at risk of injury; or b) similar to the compared relative difference in step (a), determining that the area of interest is healthy; or c) higher than the compared relative difference in step (a), determining that the area of interest has high fitness potential.
  • a method of the invention further comprises repeating steps (i) to (iii) after a period to determine whether there is a change in the fitness potential of the area of interest.
  • the period is at least one day, at least a week, at least two weeks, or at least a month.
  • a method for determining a change in the fitness potential of an area of interest in a tissue of a subject comprising: i) determining an echogenicity value of a first area of the tissue, and an echogenicity value of a second area of the same tissue spatially distant from the first area, wherein the area of interest is the first area; ii) determining a relative difference between the echogenicity values obtained for the first and second areas in step (i); iii) comparing the relative difference obtained in step (ii) with a relative difference obtained for a corresponding first and second area of the same tissue of the same or different subject; iv) repeating steps (i) to (iii) after a period; and v) determining whether there is a difference between the compared relative difference obtained in step (iii) and the compared relative difference obtained in step (iv); and if the compared relative difference obtained in step (iii) is: a) higher than the compared relative difference obtained in step
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • the period is at least one day, at least a week, at least two weeks, or at least a month.
  • the second area in step (i) is healthy tissue, and the first and second areas in step (iii) are healthy connective tissues.
  • the area of interest comprises injured tissue, and if the compared relative difference obtained in step (iii) is higher than the compared relative difference obtained in step (iv), determining that the injury to the area of interest is healing.
  • the area of interest is healthy tissue, and if the compared relative difference obtained in step (iii) is lower than the compared relative difference obtained in step (iv), determining that that the area of interest is at risk of injury.
  • the tissue comprises connective tissue.
  • the tissue comprises tendon or ligament tissue.
  • the tissue comprises muscle tissue.
  • the tissue comprises cardiac muscle tissue.
  • a method for determining the fitness potential of a muscle tissue of interest comprises: i) determining an echogenicity value of a muscle tissue of interest; and ii) if the echogenicity value obtained in (i) is: a) less than an echogenicity value for a corresponding muscle tissue, determining that the fitness potential of the tissue of interest is lower than the fitness potential of the corresponding muscle tissue; b) greater than an echogenicity value for the corresponding muscle tissue, determining that the fitness potential of the tissue of interest is higher than the fitness potential of the corresponding muscle tissue; or c) the same as an echogenicity value for the corresponding muscle tissue, determining that the fitness potential of the tissue of interest is the same as the fitness potential of the corresponding muscle tissue.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • the corresponding muscle tissue is healthy tissue
  • the method comprises, if the echogenicity value determined in step (i) is: a) less than an echogenicity value for the corresponding muscle tissue, determining that the tissue of interest is injured or at risk of injury; b) greater than an echogenicity value for the corresponding muscle tissue, determining that the tissue of interest has high fitness potential; or c) the same as an echogenicity value for the corresponding muscle tissue, determining that the tissue of interest is healthy.
  • the method further comprises repeating steps (i) and (ii) after a period to determine whether there is a change in the fitness potential of the tissue of interest.
  • the period is at least one day, at least a week, at least two weeks, or at least a month.
  • the corresponding muscle tissue is the same muscle tissue of the same subject.
  • the echogenicity value of the corresponding muscle tissue is a predetermined value previously obtained.
  • the echogenicity value of the corresponding muscle tissue is a predetermined value previously obtained from the same subject.
  • the predetermined echogenicity value was obtained when the muscle tissue of interest was healthy.
  • the echogenicity value of the muscle tissue of interest obtained in step (i) was obtained after an injury to the muscle tissue.
  • the corresponding muscle tissue is the same muscle tissue of a different subject.
  • the echogenicity value of the corresponding muscle tissue is a predetermined echogenicity value obtained from a different subject.
  • the echogenicity value of the corresponding muscle tissue was obtained after an injury to the muscle tissue of interest.
  • the echogenicity of the muscle tissue of interest obtained in step (i) is obtained while the injury to the muscle tissue of interest is healing.
  • a method for determining a change in the fitness potential of a muscle tissue of interest in a subject comprising: i) determining an echogenicity value of the muscle tissue of interest; ii) repeating step (i) after a period; and iii) if the value obtained in step (ii) is: a) higher than the value obtained in step (i), determining that the fitness potential of the muscle tissue of interest has increased; or b) similar to the value obtained in step (i), determining that the fitness potential of the muscle tissue of interest has remained the same; or c) lower than the value obtained in step (i) , determining that the fitness potential of the muscle tissue of interest has reduced.
  • a method of the invention may be implemented on a general purpose computer, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • the computerized method may be implemented on a general purpose computer in software such as an application or app.
  • the period is at least one day, at least a week, at least two weeks, or at least a month.
  • the muscle tissue of interest is an injured tissue, and if the value obtained in step (ii) is higher than the value obtained in step (i), it is determined that the injury to the tissue of interest is healing.
  • the muscle tissue of interest is a healthy tissue, and if the value obtained in step (iii) is lower than the value obtained in step (ii), it is determined that the tissue of interest is at risk of injury.
  • the muscle tissue is cardiac muscle tissue.
  • the echogenicity values are determined quantitatively.
  • the echogenicity values are determined by ultrasonography.
  • the echogenicity values are determined by quantifying the echogenicity of ultrasonographic images.
  • the echogenicity is quantified by grey scale analysis of ultrasonographic images.
  • a method of the invention includes analysis of cross-sectional ultrasonographic images taken of the tissues.
  • a method of the invention includes analysis of longitudinal ultrasonographic images taken of the tissues.
  • a mean echogenicity value is determined for each tissue.
  • the tissue of interest comprises damaged tissue.
  • a mean echogenicity value is determined for a lesion in the damaged tissue.
  • a mean echogenicity value is determined for tissue excluding a lesion in the damaged tissue.
  • tissue damage is the result of an injury to the subject.
  • the injury is an acute injury.
  • the muscle tissue is cardiac muscle tissue, and the injury is caused by decreased or complete cessation of blood flow to the cardiac tissue.
  • the injury is caused by a full or partial occlusion of a blood vessel.
  • the blood vessel is a coronary artery.
  • the injury is caused by a tear or strain.
  • the injury is an overload injury.
  • the injury is a chronic injury.
  • the injury is caused by long-term disruption of blood flow to the tissue.
  • the tissue is cardiac tissue and the injury is caused by atherosclerosis.
  • the muscle tissue is human muscle tissue.
  • the subject is a human subject.
  • Figure 1 shows an ultrasonogram displayed on a computer display of a subtle core lesion in the lateral aspect of superficial digital flexor tendon (SDFT) with generalised surrounding tendonitis of a horse (ID 1 1 1 1 12): (a) before administration of any pharmaceutical composition comprising vitamin A; and (b) after daily administration of a pharmaceutical composition comprising vitamin A for 14 days;
  • SDFT superficial digital flexor tendon
  • Figure 2 shows an ultrasonogram displayed on a computer display of a nasty SDFT core lesion in the medial aspect not quite involving paratenon for a horse (ID REG6): (a) before administration of any pharmaceutical composition comprising vitamin A; and (b) after daily administration of a pharmaceutical composition comprising vitamin A for 14 days;
  • Figure 3(a) shows a cross-sectional ultrasonogram displayed on a computer display of the major tendons/ligaments present in the left foot of a horse (normal equine anatomy).
  • Figure 3(b) shows a longitudinal ultrasonogram (left) of the left foot of a horse compared with a cross-sectional ultrasonogram (right) of the left foot of the same horse (normal equine anatomy);
  • Figure 5 shows a cross-sectional ultrasonogram displayed on a computer display of a lesion in the left forelimb check ligament in a horse (ID 1431 ): (a) before administration of any vitamin A supplement comprising vitamin A; (b) after daily administration of a pharmaceutical composition comprising vitamin A for 3 weeks; (c) after daily administration of a pharmaceutical composition comprising vitamin A for 5 weeks; and (d) after daily administration of a pharmaceutical composition comprising vitamin A for 7 weeks.
  • IDL 1431 shows a cross-sectional ultrasonogram displayed on a computer display of a lesion in the left forelimb check ligament in a horse (ID 1431 ): (a) before administration of any vitamin A supplement comprising vitamin A; (b) after daily administration of a pharmaceutical composition comprising vitamin A for 3 weeks; (c) after daily administration of a pharmaceutical composition comprising vitamin A for 5 weeks; and (d) after daily administration of a pharmaceutical composition comprising vitamin A for 7 weeks.
  • Figure 6 shows a cross-sectional ultrasonogram displayed on a computer display of a lesion in the left forelimb SOFT in a horse (ID 8827): (a) before administration of any vitamin A supplement comprising vitamin A; (b) after daily administration of a pharmaceutical composition comprising vitamin A for 3 weeks; (c) after daily administration of a pharmaceutical composition comprising vitamin A for 5 weeks; and (d) after daily administration of a pharmaceutical composition comprising vitamin A for 7 weeks;
  • Figure 7 shows a cross-sectional ultrasonogram displayed on a computer display of a lesion in the left hindlimb medial suspensory branch ligament in a horse (ID 10520): (a) before administration of any vitamin A supplement comprising vitamin A; (b) after daily administration of a pharmaceutical composition comprising vitamin A for 3 weeks; (c) after daily administration of a pharmaceutical composition comprising vitamin A for 5 weeks; and (d) after daily administration of a pharmaceutical composition comprising vitamin A for 7 weeks, (d) shows improvements in axial aspect of the branch;
  • Figure 8 shows a cross-sectional ultrasonogram displayed on a computer display of a lesion in the left forelimb SDFT in a horse (ID 111112): (a) before administration of any vitamin A supplement comprising vitamin A; (b) after daily administration of a pharmaceutical composition comprising vitamin A for 3 weeks; (c) after daily administration of a pharmaceutical composition comprising vitamin A for 5 weeks; and (d) after daily administration of a pharmaceutical composition comprising vitamin A for 7 weeks.
  • Figure 9 shows a cross-sectional ultrasonogram displayed on a computer display of a lesion in the left forelimb SDFT in a horse (ID 123345): (a) before administration of any vitamin A supplement comprising vitamin A; (b) after daily administration of a pharmaceutical composition comprising vitamin A for 3 weeks; (c) after daily administration of a pharmaceutical composition comprising vitamin A for 5 weeks; and (d) after daily administration of a pharmaceutical composition comprising vitamin A for 7 weeks;
  • Figure 10 shows a cross-sectional ultrasonogram displayed on a computer display of a lesion in the right forelimb lateral SDFT in a horse (ID 1234567): (a) before administration of any vitamin A supplement comprising vitamin A; (b) after daily administration of a pharmaceutical composition comprising vitamin A for 3 weeks; (c) after daily administration of a pharmaceutical composition comprising vitamin A for 5 weeks; and (d) after daily administration of a pharmaceutical composition comprising vitamin A for 7 weeks.
  • Tendon is clearly filling in well;
  • Figure 11 shows a cross-sectional ultrasonogram displayed on a computer display of a lesion in the left forelimb SDFT in a horse (ID Q1 Q): (a) before administration of any vitamin A supplement comprising vitamin A; (b) after daily administration of a pharmaceutical composition comprising vitamin A for 3 weeks; (c) after daily administration of a pharmaceutical composition comprising vitamin A for 5 weeks; and (d) after daily administration of a pharmaceutical composition comprising vitamin A for 7 weeks;
  • Figure 12 shows a cross-sectional ultrasonogram displayed on a computer display of a lesion in the left forelimb SDFT in a horse (ID REG6): (a) before administration of any vitamin A supplement comprising vitamin A; (b) after daily administration of a pharmaceutical composition comprising vitamin A for 3 weeks; (c) after daily administration of a pharmaceutical composition comprising vitamin A for 5 weeks; and (d) after daily administration of a pharmaceutical composition comprising vitamin A for 7 weeks;
  • Figure 13 shows a longitudinal ultrasonogram displayed on a computer display of a lesion in the right forelimb lateral suspensory branch ligament in a horse (ID REG9): (a) before administration of any vitamin A supplement comprising vitamin A; (b) after daily administration of a pharmaceutical composition comprising vitamin A for 3 weeks; (c) after daily administration of a pharmaceutical composition comprising vitamin A for 5 weeks; and (d) after daily administration of a pharmaceutical composition comprising vitamin A for 7 weeks.
  • Image at week 7 Figure 12(d) shows improvement of injury as deeper lesion less visible;
  • Figure 14 shows a cross-sectional ultrasonogram displayed on a computer display of a lesion in the left forelimb check ligament in a horse (ID 1833): (a) before administration of any vitamin A supplement comprising vitamin A; and (b) after daily administration of a pharmaceutical composition comprising vitamin A for 5 weeks. Some improvement of check ligament injury appearance.
  • the horse also received platelet rich plasma;
  • Figure 15 shows a cross-sectional ultrasonogram displayed on a computer display of a lesion in the right forelimb check ligament in a horse (ID 1833): (a) before administration of any vitamin A supplement comprising vitamin A; and (b) after daily administration of a pharmaceutical composition comprising vitamin A for 5 weeks;
  • Figure 16 shows a cross-sectional ultrasonogram displayed on a computer display of a lesion in the left forelimb lateral SDFT in a horse (ID 6168): (a) before administration of any vitamin A supplement comprising vitamin A; and (b) after daily administration of a pharmaceutical composition comprising vitamin A for 3 weeks.
  • the figure shows good infilling of lateral SDFT lesion;
  • Figure 17 shows line graphs depicting size of lesion (as a % of baseline lesion size) in tendon/ligament injuries at specified time points after original injury (OG): (a) shows tendon/ligaments as a single cohort; (b) shows tendon injuries as a separate, single cohort; (c) shows ligamentous injuries as a separate, single cohort; and (d) shows ligamentous injuries as a separate, single cohort with outlier removed from data set. Data are presented as actual values for each subject;
  • Figure 18 shows a line graph depicting the effect of post-treatment maintenance dose of vitamin A supplement on the size of tendon/ligamentous lesions: (a) shows mean lesion size from week 0 to week 7 on full-treatment doses of vitamin A supplement before splitting into the values of the maintenance dose and placebo groups for week 7 to week 14; and (b) shows the lesion size for both maintenance and placebo groups from week 0 through to week 14, as well as the mean values for the groups from week 0 to week 7;
  • Figure 19 shows a series of cross-sectional ultrasonograms each displayed on a computer display of a tendon injury that became re-injured after administration of full-treatment doses of vitamin A supplement was stopped and a maintenance dose of supplement was administered.
  • Figure (a) shows an ultrasonogram of the lesion at baseline (week 0) before treatment with vitamin A supplement commenced;
  • (b) shows an ultrasonogram at week 7 of administration with full-treatment doses of vitamin A supplement;
  • (c) shows ultrasonogram of the lesion at week 14 (after 7 weeks of post full-treatment maintenance doses of vitamin A supplement);
  • Figure 20 shows a cross-sectional ultrasonogram displayed on a computer display of the major tendons/ligaments present in the left foot of a horse (with normal equine anatomy) displayed on a computer display. Outlines of the SDFT and adjacent DDFT are shown;
  • Figure 21 shows a diagram of supportive tendons and ligaments of the equine foot, including the SDFT, DDFT, LDET, CDET, and check ligament;
  • Figure 22 is a schematic diagram of a computer system for implementing methods described herein;
  • Figure 23(a) shows a cross-sectional ultrasonogram of the major tendons/ligaments present in the foot of a horse, with a lesion present in the SOFT displayed on a computer display.
  • Figure 23(b) shows the outline of the SDFT, and the outline of the lesion within it displayed on a computer display;
  • Figure 24 shows cross-sectional ultrasonograms of the major tendons/ligaments present in the foot of a horse, with a lesion present in the SDFT displayed on a computer display. The outline of the SDFT, and the outline of the lesion within the SDFT are shown.
  • a histogram shows the counts within the area of the lesion.
  • a histogram shows the counts within the area of the SDFT excluding the lesion;
  • Figure 25 shows a cross-sectional ultrasonogram of the SDFT and DDFT present in the foot of a horse, with a lesion present in the SDFT displayed on a computer display.
  • the outline of the SDFT is shown in red, the outline of the lesion within the SDFT is shown in yellow, and the outline of the adjacent DDFT is shown in green.
  • a histogram shows the counts within the area of the lesion;
  • Figure 26 shows the effect of administration of vitamin A and PRP on equine tendon injury.
  • the figure shows a line graph depicting lesion size (as a percentage of baseline lesion size) and echogenicity values (blue line is ratio of echogenicity of lesiomhealthy corresponding tendon, red line is ratio of injured tendomhealthy corresponding tissue) in an injured equine tendon at specified time points after initial injury.
  • Full dose of vitamin A commenced at week 0, which was replaced with maintenance dose at week 7, at week 8 the horse was put back on full-dose vitamin A before commencing PRP treatment at week 1 1 ;
  • Figure 27(a) shows a line graph depicting the mean echogenicity ratio of a tendon lesion to an adjacent healthy tendon at specified time points after commencing supplementation. Data are presented as mean values for the tissues, with error bars representing the standard error of the mean. A value of 1 would indicate perfect regeneration of native tendon.
  • Figure 27(b) shows a cross-sectional ultrasonogram displayed on a computer display showing the outline of the tendon lesion of (a) with the injured tendon also outlined.
  • Figure 27(c) shows a cross-sectional ultrasonogram displayed on a computer display showing the outline of an adjacent healthy tendon used as a comparison tissue to calculate the echogenicity ratio, as well as the outline of the lesion and injured tendon; and
  • Figure 28(a) shows a line graph depicting the mean echogenicity ratio of an injured tendon (with the area of lesion excluded) to an adjacent healthy tendon at specified time points after commencing supplementation. Data are presented as mean values for the tissues, with error bars representing the standard error of the mean. A value of 1 would indicate perfect regeneration of native tendon.
  • Figure 28(b) shows a cross-sectional ultrasonogram, displayed on a computer display, showing the outline of the tendon lesion of (a) with the injured tendon also outlined, the lesion is excluded from the area of injured tendon for analysis.
  • Figure 28(c) shows a cross-sectional ultrasonogram, displayed on a computer display, showing the outline of an adjacent healthy tendon used as a comparison tissue to calculate the echogenicity ratio, as well as the outline of the lesion and injured tendon.
  • This example describes the effect of a pharmaceutical composition comprising vitamin A in treating tendon injury in horses.
  • Tendon injuries result in the formation of a fibrovascular scar that never attains the characteristics of normal tendon.
  • Tendon healing is characterised by the formation of fibrovascular scar tissue, as tendon has very little intrinsic regenerative capacity.
  • the molecular mechanisms resulting in scar tissue formation after tendon injuries are not well understood (as reviewed in Schneider etal. Rescue plan for Achilles: Therapeutics steering the fate and functions of stem cells in tendon wound healing-, Advanced Drug Delivery Reviews 129 2018352-375).
  • a blood clot forms that serves as a preliminary scaffold for invading cells followed by a more robust vascular network which is essential for the survival of tenocytes engaged in the synthesis of new fibrous tissue.
  • fibroblasts are recruited to the injured site and produce initially disorganised extracellular matrix components.
  • a remodelling stage commences characterised by tissue changes resulting in a more fibrous appearance and eventually a scar-like tendon tissue can be observed.
  • Tendon injury has a similar pathophysiology to injury in other tissues (including spinal cord injury) in that they may be characterised by excessive deposition of scar tissue.
  • Evidence for an effective treatment of tendon injury is considered to provide evidence also for an effective treatment of other types of injury (including spinal cord injury), for example, through inhibition of scar tissue formation.
  • Vitamin A palmitate also known as preformed vitamin A, or retinyl palmitate
  • coconut oil to provide a final vitamin A concentration of 10,000 lll/ml.
  • Administration of pharmaceutical composition :
  • Horses with tendon injury were orally administered vitamin A palmitate mixed with coconut oil, at a dose of 160,000 III once per day for 14 days.
  • Figure 1 (a) shows a subtle core lesion in the lateral aspect of the superficial digital flexor tendon (SOFT) with generalised surrounding tendonitis.
  • Figure 1 (b) shows that the core lesion has filled in somewhat and is less hypoechoic, suggesting that something has “plugged” the hole. Whilst the nature and quality of the tissue in the lesion is hard to assess with ultrasonography, it certainly appears to be making positive progress after only two weeks.
  • Figure 2(a) shows a nasty SDFT core lesion in the medial aspect not quite involving paratenon. Again the lesion appears to be less hypoechoic on second scan ( Figure 2(b) - after daily administration of the composition for 14 days) suggesting the lesion is filling in with tissue of some sort. Again, the nature and quality of the tissue filling this lesion is hard to assess with ultrasound, but the lesion appears to be making positive progress after only two weeks.
  • This example describes the effect of a vitamin A supplement in treating connective tissue injuries in horses.
  • Vitamin A has multiple functions in animals involving (and not limited to) development, and modulation of protein synthesis, and also possesses anti-inflammatory properties. There is some evidence that vitamin A plays a role in scar tissue formation and maintenance. This example aims to demonstrate the safety, and establish the clinical efficacy, of the usage of vitamin A supplementation in horses with tendon or ligament injuries.
  • Figure 3(b) shows a longitudinal ultrasonogram (left) of the left foot of a horse compared with a cross-sectional ultrasonogram (right) of the left foot of the same horse (normal equine anatomy).
  • the lesions in the cross-sectional images were measured manually, aided by online software to determine the lesion size as a percentage of the overall cross-sectional area.
  • the longitudinal images were presented to a consultant musculoskeletal radiologist who applied a 5-level grading system of the appearance of the injury corresponding to approximately 0%, 25%, 50%, 75% and 100% lesion size. Side effects and tolerability were also recorded.
  • Vitamin A palmitate (retinyl palmitate) in a vehicle, delivered in dry feed based on the upper safe concentration in feeds (16,000 III per kg feed dry matter).
  • Horses with connective tissue injuries were orally administered vitamin A palmitate in a vehicle, at a dose of 160,000 IL) vitamin A once per day for 7 weeks.
  • the dose administered was decided based on the known toxic dose in horses (1 ,000 ID per kg (National Research Council. Nutrient Requirement of Horses: Fifth Revised Edition. The National Academys. 1989)) and the proposed upper safe concentration in feeds (16,000 IL) per kg feed dry matter (Ralston SL. Nutritional Requirements of Horses and Other Equids. MSD Veterinary Manual, 2021 )) which yielded a dose of 160,000 IL), corresponding to 32% of the toxic dose, assuming a 500kg horse consuming 10kg of dry feed. There were no adverse events reported and the supplement was well tolerated by the subjects.
  • the injuries comprised 9 tendon and 6 ligament injuries, with 12 injuries on the left side of the horse and 3 on the right.
  • the mean time since injury was ⁇ 12 months.
  • the tendon injuries comprised 2 acute injuries ( ⁇ 1 month old) and 7 chronic injuries, with a mean time since injury of 13.1 months, and a range of 9-20 months.
  • the ligamentous injuries comprised 6 chronic injuries, with a mean time since injury of 14.3 months and a range of 4-30 months.
  • the most commonly injured ligament was the left fore check ligament.
  • the inclusion criteria were polo horses with diagnosed tendon/ligament injuries regardless of time since injury. There were no exclusion criteria.
  • Figures 5 to 16 show ultrasonograms of some of the tendon/ligamentous injuries of the data set at various time points from week 0.
  • Table 1 shows the results of the trial, comprising data for each individual lesion.
  • tenocytes also known as tendon fibroblasts
  • ECM tendon extracellular matrix
  • Tendons are characterised by an exceptionally organised, anisotropic extracellular matrix with primarily type I collagen, although small amounts of type III collagen are also present (Fratzl P. Collagen: Structure and Mechanics, an Introduction. Collagen. Springer US; 2008. p. 1-13; Kannus P. Structure of the Tendon Connective Tissue. Scand J Med Sci Sport. 2000;10(6):312— 20).
  • Equine tendon scar tissue has been shown to have higher than usual levels of type III collagen (20- 30%) (Williams I etal. Cell Morphology and Collagen Types in Equine Tendon Scar. Res Vet Sci.
  • Vitamin A is well known to play a role in the modulation of the synthesis of extracellular matrix proteins, including collagens, laminins, entactin, fibronectin, elastin and proteoglycans. It also has a role in the expression of various metalloproteinases, including collagenase. As scar tissue is due to excess deposition of disoriented collagen and physiologically abnormal proportions of collagen type by fibroblasts, this may allude to a plausible mechanism how vitamin A may influence fibroblasts maintaining scar tissue to instead produce native tendon tissue.
  • This example describes the pathophysiology of equine tendon/ligament lesions before and after treatment with vitamin A supplement.
  • Ultrasonography images were captured at the site of maximal injury. Depending on the nature of the injury, either cross-sectional or longitudinal views were taken. The lesions in these cross-sectional images were measured manually, aided by online software to determine the lesion size as a percentage of the overall cross-sectional area.
  • the longitudinal images were presented to a consultant musculoskeletal radiologist who applied a 5-level grading system of the appearance of the injury corresponding to approximately 0%, 25%, 50%, 75% and 100% lesion size. Side effects and tolerability were also recorded.
  • the injuries comprised 3 tendon and 4 ligament injuries.
  • the inclusion criteria were polo horses with diagnosed tendon/ligament injuries regardless of time since injury.
  • the exclusion criteria were horses with acute connective tissue injuries.
  • Figure 17(a) shows the size of the 7 lesions under investigation from the time of original injury, at baseline, and at 3, 5, and 7 weeks into the trial.
  • the mean lesion size was 43.97% at the time of original injury and 49.43% at baseline (time treatment with vitamin A supplement began), but this difference was not statistically significant.
  • tendon and ligament lesions were treated as two separate cohorts, there was an apparent divergence in natural healing progression between the two tissues from the time of original injury to when treatment began.
  • Example 4 Effect of post-treatment maintenance dose of vitamin A supplement on connective tissue injuries
  • This example shows the effect of administering a post-treatment maintenance dose of vitamin A supplement on treating connective tissue injuries in horses.
  • the results provide evidence for continuing at least a maintenance dose of vitamin A supplement past 7 weeks for connective tissue injury healing progression.
  • vitamin A palmitate retinyl palmitate
  • Figure 18(a) shows the mean lesion size from week 0 to week 7 on fulltreatment doses of vitamin A supplement before splitting into the values of the maintenance dose and placebo groups.
  • the mean lesion size of the placebo group increased from 31.73% to -35.50%.
  • the mean lesion size of the maintenance dose group decreased from 31 .73% to -20.00% from week 7 to week 14.
  • the data shows that there was continued improvement in the healing of injured connective tissues for subjects that were administered maintenance dose of vitamin A supplement, and deterioration of the lesions for subjects that were administered placebo.
  • FIG. 21 (a) shows an ultrasonogram at baseline (Fig. 21 (a)), week 7 (7 weeks of treatment with full-treatment doses of vitamin A supplement) (Fig. 21 (b)), and week 14 (7 weeks of treatment with maintenance dose vitamin A supplement) (Fig. 21 (c)).
  • the size of the lesion decreases at 7 weeks of full-treatment doses, as shown by a reduction in the hypoechoic area of the ultrasonogram ( Figure 19(b)).
  • the lesion becomes much more hypoechoic after post-treatment maintenance dose has been administered for 7 weeks ( Figure 19(c)).
  • Tendons attach muscle to bone, transmit forces to elicit movement, and are composed of collagen. In healthy tendons, good parallel alignment allows for optimal force transmission.
  • Figure 3(a) shows a cross-sectional ultrasonogram of the major tendons/ligaments present in the left foot of a horse (normal equine anatomy).
  • Figure 3(b) shows a longitudinal ultrasonogram (left) of the left foot of a horse compared with a cross-sectional ultrasonogram (right) of the left foot of the same horse (normal equine anatomy).
  • Figure 20 shows the SDFT and its adjacent DDFT outlined.
  • the region of maximal injury (by lesion size) can be captured with ultrasound images.
  • Lesion size (expressed as a percentage of the area of the tendon itself) - see Figure 23.
  • the lesions in the cross-sectional images are measured manually, aided by online software to determine the lesion size as a percentage of the overall cross- sectional area;
  • ultrasonograms or captured ultra sound images also referred to herein as ultrasonographs
  • the methods may be implemented on a computer system 100 including a general purpose computer 102, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • a smart phone is illustrated in Figure 22.
  • the computerized method may be implemented on a computer or general purpose computer in software such as an application or app.
  • a computer may be configured to carry out the methods described herein. This reflects the computational efficiency of the methods described herein.
  • the computer 102 may comprise a processor 104, memory 106 and a display or screen 108, such as a liquid crystal display (LCD) or an organic light emitting diode (OLED) display.
  • the screen may be a touch screen.
  • the computer may also include at least one input port 110 and at least one output port 1 12.
  • a computer 102 configured to carry out the methods described herein may be provided with software or computer program code to carry out the method.
  • the software or computer program code may be contained or stored on a computer readable medium, such as a hard- drive, CD-ROM, DVD-ROM, or solid-state memory 106.
  • the computer readable medium may be a non-transitory computer-readable medium.
  • the ultrasonograph data from an ultra sound scanner scanning the subject may be uploaded to a server 114 or into the cloud. Subsequently, the ultrasonograph may be input into the computer 102 through an input port 110 typically over the Internet through a wireless local area connection such as WiFi or a direct Ethernet connection. Alternatively, the computer may be connected by an input port 110 directly in communication connection to the ultrasound scanner. In which case, the ultrasonograph data is transferred directly from the ultrasound scanner to the computer.
  • the communication connection may be wireless, such as using by short range wireless standard such as Bluetooth.
  • the communication connection may be wired, such as using a Universal Serial Bus (USB) connection. Example USB generations that may be used are USB 2.0, USB 3.0 or USB-C.
  • the measurement may be made automatically by the computer and not manually by a user.
  • the computer identifies an area understood to be a lesion and another area understood to be the overall cross-sectional area of the tendon/ligament automatically.
  • This analysis is based on a grayscale ultrasound image.
  • the computer determines a portion of the image that is the tendon/ligament by using image segmentation based on the grayscale values of the image.
  • the tendon/ligament has a particular range of grayscale values or intensities.
  • the edges of the lesion are determined using edge detection methods applied to the grayscale ultrasound image. Edge detection methods determine an edge at a position where image brightness changes sharply or there is a discontinuity. Various known edge detection methods may be used such as a search based or zero-crossing based method.
  • Tendons attach muscle to bone, transmit forces to elicit movement, and are composed of collagen. In healthy tendons, good parallel alignment allows for optimal force transmission.
  • Figure 3(a) shows a cross-sectional ultrasonogram of the major tendons/ligaments present in the left foot of a horse (normal equine anatomy).
  • Figure 3(b) shows a longitudinal ultrasonogram (left) of the left foot of a horse compared with a cross-sectional ultrasonogram (right) of the left foot of the same horse (normal equine anatomy).
  • Figure 20 shows the SOFT and its adjacent DDFT outlined.
  • the region of maximal injury (by lesion size) can be captured with ultrasound images.
  • Lesion size (expressed as a percentage of the area of the tendon itself) - see Figure 23.
  • the lesions in the cross-sectional images are measured manually, aided by online software to determine the lesion size as a percentage of the overall cross- sectional area;
  • the echogenicity of an injured tendon is assessed by comparing grey scale statistics of the tendon with the values of a healthy adjacent tendon tissue. Due to equine anatomy, there is always a directly adjacent healthy tendon to use as a control (ultrasonography is not very affected by depth of tissue).
  • a quantitative measure of echogenicity of each structure is computed for every image. This is performed by grey scale analysis, for example using the open-source image processing software, lmageJ2 (version 2.3.0/1 .53f).
  • the mean grey scale (MGS) values of each of the two structures are collected. This produces a value between 0 (black) and 255 (white), acting as a proxy for the echogenicity of the tendon.
  • An SDFT:DDFT ratio is produced from the resultant values of each image for each limb (for example, SDFT/DDFT).
  • the ratio of mean echogenicity of the injured tendon to that of the healthy tendon is determined to assess the extent of damage/healing at the lesion.
  • This example describes the effect of a combination therapy of vitamin A supplement with PRP in treating equine connective tissue injury.
  • Vitamin A palmitate (retinyl palmitate) in a vehicle, delivered in dry feed at 16,000 IU per kg feed dry matter (full-dose treatment) or 8,000 IU per kg feed dry matter (maintenance dose treatment).
  • Full-dose treatment oral administration of vitamin A palmitate in a vehicle, at a dose of 160,000 IU vitamin A once per day.
  • Maintenance dose treatment oral administration of vitamin A palmitate in a vehicle, at a dose of 80,000 III vitamin A once per day.
  • Rania (a female horse) sustained a tendon injury in April 2021 and was started on full-dose treatment with vitamin A for 7 weeks. She improved tremendously well in both lesion size and echogenicity, achieving nearly full resolution of her injury. After her initial treatment period of 7 weeks, she was administered a maintenance dose (half-dose) of vitamin A. Almost immediately after halving her dose, in week 8, she sustained an horrendous reinjury, and was placed back on full-dose treatment with vitamin A. Rania was administered PRP at week 11. She was box rested from when she sustained here original injury, but started full work from week 20.
  • Results The results are shown in Figure 26.
  • Lesion size (left hand axis) is represented in green (shown as the top line at the y axis for lesion size).
  • Echogenicity values (right hand axis) are shown in blue and red.
  • the blue line (shown as the bottom line at the y axis for lesion size) shows a plot of the values for the ratio of lesion:healthy tissue. This provides an assessment of the echogenicity of the main lesion.
  • the red line (shown as the middle line at the y axis for lesion size) shows a plot of the values for the ratio of injured:healthy tissue. This provides an assessment of the echogenicity of the rest of the injured tendon.
  • the plots in Figure 26 show that, over the first 7 weeks of full-dose treatment with vitamin A supplement, the lesion size decreased dramatically from just under 20% to -2.5%. The values for the echogenicity ratios also increased over this period, achieving near full resolution of her injury. Following reinjury (week 8), the lesion size increased to 21 .52% of the tendon, and the values for the echogenicity ratios fell to -0.350 and -0.750 for the blue and red lines, respectively. At week 11 (3 weeks after restarting full-dose treatment), the lesion size was similar, at 20.62%, but with considerable improvements in echogenicity values (-0.900 and -1 .050 for the blue and red lines, respectively).
  • the scan at week 24 shows that the lesion size measures 2.19%, which is stable from the scan at week 20 (showing 2.01%).
  • the benefits from the combination therapy may largely be plateauing, although there may still be some remodelling of the main scar tissue.
  • the values which are plateauing are almost identical to the values achieved at week 7 (just before the re-injury).
  • This example shows the effect of vitamin A supplement on the echogenicity and health of tendon injury.
  • tissue such as a tendon
  • the health of a tissue can be assessed by comparing the echogenicity of the tissue with that of a corresponding healthy tissue.
  • Healthy tendons comprising native tissue and normal architecture are usually hyperechoic and appear white on the sonogram; they are capable of reflecting ultrasound that is cast over the tissue.
  • An injured tendon comprising a lesion will appear as less hyperechoic, and more hypoechoic as tendon fibres are interrupted and defects are usually filled with fluid, blood, or fat. Severe lesions will be anechoic, and will display as completely dark on the sonogram.
  • Ultrasonography Full length ultrasonography of the injured tendon and adjacent healthy tendon was performed at baseline as well as 3 weeks, 5 weeks and 7 weeks into the trial. Ultrasonography images were captured at the site of maximal injury of the injured tendon. Depending on the nature of the injury, either cross-sectional or longitudinal views were taken. The echogenicity of a tendon lesion was assessed by comparing grey scale statistics of the tendon lesion with the values of healthy adjacent tendon tissue ( Figure 27(b)). Due to equine anatomy, there is always a directly adjacent healthy tendon to use as a control (ultrasonography is not very affected by depth of tissue).
  • the statistics comprised determining the mean pixel intensity at a number of random points on the lesion and the healthy tendon, and calculating a mean value for the echogenicity of each tissue.
  • a ratio of mean echogenicity of the lesion and the healthy tissue was determined to assess the extent of damage/healing at the lesion.
  • Vitamin A palmitate (retinyl palmitate) in a vehicle, delivered in dry feed based on the upper safe concentration in feeds (16,000 III per kg feed dry matter).
  • Horses with connective tissue injuries were orally administered vitamin A palmitate in a vehicle, at a dose of 160,000 IU vitamin A once per day for 7 weeks.
  • the dose administered was decided based on the known toxic dose in horses (1 ,000 IU per kg (National Research Council. Nutrient Requirement of Horses: Fifth Revised Edition. The National Academys. 1989)) and the proposed upper safe concentration in feeds (16,000 IU per kg feed dry matter (Ralston SL. Nutritional Requirements of Horses and Other Equids. MSD Veterinary Manual, 2021 )) which yielded a dose of 160,000 IU, corresponding to 32% of the toxic dose, assuming a 500kg horse consuming 10kg of dry feed. There were no adverse events reported and the supplement was well tolerated by the subjects.
  • the injuries comprised 9 tendon and 6 ligament injuries, with 12 injuries on the left side of the horse and 3 on the right.
  • the mean time since injury was ⁇ 12 months.
  • the tendon injuries comprised 2 acute injuries ( ⁇ 1 month old) and 7 chronic injuries, with a mean time since injury of 13.1 months, and a range of 9-20 months.
  • the ligamentous injuries comprised 6 chronic injuries, with a mean time since injury of 14.3 months and a range of 4-30 months.
  • the most commonly injured ligament was the left fore check ligament.
  • the inclusion criteria were polo horses with diagnosed tendon/ligament injuries regardless of time since injury. There were no exclusion criteria.
  • the mean echogenicity ratio of the lesion and healthy tendon increased each week from baseline to week 7 ( Figure 27(a)), which was statistically significant. A value of 1 would indicate perfect regeneration of native tendon.
  • the mean echogenicity ratio was 0.52 at baseline, and 0.69 at week 7, equating to a % increase of 32.7%.
  • the mean echogenicity ratio from baseline to week 7 showed a continuing positive gradient. This shows that the lesion is being replaced with native tendon tissue at a constant rate, providing evidence for continuing trials with full dose of vitamin A supplement past 7 weeks to achieve even more regeneration of the tendon.
  • Figure 27(b) shows an outline of the whole injured tendon and area of lesion.
  • Figure 27(c) shows an outline of an adjacent healthy tendon (as well as the outline of the injured tissue and lesion) used as a comparison tissue.
  • Figure 28(b) shows that the mean echogenicity ratio at week 0 was 0.76, which increased marginally to 0.82 at week 7, which was statistically significant. It was observed that the lesion size had normalised to the size of the tendon itself, suggesting that the lesion was not contained to the point of maximal injury, but that the health of the whole tendon was impaired.
  • Polo and horse racing are two such sports.
  • polo ponies are exercised in a clockwise direction and trained to canter with a right forelimb lead owing to the right handed nature of polo.
  • racehorses which are trained in both clockwise and anticlockwise directions in the UK, and take both left and right forelimb leads.
  • Equine athletes were randomly selected to participate in the study: 5 healthy polo ponies and 9 healthy racehorses. They were recruited by the senior author. The inclusion criteria were high performance equine athletes currently training for their respective sports with a regular training schedule. The sole exclusion criterion was any history of musculoskeletal injury.
  • a quantitative measure of echogenicity of each structure was computed for every image. This was performed via grey scale analysis, using the open-source image processing software, lmageJ2 (version 2.3.0/1 .53f). The mean grey scale (MGS) values of each of the two structures were collected. This produced a value between 0 (black) and 255 (white), acting as a proxy for the echogenicity of the tendon.
  • An SDFT:DDFT ratio was produced from the resultant values of each image for each limb (SDFT/DDFT). The mean SDFT :DDFT ratio for the limb was then calculated from all 7 images.
  • Table 1 Summary of mean SDFT:DDFT ratios by limb in each polo pony.
  • the SOFT is an energy-storing tendon, analogous to the Achilles tendon in humans, whereby it stretches and recoils with each stride to reduce the energy requirements of movement by up to 36%(3,4).
  • the SOFT experiences particularly high stresses and strains during exercise(5), making it prone to injury - 75-95% of equine tendon injuries occurring in the forelimb SDFT(6).
  • the result of SDFT injuries are devastating - mature adult tendons form fibrotic scars following injuries as they seem to be unable to remodel the structure of these injured tendons to their pre-injury state (4).
  • These scarred tendons inherently have less desirable biomechanical properties owing to their disorganised nature, making the athletes susceptible to reinjury rates of around 42% with conservative treatment (7).
  • Polo ponies are exercised in circular tracks, most commonly performed in a clockwise direction to encourage a right lead (8).
  • the reason for this is that all the main governing bodies of the sport of polo mandates the use of the mallet in the players’ right hand (9,10) for safety purposes. It has been shown that the non-lead limb experiences higher forces in canter (1 ) and the outside limb experiences higher forces in trot (2). This means that the left forelimb experiences greater repetitive forces during the training periods in polo ponies.
  • racehorses train and compete in both clockwise and anticlockwise directions in the UK. It is also known that racehorses regularly switch forelimb leads in races and training. A reasonable assumption would be that both left and right forelimbs experience similar amounts of repetitive loading throughout the racehorses’ career, but no empirical evidence of this is available.
  • ultrasonograms or captured ultra sound images also referred to herein as ultrasonographs
  • the methods may be implemented on a computer system 100 including a general purpose computer 102, such as a laptop computer, desktop computer, tablet computer, or smart phone as a computerized method.
  • a smart phone is illustrated in Figure 22.
  • the computerized method may be implemented on a computer or general purpose computer in software such as an application or app.
  • a computer may be configured to carry out the methods described herein. This reflects the computational efficiency of the methods described herein.
  • the computer 102 may comprise a processor 104, memory 106 and a display or screen 108, such as a liquid crystal display (LCD) or an organic light emitting diode (OLED) display.
  • the screen may be a touch screen.
  • the computer may also include at least one input port 110 and at least one output port 1 12.
  • a computer 102 configured to carry out the methods described herein may be provided with software or computer program code to carry out the method.
  • the software or computer program code may be contained or stored on a computer readable medium, such as a harddrive, CD-ROM, DVD-ROM, or solid-state memory 106.
  • the computer readable medium may be a non-transitory computer-readable medium.
  • the ultrasonograph data from an ultra sound scanner scanning the subject may be uploaded to a server 114 or into the cloud. Subsequently, the ultrasonograph may be input into the computer 102 through an input port 110 typically over the Internet through a wireless local area connection such as WiFi or a direct Ethernet connection. Alternatively, the computer may be connected by an input port 110 directly in communication connection to the ultrasound scanner.
  • the ultrasonograph data is transferred directly from the ultrasound scanner to the computer.
  • the communication connection may be wireless, such as using by short range wireless standard such as Bluetooth.
  • the communication connection may be wired, such as using a Universal Serial Bus (USB) connection.
  • USB Universal Serial Bus
  • Example USB generations that may be used are USB 2.0, USB 3.0 or USB-C.
  • lesions are described as being measured manually.
  • the input ultrasound image of the subject is displayed on a display 108 of the computer 102, such as the touch screen of a smart phone.
  • This manual measurement may be made by a user tracing an area understood to be a lesion and another area understood to be the overall cross-sectional area of the tendon/ligament by using by moving their finger over the respective areas displayed on the touch screen.
  • the computer then automatically determines the lesion size as a percentage of the overall cross- sectional area of the tendon/ligament. The result of the determination is then displayed on the display of the computer.
  • the measurement may be made automatically by the computer and not manually by a user.
  • the computer identifies an area understood to be a lesion and another area understood to be the overall cross-sectional area of the tendon/ligament automatically.
  • This analysis is based on a grayscale ultrasound image.
  • the computer determines a portion of the image that is the tendon/ligament by using image segmentation based on the grayscale values of the image.
  • the tendon/ligament has a particular range of grayscale values or intensities.
  • the edges of the lesion are determined using edge detection methods applied to the grayscale ultrasound image. Edge detection methods determine an edge at a position where image brightness changes sharply or there is a discontinuity. Various known edge detection methods may be used such as a search-based or zero-crossing based method.
  • the computer 102 automatically uses grayscale statistics to determine the echogenicity of the tendons.
  • grayscale statistics a grayscale ultrasound image is analysed. A particular range of grayscale values or intensities indicate echogenicity when compared to a particular range of grayscale values or intensities associated with a healthy tendon/ligament.
  • the determined echogenicity, echogenicity value and/or fitness potential is displayed on the display 108 of the computer. Alternatively or additionally, the determined echogenicity, echogenicity value and/or fitness potential may be saved or stored in a memory or other storage device of the computer. Alternatively or additionally, the determined echogenicity, echogenicity value and/or fitness potential may be output to an external store such as a server 114 from an output port 112.
  • Dyson SJ Medical management of superficial digital flexor tendonitis: A comparative study in 219 horses (1992-2000). Equine Vet J. 2004;36(5):415-9.

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Abstract

L'invention concerne des procédés permettant de déterminer la taille d'une lésion, ou de surveiller une modification de la taille d'une lésion dans un tissu. L'invention concerne également des procédés permettant de déterminer la capacité physique, ou de surveiller une modification de la capacité physique d'un tissu. L'invention concerne en outre l'utilisation des procédés dans le cas d'un tissu conjonctif ou musculaire, en particulier un tissu tendineux, ligamentaire ou cardiaque. Les procédés peuvent être mis en oeuvre par ordinateur.
EP23832786.0A 2022-10-19 2023-10-19 Procédés permettant de déterminer la taille d'une lésion et la capacité physique d'un tissu Pending EP4604845A2 (fr)

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GBGB2215448.8A GB202215448D0 (en) 2022-10-19 2022-10-19 Methods for determining fitness potential of connective tissue
GBGB2217225.8A GB202217225D0 (en) 2022-11-17 2022-11-17 Methods for determining fitness potential of connective tissue
GBGB2217228.2A GB202217228D0 (en) 2022-11-17 2022-11-17 Methods for determining lesion size
PCT/GB2023/052718 WO2024084220A2 (fr) 2022-10-19 2023-10-19 Procédés permettant de déterminer la taille d'une lésion et la capacité physique d'un tissu

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