We thank de Brito Fontana et al. (1) for their interest in our article (2) and for providing us the opportunity to delve further into the topic of fascicle angle effects on muscle echo intensity (EI).First, we want to clarify two incorrect representations of the wording in our article by de Brito Fontana et al [1] 1) we did not attribute EI variability "solely" to changes in fascicle angle, and 2) we did not explicitly advocate for correction of EI for fascicle angle; instead, we suggested to "consider whether changes in EI might be partly explained by a change in fascicle angle" (2).
CAN TISSUE STIFFNESS CONTRIBUTE TO CHANGES IN EI?de Brito Fontana et al. ( 1) suggested that any tissue stiffness alterations with muscle elongation might affect EI, although their referenced work did not clarify a mechanism. We agree because tissue stretching reduces cross-sectional area (3) and alters extracellular matrix orientation (4), potentially increasing tissue density variation and thus influencing tissue reflective properties. We acknowledged such potential factors in our article ("… e.g., fiber density…") (2). However, only small (2-4 kPa) changes in vastus lateralis shear modulus are observed during passive knee flexions through 90°(5,6) and probe alignment (similar to altering fascicle angle) has little effect on muscle shear modulus at rest (7-9). Thus, effects in vastus lateralis should be small or negligible. Nonetheless, further exploration of the effect of stiffness on EI is needed. FIGURE 1-Effect of beam (A) and insonation (B) (i.e., relative to fascicles) angles on echo intensity in superficial tibialis anterior, vastus lateralis, and biceps brachii and brachialis in two individuals with different SFT; open circles: lower SFT; full circles: higher SFT. Right panel displays examples of ultrasound images with changes in beam angle.