Shortening of patellar tendon after total knee arthroplasty (TKA) was previously reported by several studies. Its etiology still remains controversial. Patellar tendon shortening, a direct cause of patella baja, has a dramatic negative impact in terms of clinical outcomes after TKA. Main objective of this study is to assess the feasibility of utilizing a different technique with Ultrasound that is easy to use, cost-effective and able to eliminate the problem of differential magnification occurring in other techniques which count on standard x-rays and to establish the correlation between clinical outcomes and changes in patellar tendon length and thickness after TKA. The study was designed as prospective cohort and, after a minimum of 4-year-follow up period, 47 knees of 24 patients who had undergone primary TKA without patellar resurfacing were included in the study. All patients were scored with Kujala and HSS scores and all patellar tendons were evaluated with USG regarding their length and thickness. We used conventional grey-scale ultrasound imaging (US) to determine any changes in patellar tendon morphology. All cases were evaluated by the same radiologist. The patellar tendon was examined with the knee in 30° flexion. The flexion angle helped to stretch the extensor mechanism and avoid anisotropy (concavity) of the patellar tendon. The transducer was placed along the long axis of the tendon. The patellar tendon was initially examined in the longitudinal plane in order to measure the total length. Then, total length was divided into three parts and sagittal thickness was calculated at the proximal, median, and distal thirds of the patellar tendon. Both the length and thickness of the tendon were measured before surgery and at the 4th year of follow-up. Of the 47 knees that were included in our study, the mean pre-operative and postoperative length of the patellar tendon was 40.78±6.15 mm and 35.93±4.52 mm. Our results suggested significant shortening of the patellar tendon after primary TKA surgery (p<0.05). Intergroup analysis suggested that reduced sagittal thickness in the proximal third of the tendon was more strongly correlated with an increase in functional outcomes (p<0.05). Our results suggested no significant difference in clinical outcome scores between patients with increased or decreased length of the patellar tendon after TKA (p>0.05). We suggest that determining morphologic changes in sagittal thickness as well as length is important in explaining some of the ambiguous causes of anterior knee pain and impaired clinical outcomes after TKA. More accurate documentation of morphologic changes in the patellar tendon after TKA will certainly help to develop new techniques by surgeons or avoid some existing routines that may harm the tendon. USG is a feasible method for evaluating patellar tendon morphology after TKA but more future studies are needed