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Objective: We present the evolution of medical imaging software and its impact on the medical imaging community through the study of four open-source image analysis software platforms: 3D Slicer, FreeSurfer, FSL, and SPM. Materials and methods: We have studied the impact of these software tools over time, measured by the number of scientific citations. Additionally, we have also studied the source code evolution by measuring the lines of code and the tarball size of the stable releases and the changes in programming languages. Results and discussion: The rising number of related scientific publications confirms the popularity of these software tools in the research community, albeit some differences can be observed in the popularity of the tools. Moreover, we demonstrate that source code has evolved to modernize and optimize, at least partially thanks to the collaboration and code sharing with the user community. Furthermore, this evolution reveals an increased use of higher-level programming languages and meta-languages. Conclusions: The study of four open-source packages has revealed certain patterns in the evolution of medical imaging software and their impact on the medical image community. Further analyses and complementary metrics are suggested.