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ASSESSMENT OF THE VISA A QUESTIONNAIRE FOR ACHILLES :  TENDINOPATHY AND ITS CORRELATION WITH IMAGING. by JENNIFER MARY ROBINSON  MB.BCh., The U n i v e r s i t y of the Witwatersrand, Johannesburg,  South A f r i c a 1986  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES (School of Human K i n e t i c s ) We accept t h i s t h e s i s as conforming to the r e q u i r e d standard  THE UNIVERSITY OF BRITISH COLUMBIA  J u l y 2000  ® J e n n i f e r Mary Robinson, 2000  In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by t h e head o f my department o r by h i s o r her r e p r e s e n t a t i v e s . I t i s understood t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n .  Department o f  (  TH_WV\.gll/V  The U n i v e r s i t y o f B r i t i s h Columbia Vancouver, Canada Date c9S  ft^  O O  M  ^  ^  C  ^  ABSTRACT  Background: Because Achilles tendon disorders, which are common, have a significant morbidity among athletes, further research into efficacious treatments is necessary. Yet there is a lack of objective or quantifiable outcome measurement tools.  Purpose: The purpose of this thesis was to investigate outcome measurement tools used in Achilles tendinopathy research. In particular clinical measures that quantify the severity of the patient's condition and ultrasound and magnetic resonance imaging were examined.  Methods: A 3-month prospective study was done.  Participants: Forty five consecutive patients (27 men, 18 women; mean age 42 years, range 20-66 years) with 57 symptomatic and 33 asymptomatic Achilles tendons (mean duration 21 months, range 0.5 - 120 months) were admitted to the study.  Results: The V I S A - A questionnaire had construct validity. The V I S A - A scores of the 45 subjects correlated significantly (p<0.01) with their scores on two other clinical severity grading systems. There was also a significant difference in scores among the 45 symptomatic subjects (mean 63.75 ± 16.81) compared to the V I S A - A scores of 66 asymptomatic University students (mean 95.95 ± 7.41) (p<0.01). The test-retest reliability was 0.930, the interrater reliability was 0.903, the intrarater reliability was 0.903 and the short term reliability was 0.805.  ii  Ultrasound had a sensitivity of 0.65 and specificity of 0.67 and an overall accuracy of 0.66. The addition of colour and power doppler interrogation did not enhance the accuracy of US. M R I had a sensitivity of 0.56, a specificity of 0.94 and an overall accuracy of 0.68.  At 3 month follow up 7 of the 45 patients had improved, 37 remained the same and 1 had worsened. Only the baseline V I S A - A score correlated with the 3 month results (p<0.01) neither US nor M R I was able to differentiate between cases that would improve and those that would worsen.  Conclusion: The V I S A - A index of severity for Achilles tendon disorders offers a valid, reliable and quantifiable outcome measurement tool useful clinically and in research. Imaging lacked sensitivity and therefore not suitable as an outcome measure. Neither imaging modality proved more accurate but because of the cost and accessibility U S would be preferred when imaging is required.  iii  TABLE OF CONTENTS  Abstract  ii  List of Tables  viii  List of Figures  x  Acknowledgements  xi  INTRODUCTION  1  CHAPTER ONE:  3  LITERATURE REVIEW 1.1. Histopathology  3  1.2. Biochemical Markers  4  1.3. Clinical  4  1.4. Subjective Outcome Measurements  4  1.5. Imaging  6  1.5.1 What is the best technique to use in imaging tendons? ....6 1.5.1.1. Ultrasound  8  1.5.1.2. Magnetic Resonance Imaging  10  1.5.2 How well do Ultrasound and M R I correlate?  11  1.5.3 Does the severity of a tendon problem correlate with imaging findings?  15  1.5.3.1. Ultrasound  15  1.5.3.2. Magnetic Resonance Imaging  16  iv  1.5.3.3. Conclusion  18  1.5.4. Can imaging severity be regarded as a prognostic indicator in Achilles tendon disorders?  18  1.5.4.1. Ultrasound  21  1.5.4.2. Magnetic Resonance Imaging  21  1.5.5. What is the overall value of imaging in Achilles tendon disorders?  22  1.5.5.1. Ultrasound  22  1.5.5.2. Magnetic Resonance Imaging  22  1.6. Summary and Rationale For Study  25  C H A P T E R TWO:  26  T H E V A L I D I T Y A N D R E L I A B I L I T Y OF A C L I N I C A L A N D R E S E A R C H M E A S U R E OF S E V E R I T Y OF A C H I L L E S T E N D O N DISORDERS T H E V I S A - A QUESTIONNAIRE. 2.1 Introduction  26  2.2 Materials and Methods  29  2.2.1 Population Identification  ....29  2.2.1.1. Ethics Approval  29  2.2.1.2. Subject Recruitment  29  2.2.1.3. Clinical Examination  31  2.2.2. Item Generation  33  2.2.3. Item Reduction  33  2.2.4. Item Scaling  33  2.2.5. Pretesting  34  2.2.6. Weighting  35  2.2.7. Validity  36  2.2.8. Reliability  38  2.3. Results  38  2.3.2 Validity  38  2.3.3. Reliability  44  2.4 Discussion  44  2.5 Conclusion  46  CHAPTER THREE:  47  ARE OPTIMISED ULTRASOUND AND MAGNETIC RESONANCE IMAGING OF V A L U E IN ACHILLES TENDON DISORDERS? 3.1 Introduction  48  3.2 Patients and Methods  48  3.2.1. Clinical  48  3.2.1.1. Patients  48  3.2.1.2. Clinical Severity  48  3.2.1.3. Follow Up  48  3.2.2. Imaging  49  3.2.2.1. Ultrasound  49  3.2.2.2. Grading of US severity  51  3.2.2.3 Magnetic Resonance Imaging  52  3.2.2.4. Grading of MR severity  54  vi  3.2.3. Data Analysis  54  3.3. Results  55  3.3.1. Imaging  55  3.3.1.1. Ultrasound  55  3.3.1.2. Ultrasound Severity  58  3.3.1.3. Magnetic Resonance Imaging  58  3.3.1.4. M R I Severity  62  3.3.1.5. Follow up  62  3.3.1.6. Correlation between U S and M R I  63  3.4 Discussion  66  3.5. Conclusion  68  CONCLUSION AND RECOMMENDATIONS  69  BIBLIOGRAPHY  70  APPENDIX A  78  vii  LIST OF T A B L E S  Table 1.1. List of grading systems for Achilles tendinopathy identified in a literature search  5  Table 1.2. A list of all original papers dealing with imaging of the Achilles tendon  7  Table 1.3. List of review papers dealing with imaging and Achilles tendons  8  Table 1.4. Technical factors in performing US on tendons  9  Table 1.5. Techniques in Magnetic Resonance Imaging of Achilles tendons  12  Table 1.6. Table of studies correlating clinical findings, US, M R I and surgical findings  13  Table 1.7. Studies reporting false negative US results  17  Table 1.8. Studies reporting false negative M R I results  17  Table 1.9. Studies reporting false positive US and M R I results  19  Table 1.10. Imaging findings correlated to clinical outcome  20  Table 1.11. Sensitivity and Specificity of US and M R I  23  Table 1.12: Meta-analysis of US and M R I results from adequate studies  24  Table 2.1. V I S A - A Achilles tendon questionnaire  27  Table 2.2. Activity of patients before and after onset of symptoms  30  Table 2.3. Questions identified by "Experts" as important in assessing Severity of Achilles tendinopathy  35  viii  Table 2.4. Percy and Conochie's grading scheme for results of surgery of Achilles tendinopathy and a modification for non surgical patients ..37 Table 2.5. Tendinopathy grading system of Curwin and Stanish  37  Table 2.6. Summary of Reliability of V I S A - A score  44  Table 3.1. U S results  55  Table 3.2. Chart listing clinical diagnosis and US correlation  55  Table 3.3. Relationship between clinical findings and colour and power doppler flow on US  57  Table 3.4. Relationship between positive colour flow on US and clinical thickening of the tendon  57  Table 3.5. Relationship between onset of symptoms and colour doppler flow on US  58  Table 3.6. M R I results  58  Table 3.7. Relationship between M R I results and clinical severity  60  Table 3.8. Relationship between clinically thickened tendons and positive M R I  60  Table 3.9. Relationship between imaging severity at baseline and clinical outcome at 3 month follow up  63  Table 3.10 Correlation between US and M R I  63  Table 3.11. Correlation between US and M R I and V I S A - A score  64  ix  LIST OF F I G U R E S  Figure 2.1. Clinical examination of patient showing thickening of left Achilles tendon  32  Figure 2.2. Scatter Plot of V I S A - A score compared to modified Percy and Conochie's grade of severity  40  Figure 2.3. Scatter Plot of V I S A - A score compared to Curwin and Stanish's grade of severity  41 .  Figure 2.4. Frequency histogram of V I S A - A scores among non surgical patients with normal curve superimposed  42  Figure 2.5. Box Plot showing V I S A - A scores among asymptomatic students and symptomatic subjects  43  Figure 3.1. U S was performed with the patient prone  50  Figure 3.2. Bilateral tendon M R I was performed using a quadrature head coil  53  Figure 3.3. Hypoechoic lesion as seen on US (sagittal view)  56  Figure 3.4. Intratendinous high signal intensity seen on Tl-weighted M R I  59  Figure 3.5. Combined box plot and scatter plot showing relationship between clinical severity and thickening of the tendon in patients with positive M R I results  61  Figure 3.6. Correlation between US and M R I and V I S A - A score  65  ACKNOWLEDGEMENTS  I would like to thank the 45 subjects who made themselves available for the study. I would also like to thank the staff of the Department of Radiology of the Vancouver Hospital and Health Sciences Centre, University of British Columbia for their assistance in collecting the imaging data. Finally I would like to thank my supervisors Drs. Jack Taunton, Karim M . Khan, Bruce Forster and Rob Lloyd Smith for the inspiration and encouragement to do this study and for the invaluable advice.  xi  INTRODUCTION  Tendon injuries account for a substantial portion o f overuse injuries i n sports.  4  6  A m o n g recreational athletes the Achilles tendon is one o f the most common sites o f injury. Overuse Achilles injuries occur particularly among athletes involved in 7  running  2 6 8 - 1 0  racquet sports, jumping sports, " 11  9  11  soccer  1112  and dancing. A m o n g 12  top level runners the incidence o f Achilles tendon overuse injury is 7% to 9%. There is significant morbidity associated with an Achilles tendon i n j u r y  1 3 1 4  because o f  persistent symptoms, recurrences and i n 2 % to 1 6 % o f athletes abandonment o f 15  their sport.  7  6  16  1 7  Achilles tendinopathy refers to the clinical syndrome o f pain in the region o f the Achilles tendon with diffuse or nodular swelling in that area.  Treatment, typically  consists o f relative rest, anti-inflammatory medication, physical therapy, 18  18  modalities, ice, strengthening exercises, orthotics, heel lifts, stretching and even surgery  6 1 5  for persistent cases. However, few controlled studies have tested the  efficacy o f these forms o f treatment.  6  7 1 4 1 7 - 2 1  Double-blind, randomised, placebo controlled trials are required to test treatment 99 94  efficacy.  " Ideally the severity o f the patients condition should be measured because  more severe injuries may take longer to i m p r o v e  1 4 2 3  and stratification permits  comparison among similar groups. The end point or desired outcome should be 9S  defined  but there is a lack o f a standardised system o f assessing this i n  orthopaedics. " A standard disease-specific grading system facilitates researchers to 26  28  1  better assess efficacy o f treatment and compare different methods o f treatment. Evidence based treatments may then be used in clinical practice.  The purpose o f this thesis was to investigate outcome measures o f use in Achilles tendinopathy research. In particular attention was focused on clinical measures that may be used to quantify the severity o f the patient's condition and to assess changes in condition. Secondly, the value o f imaging as a potential outcome measure was also investigated.  2  CHAPTER ONE  LITERATURE REVIEW  Because Achilles tendon disorders, which are common, have a significant morbidity among athletes involved in many sports, it has been recognised that further research into efficacious treatments is necessary. Part o f the difficulty i n assessing differences in treatment results is due to a lack o f objective or quantifiable outcome measurement tools.  A literature search was done to identify and analyse potential outcome measures which have been used in Achilles tendon research. Potential outcome measurements include: histopathology; biochemical markers; clinical findings; subjective outcome measures and imaging findings.  1.1.  HISTOPATHOLOGY  While histopathological evidence o f disease progress is an important gold standard in diagnostics, this is unsuitable for use as an outcome measurement tool in the research and clinical setting. Firstly patients who have improved are not likely to agree to biopsy in order to confirm healing. Secondly, surgery is unacceptable to a patient with a mild Achilles tendinopathy. Thirdly, repeat biopsies may influence tissue such that second and third biopsy results may show evidence o f the surgical procedure rather than the nature o f the tissue healing. Finally, histopathology has a false positive rate: Kannus and Jozsa found histopathological abnormalities in 160 o f 445 cadaver 3  tendons o f healthy individuals with no tendon complaints  32  and Astrom and Rausing  found histopathological changes in 20% o f asymptomatic control tendons.  33  1.2. BIOCHEMICAL MARKERS  In general, laboratory or biochemical examinations play a minor role i n the diagnosis of tendon disorders. There are no measurable markers o f disease activity that would prove useful in a clinical or research setting.  1.3. CLINICAL  In clinical practice a careful history and physical examination forms the basic standard for diagnosing tendon conditions.  However in a research setting clinical  28  examination findings are variable  and individuals may present with a number o f  positive clinical findings. Without a standard clinical assessment tool it is difficult 25  to quantify clinical findings and there may be observer bias.  25 3 7  Patients present  mainly because o f pain, which is an entirely individual experience and therefore 2  difficult to quantify. " 38  40  Nevertheless there has been an attempt to quantify subjective  information.  1.4. SUBJECTIVE OUTCOME MEASUREMENTS  While pain is the usual presenting symptom, " 38  40  functional status is also an important  outcome measure. There is a surprising low correlation between pain and 41  disability and therefore an outcome measurement tool must record pain, function 25  4  and activity.  In a search for relevant outcome systems, five grading schemes have  been identified and listed in Table 1.1. There are however a number of limitations to these grading systems and a need is identified for a more specific and more sensitive measurement tool. A subjective index of severity of Achilles tendinopathy disorders may then be used in research and in the clinical setting.  Table 1.1. List of grading systems for Achilles tendinopathy identified in a literature search. Author Date  Population intended  Type of Rating system  Comments  Percy and Conochie 1978 (Table 2.4)  Results of surgery of Achilles tendinopathy.  Four point descriptive scale of excellent, good, fair and poor arbitrarily devised.  Arbitrary categories derived. Not validated and reliability not tested.  Curwin and Stanish 1984 (Table 2.5)  Grading of tendinopathy in general.  A 6 point scale, combining the domains of pain and activity in one scale  Arbitrary categories derived, not specific to Achilles tendons. Limited in sensitivity. Not validated and reliability not tested  The American Orthopaedic Foot and Ankle Society. Kitaoka, et  Ankle hindfoot scale for patients undergoing ankle surgery  3 domains of pain, function and alignment, scored over 9 questions on a four point categorical scale totalling 100 possible points.  This is non specific for Achilles tendon disorders, particularly as symptoms such as morning stiffness, pain during and after activity and pain with stairs are not represented and activity level is not documented.  Surgically treated ruptured Achilles tendons.  11 questions scored on mostly a 4 point Likert Scale. Items include Range of Motion, Calf circumference, Thompon's test, Strength testing, Pain, sports activity, sensitivity to weather and subjective assessment.  All (excepting pain and sports activity items) not applicable to Achilles tendinopathy. The four point Likert scale has been shown to be insensitive to subtle changes in clinical condition. The questionnaire was not validated and reliability not tested.  8 Questions covering the domains of Pain, stiffness, muscle weakness, range of motion and footwear restriction, plus subjective outcome and calf muscle strength all included in 4 point Likert scale, totalling 100 points.  Redundancies in the questions. The four point Likert scale has been shown to be insensitive to subtle changes in clinical condition. The questionnaire was not validated and reliability not tested.  42  43  a/.  67 9  4144  1994 Thermann et 1997  Leppilahti et al. modified from Boy den et al} 1998 6  Surgically treated ruptured Achilles tendons  27 2 8  27 2 8  1.5. I M A G I N G  C o n t r o v e r s y exists o v e r the v a l u e o f i m a g i n g i n assessment o f A c h i l l e s t e n d o n d i s o r d e r s . In p a r t i c u l a r a literature s e a r c h w a s p e r f o r m e d to a n s w e r the f o l l o w i n g questions. (1) W h a t is the best t e c h n i q u e to use i n i m a g i n g t e n d o n s ? (2) H o w w e l l d o U l t r a s o u n d ( U S ) a n d M a g n e t i c R e s o n a n c e I m a g i n g ( M R I ) c o r r e l a t e ? (3) D o e s the s e v e r i t y o f a t e n d o n p r o b l e m c o r r e l a t e w i t h i m a g i n g f i n d i n g s ? (4) C a n i m a g i n g s e v e r i t y be r e g a r d e d as a p r o g n o s t i c i n d i c a t o r i n t e n d o n d i s o r d e r s ? (5) W h a t is the overall value o f i m a g i n g i n A c h i l l e s tendon disorders? A literature r e v i e w w a s done u s i n g M E D L I N E database ( f r o m 1966 to the present), w h i c h w a s s e a r c h e d f o r a n y a r t i c l e s r e l a t e d to A c h i l l e s t e n d o n a n d i m a g i n g . A d d i t i o n a l r e f e r e n c e s w e r e r e v i e w e d f r o m the b i b l i o g r a p h i e s o f the r e t r i e v e d articles. A total o f 2 6 o r i g i n a l papers ( T a b l e 1.2) a n d 8 r e v i e w a r t i c l e s ( T a b l e 1.3) w e r e i d e n t i f i e d .  1.5.1 What is the best technique to use in imaging tendons?  B e f o r e U S a n d M R I , soft-tissue r a d i o g r a p h y w a s the m o s t p o p u l a r i m a g i n g e x a m i n a t i o n i n A c h i l l e s t e n d o n d i s o r d e r s . B u t t e n d o n s are n o t v i s i b l e o n n o r m a l 2  r a d i o g r a p h s b e c a u s e o f the l i m i t e d contrast b e t w e e n n o r m a l m u s c l e a n d t e n d o n a n d injured tissue.  A l t h o u g h xeroradiography, bursography, tenography and  a r t h r o g r a p h y w e r e u s e d to i n c r e a s e tissue contrast, the i m p o r t a n c e o f these m o d a l i t i e s has d i m i n i s h e d .  2 7 9  C o m p u t e r T o m o g r a p h y ( C T ) has also largely been replaced b y U S  a n d M R I , p a r t i c u l a r l y as K a l e b o  et al.  52  and Weinstabl  increased accuracy w i t h U S or M R I .  6  et al.  61  have shown an  v  fl  .3 (-J 00  end  cfl W  end  (  >s  <N  r  a a  end  a^ o CA:-a o ,:\ T3 a cs . a o o! C CD  5 -a c CD  =  C/l  IS  O  1  a  • • • • • • • •  =  i  i  C/J  a - a  -a  £ i c N ;  •y.  r l  to >  • •  4)  oo v:  OH  O  r.  o  O'  OH 00  OH  O  oo O  00  •O O  O O OH  o  —  CN  cfl  C&  s IS a.  CS  .b  fe £  S vo*  _  fl  fl o  b hp e o c oio  • o  3 o  < 60  o  opf'  o  o  o  • • • •  3 OH O  I  t i  r-O t— VO CN- VO  1 B'3  •fi  o Cfl  v  B  CD OS  *•* O0  D. O  fl  =  /-. cfl " C '' C > ' cfl j S I .Si:.Hi S^-o .SJ- o Cfl B  '  OH  &  '  O  OV C—  t  r  X CN ' ^  ±: fife c I*  y  cBfl . tfl ' cfl  j2  . C O  —  o  i  5 ~  (N  f  ri  I  r-.  O  -si  cn h-ifN ifk  cfl e  «  I cs  :  a.: o. 1^ r- o i  D.. CN = u;  0O M .vO. r I I ••  O  <  f Si  = = c  OH  CN  CN  ~  CS  ,  '—'  60 CS  O  I  60 .g  "3 T3  & OH  g  '5b  •c  T3  _o  XJ  B  OO  o  Hi  o  ta fl cs  H-»  GO  • B'.B. „ . „  "o O  ° S c ^ .S ^ 1  CO  C3  ^ i4  G  J  on Z  P L H ; Q 2,< O  a  Table 1.3. List o f review papers dealing with imaging and Achilles tendons Author/ Date Josza and Kannus 199 Khan and Kannus 2000 Khan et'al 1998" ~ "  Study design reucw letter editorial •  Jacobson' 1999  review  7  72  73  4  Title  U/S  Human Tendons • >;'" __ :£,_„.' . Use of Imaging data for predicting outcome Treat the patient, not the x-ray: advances in" diagnostic imaging do not replace the need for clinical_interpretatiori; ' , . ,' s... i. Muskuloskeletal sonography and MR imaging. A role for both imaging_methods Magnetic Resonance Imaging of Pathological Conditions of the Achilles Tendon. . Tendon Injuries of the lower extremity: Magnetic Resonance assessment Magnetic Resonance Imaging of Tendon Pathojogy aboutihe_Eoot and_AnkJe^_^ ' Pictorial review: the sonographic diagnosis of pathology in the Achilles tendon. i  ;  Panageas etal.  75  1990  review  Mink et al.'° 1991 Kabbani and Mayer  1993  review  O'Reilly and Massouh 1993  78  review  1.5.1.1. Ultrasound: Table 1.4 summarises technical factors to take into account in imaging tendons by U S . The recommendations are for real time ultrasound with a frequency o f 5 M H z to 15 M H z  8 5  47 5 0  using linear transducers  81  utilising both longitudinal and transverse  81  views.  Care must be taken to place the probe parallel to the fibres in longitudinal  scans and strictly perpendicular in transverse scans. " 80  82  A thickness o f 4.0 - 6.7 m m  on transverse images is considered n o r m a l and a bursa with thickness less than 2-3 54  on  m m is considered normal,  but the appearance o f the bursa depends on flexion and  extension o f the ankle. A stand off pad is not necessary. 49  61  Imaging o f the  paratendon is unreliable. Grading o f imaging findings may be possible either on a 3 69  point scale, (normal, thickened or hypoechoic), or by area o f hypoechogenicity on 60  axial view. Power and colour doppler have not been studied for the Achilles tendon, 5  but in studies o f the patellar tendon  colour flow may be increased in abnormal areas,  which offers objective evidence o f abnormalities that are not operator dependant. Similarly positive power doppler may also offer objective evidence o f tendon abnormality on U S ,  88  although these two techniques are as yet experimental.  MR  Table 1.4. Technical factors in performing U S on tendons. Author/ Fornage  M  Date 1987  a  t  Technical advance The obliquity of the hypoechogenicity du Therefore the probe fibres in longitudinal scans.  s  h  i  e  s  B a r b o l i n i Fornage  1988  C  s  K  r  a a  8  o  B  e  ra  b  A  s  M  o  v  r  e  u  t  o  t  . 1  l r  o i  o  t  etal.  r  c  h  a  m  F  e  s  s  e  l  e  W  e  w  i  n  b  -  b  etal.  a  n  e  r  N  a n Rd e F a l o t i r m e n u l at r a g s o eu n1 d r9 a t 8h e r 6 t h a n B - m o d e  0  4  7  . 1  l  i  near transducers with beams perpendicular to the superficial ndon preferable. Frequency of the probe from 5 MHz to 10 MHz lows an overview of the entire tendon at the lower frequencies d then optimal spatial resolution at the higher frequencies. Both ngitudinal and transverse views required. e of a stand off pad improves contact between the surface of the o b e a n d t h e a n a t o m i c s t r u c t u r e sa l l o w i n g v i s u a l i s a t i o no f t h e bcutaneous tissue.  9D e 9s c r 0 i b e d t h e n o r m a l t h i c k n e s s o f t h e t e n d o n a s 4 . 0 - 6 . 7 m m i n h e a l t h y a d u l t s w i t h a t h l e t e st e n d o n s t h i c k e r t h a n 6 m m . s  s  7  elderly enicity idth of se for  6  s  4  9S u 5g g e s t e d h i g h e r f r e q u e n c i e s o f 1 0 - 1 5 M H z , w h i c h d i f f e r e n t i a t e d anatomically distincttendon portions arising from the soleus and gastrocnemius muscles.  9  6  tendon  m T h eer e l i s a a l et a r gae v al r i a .t i 1o n i9n s h 9a p e 5o f t h e t e n d o n c a u s i n g u p t o 25% variationin the measured thickness values.The tendon thickness correlateswith body height.  . 1  9  9  e  flexion  static US.  Confirmed the angle dependence of the echogenicity of (anisotrophy) in a controlled ex vivo setting.  s  l  9  9 6  y  Showed width of tendon larger in elderly athletesthan sedentary controls.There were no differences in echog a m o n g a t h l e t e sa n d s e d e n t a r y i n d i v i d u a l s . S u g g e s t e d w tendon during transverse imaging betterdimension to u detecting inter tendon differences.  o et a  1  P O W E R  m  8  r et a  n  t  1998  A  N  4  1994  e  Gibbon and Cooper  8  e  m etal. 1 n  C O L O U R A N D  9  g  n  l  r v  5  results in a false d r e f r a c t i o no f t h e U S b e a m s . s t r i c t l yp a r a l l e l t o t h e t e n d o n lyperpendicular in transverse  8D e s c 7r i b e d t h e v a r i a b i l i t y o f t h e r e t r o c a l c a n e a l b u r s a w i t h and extension of the ankle.  9  Li te al an lo Us pr su e  n  i  . 1  l  1 9 8 8  etal.  Kallinen and Suominen  K  n et a  1  s  i  o  superficial tendon e t o r e f l e c t i o na n should be placed scans and strict  8  9  5  Imaging of paratendon unreliable. U S g u i d e d p e r c u t a n e o u s b i o p s yf e a s a b l e .  6  No stand off pad used.  1  a  u  l  t et a  1  9  9  8  l  s  . 1G r a d 9e d 9U S 8f i n d i n g s a s 1 = n o r m a l ; 2 = e n l a r g e d t e n d o n ; 3 = with hypoechoic lesions regardless of size. 6  0  tendon  Review of US technique. Confirmed measurement in axial plane. Defined abnormal retrocalcanealbursa as thicker than 2-3mm at insertion.  7  D O P P L E R  etal.  1  g et a  9  l  9  4  . 1  9  s  Assessed value of power doppler among a variety of musculoskeletal complaints including shoulder, elbow "tendonitis, b u r s i t i s . "H y p e r a e m i a s e e n i n a r e a s i d e n t i f i e d a s a b n o r m a l o n g r e y scale. 8  9 I n8 c r e a s e d c o l o u r f l o w i n a r e a s a l r e a d y i d e n t i f i e d a s a b n o r m a l grey scale. s  9  9  on  1.5.1.2. Magnetic Resonance Imaging: O n M R I (Table 1.5) normal tendons appear black on all sequences due to dense collagen. O n T l -weighted and T2-weighted M R I tissue contrast is enhanced and 90  fluid and pathological processes appears grey (low signal intensity) on T l - weighted images and white (high signal intensity) on T2 -weighted images.  91  Other pulse  sequences have been developed including partial flip angle, gradient reversal, fat suppression, chemical shift and three-dimensional volumetric imaging. Contrast 91  between abnormal increase in water content may be optimised by gradient acquisition; short tau inversion recovery or long repetition time/echo time ( T R / T E ) sequences.  76  Spin-Echo Tl-weighted and T2-weighted images in various planes as  well as either fat-suppressed or fast inversion recovery sequence have also been used to look for fluid and oedema.  92  In the patellar tendon and therefore possibly in the  Achilles tendon, T2-weighted sequences (particularly the T2*-weighted G R E sequences) may have greater sensitivity than the Tl-weighted protocols. Similarly 5  contrast enhanced imaging may increase sensitivity o f detecting abnormalities in the Achilles tendon.  70  A head coil may be used to assess bilateral tendons  63 7 6  then a 3mm  slice thickness without an interslice gap is usually used, with a 256-matrix for T l weighted images and 128 matrix for T2 weighted images.  Imaging o f paratendon is unreliable  66 6 9  76  and the dimensions o f the retrocalcaneal  bursa are variable. Although generally a dimension o f more than 1 m m in the anteroposterior plane, 11 m m in the transverse plane and 7 m m in the craniocaudal plane may be considered abnormal. The appearance o f normal tendon is also 65  variable, with 4 5 % o f asymptomatic tendons showing heterogenous signal intensity with distal stripes or punctate f o c i .  66  Small intermediate intensity intratendinous 10  regions have also been detected in 4% of asymptomatic cases on F L A S H .  For  Achilles tendons the magic angle phenomenon is not as crucial as for a curved tendon such as the rotator cuff, however, artefactual hyperintensity on short-TE and GRE images due to T2 augmentation, must be considered.  92 9 3  1.5.2 How well do Ultrasound and M R I correlate?  Five studies (Table 1.6) were identified that assessed US and M R I among the same group of patients. Weinstabl et al.  67  and Neuhold et a/. were able to confirm the 68  appearance of total rupture on imaging, but this was also identified clinically and confirmed at surgery for 8 patients in both studies. For the remaining 20 patients with unclear clinical diagnosis, imaging was presumed to be the gold standard, and all patients had positive findings on imaging. While in both of these two studies the absolute diagnosis (for example tendinosis, partial rupture or peritendinosis) did not correlate exactly among the two imaging modalities. Surgery was only performed in 20% of these patients and did not offer additional information to assist identifying unique imaging features of specific diagnoses. This is not surprising considering that partial ruptures and tendinosis show the same degenerative histological features, and therefore it would be expected that the imaging findings would be the same in both these conditions.  33  11  Table 1.5. Techniques in Magnetic Resonance Imaging o f Achilles tendons. Author / Date  Technical advances  Beltranera/. 1987  Normal tendons appear black on all sequences due to dense collagen. T l weighted sequences yield high contrast between the dark tendon and the bright signal from the surrounding fat.  y  Quinn etal. 198763  Utilised 1.5T superconductive M R unit. Use of head coil. T l weighted spin density and T2-weighted spin echo images obtained.  Kerr era/. 1990  Suggested obtaining both T l -weighted and T2-weighted images as tissue contrast is enhanced. Fluid is of low signal intensity (grey) on T l - weighted images and high signal intensity (white) on T2 -weighted images. Pathologic processes ought to demonstrate a pattern of signal intensity similar to that of fluid. Other pulse sequences have been developed. Introduced other sequences including partial flip angle, gradient reversal, fat suppression, chemical shift and three dimensional volumetric imaging.  y  Mink etal. 1991'  Contrast between abnormal increase in water content may be optimised by Gradient acquisition; short tau inversion recovery or long (Repetition time/echo time) TR/TE. sequences. Use of head coil to assess bilateral tendons. 3mm slice thickness without an interslice gap usually used, with a 256-matrix for T l weighted images and 128 matrix for T2 weighted images.  Erickson et al. 1993  y  Brandser et al. 1995  Astrome/a/. 1996"  Bottger er a/. 1997  Khan etal. 1998  5  Movin etal. 1998 Soila etal. 1999  6  6  y  Described magic angle phenomenon in tendons that become artefactually hyperintense on short-TE and G R E images due to T2 augmentation. Review of M R I appearance of normal and injured tendons. Reinforced importance of magic angle. Suggested using Spin-Echo Tl-weighted and T2weighted images in various planes as well as either fat-suppressed or fast inversion recovery sequence to look for fluid and edema. Tl-weighted and T2-weighted images (SE TE/TR 30/587 and 8572000, respectively) with 4 mm slices in sagittal plane and Tl-weighted iamges (SE TE/TR 30/693) with 5 mm slices at 10 mm intervals in the axial plane. Imaging of paratendon unreliable. Defined the dimensions of a normal and abnormal retrocalcaneal bursa. Asymptomatic ankles have detectable bursa, but of a dimension of no more than 1 mm in the anteroposterior plane, 11 mm in the transverse plane and 7 mm in the craniocaudal plane. Assessed patellar tendons. First to suggest that the T2-weighted sequences (particularly the T2*-weighted G R E sequences) have greater sensitivity than the Tl-weighted protocols. However the Tl-weighted signal can image most cases of patellar tendinopathy. Contrast enhanced imaging may increase sensitivity of detecting abnormalities. Described the normal appearance of the tendon, utilising images at 1.5T with axial high resolution Tl-weighted gradient echo (fast low-angle shot (FLASH)) and short inversion recovery (STIR) sequences. Showed heterogenous signal intensity with distal stripes or punctate foci. Small intermediate intensity intratendinous regions detected in 4% of asymptomatic cases on F L A S H . Paratenon visualised in all cases on both sequences.  12  ~P  bfj  « 5  i r=  E a. _P  1 -  M  Q 3  C  ! ~a  j  fl  CQ ic  a:  <  fl  rV  3  8.1 s  15  ™«g  > >  u t  t? 2 S-  c  ra  i3| > o 2  w  3  i  o  fl  ^  C  —  ti  bO bOT3 fl fl C  S tn H 3  £ £ (2  —  tN  oo  N  §  S tn  r-  OO  IN  —' (N  (N  ^1 M  r» ^  O —  a. c  to tn D D  a. c S S  CJ  .5 -  S « cn 2 g-E  N  N O N O — ' CN — ' C N © ^ a. 1  i-sll o  E  5  : o-£o I  O  CT\ O  CTi  O  ON O  0\  1  w  N  O  -  "  — © — o  a  « DO O cj C- P t/3 C/l  ss  i  H  '  toolgg D D S S  2 -  „ o o 9 o fl -B •%  €  &I §"1» S nc "  1  co  a e ~ ~  5 -3 cn <n £ tn o D D S  S  I 'fi  1 D  c f |  D  S S w o  -P " P  •5  11  Z  33  f a  3  ra  w  O  B tu 3  <N  ' (N O -  a,  (N  2  m  5  , CJ • — « T3 ^  cn  If  T3  tu r s  CJ —  b • Z S S t ?  £  E e  - ai ai  5™  E i  o  ^ ra sSJ o_:  '5 2  DO  s ^ 'S  tn  tn  W  E 2 c fl -o o E  IS  3o  "3  c  . £ T3 P  -=  &0  U  fl — r£i to o-gS.2 (N  ca U  J i  U  M  52 5 ° a o u P bo 8-| = m  'tn O O f_  ON  ~  One is unable to draw any conclusions from these studies regarding which imaging technique is more effective.  O n the other hand, in a 1996 study b y Astrom et al.  69  of 21 tendons, all verified as  having tendinosis by surgery, it was found that presurgical U S had a sensitivity 80.1%, and specificity 92%. M R I on the other hand had a sensitivity o f 96% and specificity o f 86%. Overall accuracy o f U S was 95% and o f M R I was 93%. One would therefore conclude that neither imaging modality is superior.  M o v i n et al.  94  suggested that Gadolinium enhancement improved the imaging o f  intratendinous signal abnormality on Tl-weighted images. They also showed that when compared to U S the volume o f intratendinous change on contrast enhanced M R I was larger than the corresponding hypoechoic area on U S , although the shape and tendon enlargement was the same.  Karjalainen et al.  71  70  assessed a group o f post operative patients and showed thickening  o f the tendon on both U S and M R I in all cases where a rupture was repaired surgically, despite good clinical results. This cross sectional study offers little additional information on the comparison between U S and M R I , although it offers evidence that imaging changes remain positive in post surgery tendons, despite improvement clinically.  14  1.5.3. Does the severity of a tendon problem correlate with imaging findings?  1.5.3.1. Ultrasound: N o studies were identified, that classified tendon disorders by clinical severity prior to imaging. However, Kainberger et al. classified their 73 symptomatic patients 54  with Achilles tendon disorders into duration o f symptoms, with three classes: (1) symptoms less than 2 months; (2) symptoms lasting 2 months to one year and (3) symptoms lasting longer than one year. Unfortunately it was not clear how many patients were i n each group. Nevertheless, they found that U S was normal in 20 o f the 73 patients o f whom 14 cases had symptoms for less than 2 months (Table 1.7). Maffulli et al. and Mathieson et al. similarly suggested that their false negative U S 59  49  findings (20.5% and 40% respectively) were found in patients with acute or milder symptoms (Table 1.7.)  This is in contrast to the studies by Paavola et al., Kalebo et al. and Astrom et al. 57  52  69  who found that i n patients severe enough to undergo surgery, there were some false negative U S findings. Paavola et al. for example found among 80 symptomatic 57  53  tendons 3 that were normal on U S yet abnormal at surgery and Kalebo et al.  found,  in their series o f 37 tendons undergoing surgery for a clinically suspected partial rupture, that 5 patients had negative U S , yet surgery revealed oedema, peritendinitis or post operative changes. Astrom et al. who operated on one false negative U S 69  patient still found pathology on histology although the grading o f the histology was less severe than the patients with abnormal imaging (Table 1.7).  15  Biopsy evidence also reveals abnormal histology in normoechoic areas o f a tendon. M o v i n et al. were able to obtain a histological grade o f severity for all 20 o f their 10  subjects with Achilles tendon pain. Clinically all patients had a painful, swollen tendon and all had U S directed biopsy o f any hypoechoic lesions as well as biopsy o f the adjacent normoechoic areas. It was found that all hypoechoic areas were markedly abnormal on biopsy, and even normoechoic areas were moderately abnormal on histopathology, implying that the correlation between what is seen at imaging is not necessarily what is expected at pathology.  1.5.3.2 MRI: Astrom et al.  69  and M o v i n et al. acknowledged that all o f their cases were severe 70  enough to have warranted surgery. Astrom et al. found that tendons that were thicker and had increased signal intensity on M R I had higher (worse) histopathological scores than those with normal imaging. M o v i n et al. too found one case o f false negative imaging, however, in neither o f these studies was the clinical outcome reported and the clinical significance o f the false negative M R I is unclear. Nevertheless it would suggest that in M R I a negative result in a symptomatic patient does not necessarily mean a milder condition (Table 1.8).  16  Table 1.7. Studies reporting false negative US results.  Author / Date  Imaging Modality  Rate of false negatives  Comment on severity  Acute or mild cases only Maffulli et al." 11987  US  8/55 (20%)  Mathieson et a/. A988  US  8/20 (40%)  Kainberger et a/. /1990  US  20/73 (27%)  Possible acute cases Resolved in 4-6 months. 14 acute cases with no swelling.  Severe surgical cases Lehtinene?a/. /1994  us  2/34 (3%)  Astrom et  us  5/26 (19%)  us  3/79 (4%)  Severity undefined. Kalebo et a/. /1990 Weinstabl et al /1991 Nehrer et a/. /1997  us us us  2/62 (2%) 1/10 (10%) 20/48 (42%)  Archambault et al. /1998  us  11/33 (33%)  9  49  54  53  al. 11996 69  Paavola et al.  /1998  51  i2  67  56  60  One normal on surgery as well. Severe enough to warrant surgery. 2 surgery positive; one negative.  Not Stated Not Stated US graded not clinical findings. US graded not clinical findings.  Table 1.8: Studies reporting false negative M R I results.  Author / Date  Imagin g Modality  Astrom etal. 1996  MRI  69  Movin et al. 1998 10  27 patients Contrast enhanced MRI 20 patients  17  Rate of false negatives 1/27 (4%) 1/20 (5%)  Comment on severity Severe enough to warrant surgery. Severe enough to warrant surgery.  1.5.3.3. Conclusion: It would seem therefore among symptomatic patients, that there is a poor correlation between findings at U S and M R I and severity o f tendon disorder. This is reinforced by the number o f false positive imaging findings in asymptomatic tendons (Table 1.9). However no one single study has assessed the correlation o f imaging findings among a spectrum o f cases o f different clinical severity and this issue therefore remains controversial.  1.5.4. Can imaging severity be regarded as a prognostic indicator in Achilles tendon disorders?  Despite twenty-six original papers and eight review papers dealing with the value o f Ultrasound or Magnetic resonance imaging in assessing Achilles tendinopathy, the usefulness o f imaging as a predictive determinant remains controversial. K h a n and Kannus remind us that only prospective controlled studies provide evidence o f causality while cross sectional studies offer only descriptive information.  72  Four  studies (Table 1.10) have been identified that prospectively assessed outcome o f patients with Achilles tendon disorders and attempted to correlate outcome to imaging findings. A fifth study was identified that did this in a retrospective fashion.  18  Table 1.9. Studies reporting false positive U S and M R I results. Imaging  False positives  Comment  US 16 contralateral asymptomatic tendons  7/16(43.8%)  US presumed Gold Standard. Insufficient data - outcome not reported. Unknown significance.  Gibbon et fl/. /1999  US 38 tendons of healthy volunteers  occasional small hypoechoic foci.  US presumed Gold Standard. Insufficient data - outcome not reported. Unknown significance.  Astrom et al / 1996  US 13 asymptomatic contralateral tendons  1/13 (7.7% )  Thickening and hypoechoic lesion. Insufficient data outcome not reported. Unknown significance.  Kainberger /1990  US 24 healthy asymptomatic volunteers; contralateral asymptomatic tendon  4/24(16.7%) Thickening in 4 asymptomatic volunteers. 9/? "abnormalities of tendon structure" in contralateral tendons (7/9 previous history)  Insufficient data - outcome not reported. Unknown significance.  Nehrereffl/. /1997  US 24 asymptomatic contralateral tendons  5/24 (20.9%)  None of these had ruptured on follow up, however, insufficient data as to outcome.  Sell et o/. /1996  US 34 asymptomatic cadaver tendons. Mean age 55 years.  19/24 (79.1%) echo change and increased diameter.  Sonography prone to artefact; No correlation to strength or rupture. Histology: necroses, scars and fissures in all regions of the tendons.  Name / Date MRI  Imaging  False positives  Comment  Astrom et n/. / 1996  MRI 14 asymptomatic contralateral tendons  2/14(14.3%)  2 high signal intratendinous lesions on T l . Insufficient data - outcome not reported. Unknown significance.  Movin etal?" I\998  Contrast enhanced MRI Contralateral asymptomatic side of 20 patients.  2/? high signal abnormality near the insertion.  Insufficient data number of unilateral cases not reported, outcome not reported. Unknown significance.  Soila et al. / 1999  MRI Tl-weighted FLASH and STIR. 19 healthy volunteers (38 tendons) 62 asymptomatic contralateral tendons  Signal intensity noted: 45/100 mildly inhomogeneous intratendinous. 38/100 thin, intermediate 30/100 patchy intratendinous intermediate- high 4/100 small areas of intratendinous ground glass intermediate  Only a single sequence done, most other studies report MRI as positive if on more than one sequence. Description of normal variants.  Name / Date US Kalebo et «/. /1990 52  61  69  54  56  95  69  66  19  Table 1.10: Imaging findings correlated to clinical outcome. Author/ Date Follow up (FU)  Imaging Subjects Clinical at baseline  Findings at baseline US  Clinical at FU  Imaging at FU  Comment  Mathieson et al*'! 1988 4 - 6 months  US 20 symptomatic  8 normal 3 fluid around tendon 3 bursa 3 indistinct border 6 thickened or hypoechoic  8 resolved 3 resolved 2 resolved 3 resolved 5 surgery  8 normal 3 normal 2 normal 2 normal. 6 thickened  Thickening or hypoechoic changes on US would suggest a poorer prognosis.  Nehrer el o/. /1997 2-5 years  US 36 patients (48 symptomatic 24 asymptomatic tendons)  20 true negative 20 false negative  No ruptures No ruptures 14 good, 6 fair No ruptures  56  5 false positives 28 true positives 17 grade 1 (6-8mm)  1 rupture; 6 good, 11 fair 2 ruptures; 2 good, 4 fair 4 ruptures 1 good, 4 fair  0 better; 13% worse 18% improved 14% worse 0 better; 80% worse.  8 recovered 3 symptomatic 5 recovered 6 symptomatic 5 recovered 6 symptomatic  Not done  Outcome among the 3 grades the same, although rate of recovery different among grades, with a higher likelihood of recovery if grade 1.  5 normal US 1 hypoechoic 20 thickened and hypoechoic  Not correlated to imaging: 20 excellent 2 good 2 fair 3 poor  Not done  Tendency towards better clinical response in 6 cases that were not thickened. Excellent outcome in those with abnormal imaging.  1 normal 4 low signal & thickened 22 high signal & thickened  Not correlated to imaging: 20 excellent 2 good 2 fair 3 poor  Not done  Outcome of those with normal or thickened MRI the same as those with high signal intensity.  Not done  MRI presumed gold standard. 6 good results with only one total rupture undergoing surgery. Results at follow up biased as non randomised, open study. Prognostic value of MRI unclear.  6 grade 2 (8-10mm) 5 grade 3 (10-12mm)  Archambault et al. / 1998 retrospective 1 year  us  Astrom et nl / 1996 1 year  us  60  69  11 grade 2 (enlarged tendon) 11 grade 3 (hypoechoic changes)  MRI 27 patients chronic severe tendinopathy. All underwent surgery. Marcus et n/. /1989 3 months 62  11 grade 1 (normal)  33 patients  26 patients chronic severe tendinopathy All underwent surgery  MRI 7 patients (4 total rupture; 2 possible total rupture; 1 chronic tendinopathy)  Normal or low grade . US had better clinical outcome, and less likely to have US worsen. Incidence of rupture high compared to the reported prevalence of 0.01%. Possibly influenced by the 3 patients who had infiltrations preruture. Outcome possibly confounded by treatments, which were not stated.  3 total rupture; 1 partial tear. 1 normal continuity; 1 total rupture. 1 tendinopathy.  20  4 good results (1 surgery) 2 good results poor result.  9 6  1.5.4.1. Ultrasound: The findings o f Mathieson et al., Nehrer et al. and Archambault et al. would 49  56  60  have us believe that imaging may be predictive o f outcome. They all found that patients with normal imaging tended to have a better prognosis and that those with thickening or hypoechoic lesions tended to have a poorer prognosis. Astrom et al.  69  similarly found a tendency towards a better clinical response in those tendons that were not thickened on imaging. They do however caution that excellent results are still compatible with abnormal imaging. They also note that the patients were easily diagnosed clinically and acknowledged that all their patients were severe cases that required surgery.  1.5.4.2 MRI: Astrom et al. found that among their 27 surgically treated patients the outcome at 1 69  year follow up was the same for those with normal or thickened tendon as for those with intratendinous high signal intensity. Marcus et al. similarly had mostly good 62  results in the seven patients who all had positive M R I findings, suggesting that abnormal M R I is compatible with good clinical results.  Therefore, although earlier studies would suggest a prognostic benefit o f imaging, the issue remains controversial.  21  1.5.5. What is the overall value of imaging in Achilles tendon disorders?  1.5.5.1. Ultrasound: Seven studies were found that offered sufficient data that the sensitivity and specificity o f U S could be calculated (Table 1.11). The overall accuracy o f U S ranged from 0.65  56  to 0.95.  53  O f these studies only four (Table 1.12)  49 5 4 5 6 6 9  were felt o f sufficient quality  (radiologists blinded to the clinical findings and adequate control group used), that an attempt at a meta-analysis could be done. The sensitivity is calculated as 0.66 and specificity as 0.85 for an overall accuracy o f 0.72. The positive predictive value o f U S is calculated as 0.92 and negative predictive value as 0.50.  1.5.5.2 MRI: Only two studies had sufficient information from which sensitivity and specificity could be calculated (Table 1.11). The overall accuracy o f M R I is 0.92  69  to 0.93.  70  If a meta-analysis is done combining these two studies, a sensitivity o f 0.95 and specificity o f 0.88 is calculated, for an overall accuracy o f 0.92. The positive predictive value o f M R I is calculated as 0.93 and negative predictive value as 0.88.  22  T a b l e 1.11.  Sensitivity and Specificity o f U S and M R I  Author/ Date US Maffulli et al. 1987  Subjects (tendons)  Gold standard  Sensitivity  Specificity  Overall accuracy  Comment  55 symptomatic tendons 39 contralateral asymptomatic tendons  Clinical  0.85  1.0  0.91  Radiologist not blinded to clinical findings: May have influenced interpretation of asymptomatic cases.  Mathieson el al. 1988  20 symptomatic tendons 10 healthy controls  Clinical, and 4-6 month FU.  0.6  1.0  0.73  Radiologist blinded. Control group adequate & sufficient data reported.  Kalebo et al. 1990  78 tendons (62 symptomatic; 16 asymptomatic.)  9 surgery 69 US  1.0  0.56  0.91  US presumed gold standard and false positives misinterpreted. Not stated whether radiologists blinded or not •  Kainberger etal. 1990  73 symptomatic patients 24 asymptomatic controls  17 surgery 80 US presumed correct  0.72  0.83  0.75  Radiologists blinded. Control group adequate & sufficient data reported.  Kalebo et al. 1992"  30 patients (37 tendons) 30 asymptomatic controls  37 surgery  0.94  1.0  0.95  Not stated whether radiologists blinded or not. Control group adequate & sufficient data reported.  Astrom et al. 1996  35 symptomatic tendons 13 asymptomatic tendons 36 patients, 48 symptomatic tendons, 24 asymptomatic contralateral  26 surgery 26 clinical  0.69  0.92  0.75  Radiologists blinded. Control group adequate & sufficient data reported.  Clinical  0.58  0.72  0.65  Not stated whether blinded or not. Control group adequate & sufficient data reported.  Astrom et al. 1996  36 symptomatic tendons 14 asymptomatic tendons  27 surgery 27 clinical  0.94  0.86  0.92  Radiologists blinded. Control group adequate & sufficient data reported.  Movin et al. 1998™  20 patients  Surgical  0.95  0.93  Radiologists blinded. Control group adequate & sufficient data reported.  59  49  52  54  69  Nehrer et al. /1997 56  MRI 69  .0.9  2 3  T a b l e 1.12. M e t a - a n a l y s i s of US a n d M R I results.from a d e q u a t e s t u d i e s .  Imaging  Symptomatic  Asymptomatic  Total  US positive US negative TOTAL  53 20 73  4 20 24  57 40 97  US positive US negative TOTAL  12 20  0 10 10  12 18 30  Astrom et al. 1996  US positive US negative TOTAL  24 11 35  1 12 13  25 23 48  Nehrer et al. 1X991  US positive US negative TOTAL  28 20 48  5 19 24  33 39 72  MR positive MR negative TOTAL  34 2 36  2 12 14  36 14 50  MR positive MR negative TOTAL  19 1 20  2 18 20  20 20 40  Author / Date US Kainberger et al. 1990  Mathieson et al. 1988  4  MRI Astrom et al. 1996  69  Movin etal. 1998  70  5 4  24  1.6. SUMMARY AND RATIONALE FOR STUDY  Despite being a common problem, Achilles tendon disorders are difficult to manage and many patients have prolonged symptoms and a high morbidity.  14 7 9  Conservative  management is applied anecdotally and may fail in chronic cases. Surgical techniques have not been tested through stringent randomised controlled trials. Further 14  randomised controlled trials are needed to assess efficacy of treatment options in Achilles tendinopathy. The current lack of an acceptable, objective gold standard makes pre-treatment and post-treatment measurements arbitrary. In addition subjective outcome measurement tools are also inadequate. There is therefore a need for a quantitative index that assesses severity of Achilles tendinopathy that may be used as an outcome measurement tool in research.  Secondly, while it is clear that US or M R I are the imaging modalities of choice in Achilles tendon disorders, controversy remains over which is of more value, and whether imaging correlates to clinical severity or whether imaging offers prognostic information. There are no prospective, controlled studies of imaging in Achilles disorders and the cross sectional studies offer circumstantial evidence only.  72  There is therefore clearly a need for further research in this area, utilising a 72  prospective study design operative cases.  69 79  and testing patients of varying severity  69  25  including non  CHAPTER TWO  THE VALIDITY AND RELIABILITY OF A CLINICAL AND RESEARCH MEASURE OF SEVERITY OF ACHILLES TENDON DISORDERS - THE VISA-A QUESTIONNAIRE  2.1 I N T R O D U C T I O N  The literature review identified inadequate outcome measurement tools for assessing Achilles tendinopathy. Particularly with reference to grading subjective and clinical information (Section 1.4). A need for a simple questionnaire specific to Achilles tendinopathy was identified. The Victorian Institute of Sport (VIS) Tendon Study group (Appendix A ) undertook to develop a questionnaire specific to Achilles tendinopathy, the V I S A - A Questionnaire (Table 2.1).  The V I S A - A questionnaire consists of eight questions, covering the three domains of pain (question 1- 3), function (question 4-6) and activity (question 7 & 8.) Questions one to seven were scored out of 10 each and question 8 is scored out of 30. Scores are summed to give a total out of 100. A n asymptomatic person would score 100, someone who is symptomatic less than that.  26  Table 2.1. V I S A - A Achilles tendon questionnaire. IN THIS QUESTIONNAIRE, THE TERM PAIN REFERS SPECIFICALLY TO PAIN IN THE ACHILLES TENDON REGION  1. For how many minutes do you have stiffness in the Achilles region on first getting up?  100 0 mins  mms 0  1  POINTS •  10  2. Once you are warmed up for the day, do you have pain when stretching the Achilles tendon fully over the edge of a step? (keeping knee straight) POINTS strong no pain severe pain 0 1 2 3 4 5 6 7 8 9 10 3. After walking on flat ground for 30 minutes, do you have pain within the next 2 hours? (If unable to walk on flat ground for 30 minutes because of pain, score 0 for this question). strong severe pain  no pain  •  POINTS •  0 1 2 3 4 5 6 7 8 9 10 Do you have pain walking downstairs with a normal gait cycle? strong severe pain  no pain 0  1  2  3  4  5  6  7  8  9  POINTS •  10  5. Do you have pain during or immediately after doing 10 (single leg) heel raises from a flat surface? strong severe pain  no pain  0  1  2  3  4  5  6  7  10  6. How many single leg hops can you do without pain? no pain  strong severe pain/unable  0  1  POINTS •  POINTS •  10  7. Are you currently undertaking sport or other physical activity? 0 • Not at all 4 • Modified training ± modified competition 7 • Full training ± competition but not at same level as when symptoms began 10 • Competing at the same or higher level as when symptoms began  27  POINTS •  8. Please complete EITHER A, B or C in this question. If you have no pain while undertaking sport please complete Q8a only. If you have pain while undertaking sport but it does not stop you from completing the activity, please complete Q8b only. If you have pain which stops you from completing sporting activities, please complete Q8c only. A.  If you have no pain while undertaking sport, for how long can you train/practise?  NIL • 0  B.  ll-20mins • 14  21-30mins • 21  POINTS •  >30 mins • 30  OR If you have some pain while undertaking sport, but it does not stop you from completing your training/practice for how long can you train/practise?  NIL • 0  C.  1-10 mins • 7  1-10 mins • 4  11-20 mins • 10  21-30mins • 14  POINTS •  >30 mins • 20  OR If you have pain that stops you from completing your training/practice, for how long can you train/practise? NIL • 0  1-10 mins • 2  11-20 mins • 5  21-30mins • 7  >30 mins • 10  T O T A L SCORE (/100)  28  POINTS •  •%  2.2 M A T E R I A L S A N D M E T H O D S  2.2.1.  Population Identification  The questionnaire was not intended to be a diagnostic tool, rather an index of severity once the diagnosis of Achilles tendinopathy is made. This allows an individuals progress to be monitored. Achilles tendinopathy may be identified clinically as a combination of Achilles tendon pain, tenderness (diffuse or localised) and impaired performance. For the purposes of this study we used patients with a spectrum of 97  clinical problems.  2.2.1.1. Ethics Aproval Ethics approval was obtained from the University of British Columbia Ethics Committee, and from the Vancouver Hospital and Health Sciences Research Advisory Committee. Informed written consent was obtained for all participants prior to their participation in this study. A l l results were kept confidential.  2.2.1.2 Subject Recruitment. Sports medicine physicians, physiotherapists, podiatrists, massage therapists and fitness consultants in the Greater Vancouver Region referred the patients. The inclusion criteria into the study were adult patients older than 18 who were able to give informed consent. Patients were included if they had a diagnosis of Achilles tendinosis, paratendinitis or partial rupture with or without a retrocalcaneal or Achilles bursitis. Patients were excluded if they were pregnant or nursing. People  29  with full ruptures o f the Achilles tendon were also excluded. Patients who were unable to attend a clinical interview for whatever reason were excluded.  O f the sixty-two patients who inquired about the study, seventeen were excluded. This was because o f work commitments (7), location (2), holiday travel (3). Three people had an incorrect diagnosis (plantar fasciitis (2) and ankle sprain (1)) and two people developed unrelated conditions and preferred not to continue the study.  Forty five consecutive patients (27 men, 18 women; mean age 42 years, range 20-66 years) referred because o f symptomatic Achilles tendinopathy (mean duration 21 months, range 0.5 - 120 months) were admitted to the study. Twelve patients had bilateral symptoms and thirty-three patients had unilateral symptoms for a total o f 57 symptomatic and 33 asymptomatic tendons. Five o f the latter had previous symptoms, while twenty eight were never symptomatic. None o f the patients were sedentary, eighteen patients (40%) exercised 1 -3 hours per week, fourteen patients (31%) exercised between 4 - 6 hours per week and thirteen patients (29%) exercised more than 7 hours per week. This was a significantly lower training volume than prior to becoming symptomatic (Table 2.2).  Table 2.2. Activity o f patients before and after onset o f symptoms. Hours of activity per week 0 >0-3 >3-7 >7  Number of subjects exercising at each level prior to symptoms.* 0 8 19 18  *x =22;p<0.01 2  30  Number of subjects exercising at this level after onset of symptoms. 0 18 14 13  Ten patients had stopped their running sports because o f their Achilles tendinopathy. The usual complaint was pain with activity and morning stiffness. Tenderness was found at the m i d tendon in 41 tendons, at the insertion in 12 tendons and diffusely throughout the tendon in 2 patients (4 tendons). The same 4 were thought to have a bursitis as well and an additional 3 other patients were thought to have a bursitis in addition to the tendinopathy. Four tendons, (3 patients) had prior surgery for a Haglund deformity but remained symptomatic, and one patient had received cortisone injections into both tendons and also remained symptomatic.  2.2.1.3. Clinical examination The clinical diagnosis was made by the referring clinician and confirmed by a sports medicine fellowship trained physician. Patients were examined first standing barefoot and alignment or swelling about the Achilles tendon area was noted (Figure 2.1). Functional tests were done by asking the patients to: 1) walk; 2) do single leg heel raises for each side and 3) hop 10 times on each leg. Patients were then examined seated and ankle range o f motion and power testing o f the ankle muscles was assessed with patients' knees flexed at 90 degrees. Patients were then examined lying prone. Both Achilles tendons were examined for swelling and palpated for nodules, thickening and tenderness. The insertional area and Achilles and retrocalcaneal bursae were palpated for tenderness or thickening. The calf muscle was palpated for tenderness, gaps or nodules.  Measurement o f transverse diameter o f the Achilles tendon was done using a "Value Power" plastic calliper. Measurements were made in millimetres. The tendon was measured first at 1 c m above the calcaneal superior border, which was identified by 31  Figure 2.1. Clinical examination of patient showing thickening of left Achilles tendon.  32  palpating the edge of the calcaneus. Next the tendon was measured at its most visible thickest width and the distance of this thickest width from the calcaneal superior border was measured in centimetres.  2.2.2. Item Generation  The VIS Tendon study group first developed a successful index of severity score for Patellar tendinopathy. Following this a questionnaire was developed for use in 98  Achilles tendinopathy. A literature review was done to find items that would be appropriate for inclusion. In addition colleagues were consulted to find unpublished items used in clinical practice. The second step involved interviewing colleagues with expertise in the area of Achilles tendinopathy. Finally patients were informally interviewed regarding symptoms they felt important.  2.2.3. Item Reduction  A focus group consisting of the principal questionnaire developer, a primary care sports medicine physician and two physiotherapists reviewed the items generated. Three domains of pain, " functional status and activity with equivalent of three 38  40  41  25  questions each were felt appropriate (Table 2.1).  2.2.4. Item Scaling  A visual analog scale (VAS) has been found to be more accurate and sensitive than categorical verbal scales.  374099  "  102  The first 6 questions utilise a V A S to allow a 33  c o n t i n u o u s m e t h o d o f e x p r e s s i o n b y w h i c h the patient m a y d e s c r i b e the m a g n i t u d e  of  a subjective experience o f symptoms.  T h e final t w o q u e s t i o n s a s k e d a b o u t a c t i v i t y . H a r r i s o n  et al?  5  suggested that a c t i v i t y  m i g h t best be assessed o n a categorical rating system based o n incremental range o f v a l u e s . T h e final t w o q u e s t i o n s t h e r e f o r e u s e d a c a t e g o r i c a l r a t i n g s c a l e r a t h e r t h a n a VAS.  2.2.5. Pretesting  P r i o r to b e i n g s h o w n the V I S A - A q u e s t i o n n a i r e , a g r o u p o f  fifteen  " e x p e r t s " i n the  f i e l d o f t e n d o n i n j u r i e s w e r e a s k e d to i d e n t i f y q u e s t i o n s t h e y felt w e r e i m p o r t a n t i n assessing the s e v e r i t y o f A c h i l l e s t e n d o n d i s o r d e r s . T h e g r o u p w a s c o m p r i s e d o f 8 physiotherapists, 4 p r i m a r y care physicians, one orthopaedic surgeon and one rehabilitation specialist f r o m the A l l a n M c G a v i n Sports M e d i c i n e C e n t r e i n V a n c o u v e r . T h e i r q u e s t i o n s are l i s t e d i n T a b l e 2.3.  T h e s a m e 15 p a r t i c i p a n t s w e r e t h e n s h o w n t h e V I S A - A s c o r e a n d a s k e d t o e v a l u a t e the questionnaire. T h e y w e r e s p e c i f i c a l l y a s k e d i f there w e r e a n y q u e s t i o n s t h e y w o u l d add, and i f there w e r e a n y questions they w o u l d r e m o v e or change.  F o u r t e e n o f the participants h a d n o q u e s t i o n s to a d d , n o n e w a n t e d a n y r e m o v e d a n d none wanted any changed.  34  Table 2.3. Questions identified by "Experts" as important in assessing Severity of Achilles tendinopathy.  Question  N u m b e r of T i m e s a s k e d  Comment  Diagnostic: e . g . R u l e o u t b a c k p a i n , hip p a i n , location of p a i n , p r e v i o u s treatments.  30  N o t pertinent for severity; C o v e r e d in d i a g n o s t i c interview.  Ambigous: e . g . A r e there a n y a g g r a v a t i n g or o relieving f a c t o r s , A r e y o u limited in activities.  11  U n a b l e to quantify a n s w e r s to open ended questions. U s e f u l in initial d i a g n o s t i c interview.  T i m i n g of p a i n : Morning pain S t i f f n e s s & P a i n with stretching P a i n after activity P a i n d u r i n g activity  24  4  Question Question Question Question  Activities of daily Living P a i n at rest Pain walking P a i n u p a n d d o w n stairs  29 8 9 5  Question one Question three Q u e s t i o n four  S p o r t s Activities jogging heel raises jumping  25 9 3 8  Question Question Question Question  s e v e n a n d eight s e v e n a n d eight five six  Q u a n t i f i e d s p o r t s disability H o w long c a n y o u p l a y ? H o w far c a n y o u r u n ? Have you missed practices?  5 3 1 1  Question Question Question Question  s e v e n a n d eight eight eight eight  6 6 7  one o n e and two three three  2.2.6. Weighting  This questionnaire essentially tests the three significant domains by three questions each (question 8 is effectively 2 questions relating to pain with activity and duration of activity). By removing redundancies and eliminating items of less importance weighting of the remaining items may be the same (each question is scored out of 10) without affecting the value of the questionnaire. 35  2.2.7. Validity  F r o m t h e l i t e r a t u r e r e v i e w it h a s b e e n s h o w n t h a t t h e g o l d s t a n d a r d h i s t o p a t h o l o g y i s u n a c c e p t a b l e t o a p a t i e n t w i t h m i l d s y m p t o m s ( S e c t i o n 1.1). laboratory or biochemical markers  S i m i l a r l y there are n o  o f d i s e a s e s e v e r i t y ( S e c t i o n 1.2) a n d t h e v a l u e o f  r a d i o l o g y ( S e c t i o n 1.5) r e m a i n s c o n t r o v e r s i a l . T h e r e f o r e t h i s s t u d y u t i l i s e d a c l i n i c a l gold standard.  2  3 4  "  3 6  T h i s s t u d y t h e r e f o r e h a d to r e l y o n c o n s t r u c t v a l i d i t y . F i r s t l y the V I S A - A w a s a d m i n i s t e r e d to 4 5 p a t i e n t s w i t h A c h i l l e s t e n d i n o p a t h y . C o n c u r r e n t l y the p a t i e n t s w e r e a l s o g r a d e d a c c o r d i n g to t w o o t h e r g r a d i n g s y s t e m s that o f P e r c y a n d Conochie  4 2  ( T a b l e 2.4) a n d that o f C u r w i n a n d S t a n i s h ( T a b l e 2.5). T h e s c o r e s f r o m 4 3  the three g r a d i n g s y s t e m s w e r e c o r r e l a t e d u s i n g the P e a r s o n ' s p r o d u c t m o m e n t coefficient and Spearman's R a n k correlation coefficient.  S e c o n d l y , a class o f 66 healthy U n i v e r s i t y students, w h o w e r e not i n v o l v e d i n this study i n a n y other w a y w e r e a s k e d to c o m p l e t e the V I S A - A q u e s t i o n n a i r e . T h i r t y w o m e n a n d t h i r t y - o n e m e n (aged 2 0 - 3 2 years, m e a n 2 3 years ± 2.86) a n s w e r e d the questions.  36  T a b l e 2.4. P e r c y and C o n o c h i e ' s grading s c h e m e for results o f surgery o f A c h i l l e s tendinopathy and a m o d i f i c a t i o n for n o n surgical patients.  Percy and C o n o c h i e ' s grading scheme'  M o d i f i c a t i o n for n o n surgical patients (Nehrer  Excellent  Good  et al)  56  A patient w h o h a d full function w i t h  Amelioration o f symptoms, and  no residual disability whatsoever.  return to f u l l s p o r t i n g a c t i v i t y  A patient w i t h slightly questionable  Amelioration of symptoms, minor  weakness, an adherent scar, and m i n o r  limitations in sporting activity  sensory deficit, but no real limitation o f activities a n d f u l l return to f u n c t i o n as i n t h e p r e r u p t u r e p e r i o d . Fair  A definate weakness and some  L i m i t e d sporting activities.  limitation o f activities and a slight limp. Poor  A patient i n w h i c h there w a s a re-  A b a n d o n m e n t o f their sport.  rupture or complete failure w i t h severe weakness and a marked limp.  Table 2.5. Tendinopathy grading system o f C u r w i n and Stanish. Grading system o f C u r w i n and Stanish  4 3  Grade  Description of Pain  Disability  1  N o pain  N o effect o n activity  2  Pain only w i t h extreme exertion; pain  N o effect o n activity  resolves w h e n activity ceases. 3  4  5  6  P a i n w i t h e x t r e m e e x e r t i o n a n d 1-2  Little effect o n activity, m a y l i m i t  hours afterwards.  m o r e intense p h y s i c a l activities.  P a i n d u r i n g a n d after v i g o r o u s  Performance level decreased; Unable  activity.  to p e r f o r m s o m e n e c e s s a y tasks.  P a i n during activity forcing  Causes immediate withdrawal  termination.  activity.  P a i n w i t h daily activities.  U n a b l e to participate i n a n y sports;  from  daily activities m a y also be restricted.  37  2.2.8. Reliability  R e l i a b i l i t y i s a c o n c e p t that r e p e a t e d a d m i n i s t r a t i o n o f a q u e s t i o n n a i r e w i l l p r o d u c e the s a m e r e s u l t s .  2 8  T h e s a m e cohort o f 45 subjects w i t h A c h i l l e s t e n d o n disorders w a s u s e d to assess the reliability o f the V I S A - A questionnaire. T h e V I S A - A questionnaire w a s administered three t i m e s to e a c h patient. I n o r d e r to e x a m i n e the test-retest r e l i a b i l i t y o f the questionnaire t w o questionnaires w e r e a d m i n i s t e r e d a n h o u r apart, either o n the first or s e c o n d patient visit (this w a s r a n d o m l y assigned). A third questionnaire w a s a d m i n i s t e r e d o n e w e e k after the first to assess short t e r m r e l i a b i l i t y . F o r 16 o f the subjects o n o n e o c c a s i o n the V I S A - A questionnaire w a s administered b y either a different sports m e d i c i n e p h y s i c i a n o r a m e d i c a l student.  2.3. RESULTS  2.3.1 Validity  T h e construct validation is s h o w n i n Figures 2.2 a n d 2.3. W h i l e the V I S A - A score w a s significantly correlated to the both grades o f severity (p<0.001) there w a s a w i d e variability i n the scores. A s s h o w n i n F i g u r e 2.4 the V I S A - A scores approximate a n o r m a l c u r v e ( a l b e i t s k e w e d t o t h e right, r e f l e c t i n g t h e i n c l u s i o n o f m i l d n o n s u r g i c a l cases).  38  In the s e c o n d part o f construct v a l i d i t y testing, patients w h o are k n o w n to h a v e the c o n d i t i o n w e r e c o m p a r e d w i t h those k n o w n not to h a v e the c o n d i t i o n . F o r t y - f i v e o f the 6 6 h e a l t h y U n i v e r s i t y students h a d a V I S A - A score o f 100 ( 6 8 % ) . O f the t w e n t y o n e w i t h V I S A - A scores less than 100 - n i n e students had. scores b e t w e e n 9 0 a n d 9 9 (three o f w h o m h a d a h i s t o r y o f i n j u r y to the l o w e r l i m b s ) , ten h a d s c o r e s b e t w e e n 8 0 and 89 (two w h o had lower b o d y injuries and two w i t h achilles tendon pain), and two s c o r e d less than 8 0 (one w i t h A c h i l l e s t e n d o n p a i n , a n d the other w i t h c a l f p a i n ) . N o students w h o scored 100 o n the questionnaire h a d a h i s t o r y o f A c h i l l e s t e n d o n p a i n either i n the past or currently. A c h i l l e s t e n d o n p a i n w a s a significant predictor o f V I S A - A score (p=0.004) whereas other injuries w a s not (p=0.114). A g e d i d not correlate w i t h V I S A score (p>0.05). N e i t h e r sex (p=0.371) nor sporting activity (p=0.21) were predictors o f V I S A - A score.  W h e n c o m p a r i n g the V I S A - A scores o f the 63 students w i t h o u t a n y h i s t o r y o f A c h i l l e s p a i n ( M e a n S c o r e 9 6 ± 7.4), to the V I S A - A s c o r e o f the 4 5 subjects i n the study group ( M e a n S c o r e 63.8 ± 16.8) there w a s a significant difference b e t w e e n the s c o r e s ( p < 0 . 0 0 1 ; i n d e p e n d e n t t w o t a i l e d t-test) ( F i g u r e 2.5).  39  Figure 2.2. Scatter Plot o f V I S A - A score compared to modified Percy and C o n o c h i e ' s grade o f severity.  100  o  Percy and Conochie: Am J Sports Med,1978; 6(3)132-6.  40  Figure 2.3. Scatter Plot of VISA-A score compared to Curwin and Stanish's grade of severity.  100  90  80  1  1  70 '  60  1  50 '  < <fc  >  40  1  30 ,  1  2  3  4  5  6  Grade of Severity  Curwin and Stanish: Tendonitis: Its Etiology and Treatment; 1984  41  F i g u r e 2.4.  F r e q u e n c y histogram o f V I S A - A scores a m o n g n o n surgical patients  (normal curve superimposed).  10  T  Cl  i—i  6:4  30:0  40.0  50.0  60.0  70.0  80.0  VISA-A.Scpres.  42  90.0  Figure 2.5. Box Plot showing V I S A - A scores among asymptomatic students and symptomatic subjects.  n = 45  n = 60 Asymptomatic Students*  Symptomatic "Subjects;  43  2.3.2. R e l i a b i l i t y  The results are summarised in Table 2.6. There was no difference in scores whether the test-retest questionnaires were done at the first visit or at the second visit (p=0.576).  Table 2.6. Summary o f Reliability o f V I S A - A score Reliability  Description  Test-retest reliability  This measures whether an instrument is capable o f measuring a variable with consistency. Here one sample of individuals is subjected to the identical test on two separate occasions under the same circumstances as the first test.  Intrarater reliability  This refers to the stability o f data recorded by one individual across two or more trials.  0.90  Interrater reliability  This concerns the variation between two or more raters who measure the same group o f subjects.  0.90  Short term reliability  Tests whether the measurement remains the same over a short period o f time.  0.81  Pearson's Correlation Co-efficient 0.93  2.4 D I S C U S S I O N  This study shows that the V I S A - A questionnaire is an effective and sensitive measurement tool o f severity o f Achilles tendinopathy, across a wide spectrum o f patients. The V I S A - A questionnaire, being specific to the Achilles tendon, is preferable when compared to other non-specific scoring systems such as that developed for hind foot problems by the American Orthopedic Society,  41 4 4  that  d e v i s e d b y T h e r m a n n et al.  a n d t h a t d e v i s e d b y B o y d e n et al.  ( T a b l e 1.1). T h e  V I S A - A q u e s t i o n n a i r e is a l s o m o r e s e n s i t i v e t h a n that o f P e r c y a n d C o n o c h i e a n d that o f C u r w i n a n d S t a n i s h , s i n c e the latter t w o u s e a c a t e g o r i c a l r a t i n g s c a l e , h a s b e e n s h o w n to b e i n s e n s i t i v e to s u b t l e c h a n g e s i n c l i n i c a l c o n d i t i o n .  2 7  which  4 2 4 3  2 8  While  t h e r e i s a w i d e v a r i a b i l i t y i n t h e s c o r e s as m e a s u r e d o n t h e c a t e g o r i c a l r a t i n g s c a l e s , this m a y b e d u e to a l a c k o f s e n s i t i v i t y i n the c a t e g o r i c a l g r a d i n g s c h e m e s .  3 74 0  9 9 - 1 0 2  N o t r a i n i n g is r e q u i r e d to a d m i n i s t e r the V I S A - A q u e s t i o n n a i r e . T h e scores w e r e the same whether a d m i n i s t e r e d b y an untrained student or b y a sports m e d i c i n e trained p h y s i c i a n . T h e a d v a n t a g e therefore o f the V I S A - A q u e s t i o n n a i r e is i n a s i m p l e assessment o f subjective data. U n t i l an o b j e c t i v e m a r k e r o f disease severity is d i s c o v e r e d , s u b j e c t i v e d a t a r e m a i n s the m o s t i m p o r t a n t o u t c o m e v a r i a b l e . T h e v a l u e o f a v a l i d a n d r e l i a b l e subjective o u t c o m e m e a s u r e m e n t t o o l is i n repeated m e a s u r e s b e f o r e a n d after a n i n t e r v e n t i o n . T h e use o f a n u m e r i c a l q u e s t i o n n a i r e a l l o w s statistical c o m p a r i s o n s , u s e f u l i n the r e s e a r c h setting b o t h f o r c o n s e r v a t i v e a n d surgical therapies. Studies m a y be done i n various centres and results c o m p a r e d .  T h e V I S A - A questionnaire is not a diagnostic t o o l , other d i a g n o s e s m a y b i a s the f i n a l V I S A - A s c o r e . F o r e x a m p l e a patient w i t h a n a c u t e a n k l e s p r a i n m a y b e u n a b l e to p e r f o r m s o m e o f the f u n c t i o n a l tests.  N e v e r t h e l e s s the V I S A - A score offers c l i n i c i a n s an indicator o f severity o f their patients' c o n d i t i o n , w h i c h a l l o w s t h e m a s i m p l e t o o l to m o n i t o r p r o g r e s s a n d r e s p o n s e to therapy.  45  2.5 CONCLUSION  The V I S A - A index o f severity for Achilles tendon disorders is a valid and reliable measurement tool. It would be useful both in the clinical setting and in research settings as it has been shown to be accurate across a wide spectrum o f patients. It is also reliable to administer by practitioners who are not specialist trained. The V I S A A index offers a suitable outcome measurement tool for treatment studies, for tendinopathy research and for monitoring individual patients with Achilles tendon disorders.  46  CHAPTER THREE  ARE OPTIMISED ULTRASOUND AND MAGNETIC RESONANCE IMAGING OF VALUE IN ACHILLES TENDON DISORDERS?  3.1  INTRODUCTION  T h e e v i d e n c e p r e s e n t e d i n t h e l i t e r a t u r e s u r v e y ( S e c t i o n 1.5) i s i n c o n c l u s i v e a s t o t h e benefit o f i m a g i n g i n A c h i l l e s t e n d o n disorders. T h e r e is a n e e d for a p r o s p e c t i v e  c o n t r o l l e d study into the p r e d i c t i v e v a l u e o f U S a n d M R I .  72  In the present study, a g r o u p o f patients s u f f e r i n g f r o m A c h i l l e s t e n d o n d i s o r d e r s v a r y i n g i n s e v e r i t y f r o m m i l d to s e v e r e , a n d a c u t e to c h r o n i c w e r e a s s e s s e d c l i n i c a l l y a n d b y state o f t h e art U S a n d M R I . T h e p u r p o s e w a s t o c o m p a r e t h e t w o m o d a l i t i e s w i t h r e g a r d to their use i n m i l d cases, to assess w h e t h e r the c l i n i c a l s e v e r i t y o f the c o n d i t i o n correlated w i t h the severit y o f the i m a g i n g f i n d i n g s a n d to d i s c o v e r w h e t h e r , either m e t h o d w a s predictive o f o u t c o m e .  47  3.2 P A T I E N T S A N D M E T H O D S  3.2.1. C l i n i c a l  3.2.1.1. Patients. The forty-five consecutive patients recruited for the assessment o f the V I S A - A questionnaire (Section 2.2.1) also provided informed written consent to participate in the imaging part o f the study. Ethics approval was similarly obtained. The demographics o f the forty five subjects was: A g e range: 20 and 66 years (mean 42.35 ± S.D.I 1.35); Onset o f symptoms: Range 0.5 and 120 months (Mean 21.5 ± S.D. 29.34). Bilateral symptoms were present in 12 patients (24 tendons), giving a total o f 57 symptomatic tendons and 33 asymptomatic tendons. The symptoms were usually pain with activity and morning stiffness, and signs were m i d tendon tenderness (41 tendons), insertional tenderness (12 tendons) or diffuse tenderness (4 tendons.)  3.2.1.2. Clinical Severity The severity o f the clinical condition was ranked according to the V I S A - A questionnaire'discussed i n Chapter two.  3.2.1.3. Follow Up Patients were contacted by telephone 3 months after the initial examination and imaging studies. They were questioned on symptoms, treatment they may have undergone, and the clinical severity o f their condition was assessed using the V I S A - A  48  index and the grading system of Percy and Conochie. Patients with ongoing complaints or questions were invited to attend a clinical examination.  3.2.2. Imaging  3.2.2.1. Ultrasound Real time US was performed by one of two ultrasound technicians using a highresolution 12-5L array scanner. (Advanced Technology laboratories 5000, Bothell, WA). Their findings were confirmed by one of two radiologists who were blinded to  49  Figure 3.1. U S was performed with the patient prone.  the clinical findings or other imaging findings. U S was done the day o f or within one week o f the clinical examination. Patients were positioned prone with their feet hanging over the end o f the scanning table in a relaxed posture (Figure 3.1). A n acoustic stand-off pad or a synthetic gel spacer was not necessary. Sonograms were obtained in the sagittal plane o f the entire length o f both tendons, as well as transverse sections. Particular care was taken to ensure the scan plane was parallel to s n s n 89 1 n ^  the tendon fibres to avoid acoustic fibre anisotropy.  Thickness was measured  by the anteroposterior (AP) diameter in a transverse scan at a neutral position o f the talocrural j o i n t . 6 mm.  545 6 8 3 8 7  A thickened tendon was defined as one that was greater than  A sonographic abnormality was defined as either one or more hypoechoic  and / or hyperechoic areas evident in both the longitudinal and the transverse scans, or a fusiform swelling o f the tendon with or without hypoechoic areas.  Both colour and power Doppler interrogation was utilised in all patients.  3.2.2.2. Grading of US severity Measurements o f any hypoechoic areas were made using electronic callipers in both the axial (transverse) and sagittal (longitudinal) planes.  Length was measured on the  sagittal image, whereas width (mediolateral dimension) and height (anteroposterior dimension) were measured on the axial image. The approximate volume o f each hypoechoic lesion was calculated using the product o f length, width and height.  70  The  tendons were also graded according to a grading scheme developed by Archambault et al. Grade 1 was assigned i f the tendon appeared normal; Grade 2 was assigned i f 60  the tendon showed evidence o f thickening, with a homogeneous echotexture; Grade 3  51  w a s a s s i g n e d i f there w e r e a n y h y p o e c h o i c areas, o r c a l c i f i c a t i o n s , w i t h i n the t e n d o n w i t h or without thickening.  6 0  3.2.2.3 Magnetic Resonance Imaging M R I w a s p e r f o r m e d o n the first 25 c o n s e c u t i v e patients w h o e n r o l l e d i n the study u s i n g a 1.5 T e s l a e c h o s p e e d s c a n n e r ( G e n e r a l E l e c t r i c M i l w a u k e e , W I ) . M R I w a s d o n e w i t h i n t w o w e e k s o f the U S a n d c l i n i c a l e x a m i n a t i o n . W i t h the patient s u p i n e m u l t i p l e sagittal a n d a x i a l sequences w e r e obtained u s i n g a quadrature h e a d c o i l ( F i g u r e 3.2). T h e f o l l o w i n g sequences w e r e used: F o r T l - w e i g h t e d sagittal s p i n e c h o imaging and axial spin echo T l imaging, repetition time was 500 msec, echo time w a s 14 m s e c , s e c t i o n t h i c k n e s s w a s 3 m m w i t h n o i n t e r s l i c e g a p , f i e l d o f v i e w w a s 12 c m , matrix was 256 X 256, signals acquired were 2 and imaging time was 4 minutes 2 4 s e c o n d s . F o r sagittal fast short t a u i n v e r s i o n r e c o v e r y ( F S T I R ) : e f f e c t i v e e c h o t i m e was 32 msec, repetition time was 4,000 msec, inversion time w a s 150 msec, field o f v i e w w a s 16 c m X 16 c m , s e c t i o n t h i c k n e s s w a s 3 m m w i t h n o g a p , m a t r i x w a s 2 5 6  X  192, n u m b e r o f excitations w a s 3 and i m a g i n g time w a s 5 minutes 36 seconds. F o r t w o - d i m e n s i o n a l T 2 * - w e i g h t e d sagittal gradient-recalled echo ( G R E ) i m a g i n g : repetition time w a s 800 m s e c , echo time w a s 30 m s e c , flip angle w a s 70°, field o f v i e w w a s 12 c m , s e c t i o n t h i c k n e s s w a s 3 m m w i t h n o g a p , m a t r i x w a s 2 5 6 X 2 5 6 , s i g n a l s a c q u i r e d w e r e 1.5 a n d i m a g i n g t i m e w a s 5 m i n u t e s 1 0 s e c o n d s . M R I w a s r e a d b y two radiologists and concurrence w a s obtained for all 50 tendons.  52  Figure 3.2. Bilateral tendon M R I was performed using a quadrature head coil.  3.2.2.4. Grading of MR severity T h e size o f a n y intratendinous p a t h o l o g y w a s m e a s u r e d and the a p p r o x i m a t e  volume  o f t h e l e s i o n c a l c u l a t e d as a p r o d u c t o f t h e l e n g t h ( c r a n i o c a u d a l d i m e n s i o n o n longitudinal plane), w i d t h (mediolateral dimension o n axial plane) and height 70  (anteroposterior d i m e n s i o n o n axial plane).  F o r c o m p a r i s o n purposes the M R I w a s  a l s o g r a d e d i n a s i m i l a r m a n n e r t o t h e U S g r a d i n g a s - 1: n o r m a l , 2 : t h i c k e n e d o r 3 : intratendinous signal intensity change.  3.2.3. Data Analysis  Statistical a n a l y s i s w a s p e r f o r m e d u s i n g the Statistical P a c k a g e f o r the S o c i a l S c i e n c e s software ( S P S S ) for w i n d o w s ( v e r s i o n 7.0). Patient characteristics w e r e a n a l y s e d u s i n g d e s c r i p t i v e data. G r a d e s o f s e v e r i t y c l i n i c a l l y , b y U S arid M R I  were  compared using Pearson's correlation co-efficient and Spearman's rank correlation . for n o n parametric data. Relationship between clinical findings and i m a g i n g  findings  was analysed u s i n g a C h i - s q u a r e d analysis w i t h 2 X 2 contingency tables. F o l l o w up data w a s analysed u s i n g a C h i - s q u a r e d analysis w i t h 3 X 3 c o n t i n g e n c y tables.  54  3.3  RESULTS  3.3.1 Imaging  3.3.1.1. Ultrasound Ultrasound (Figure 3.3) correctly identified 37 o f the 57 (65%) symptomatic tendons as being abnormal and 22 o f the 33 (67%) asymptomatic tendons as being normal (Table 3.1).  Table 3.1. U S results. US results  Clinical findings  n=90 tendons  Symptomatic  Asymptomatic  Total  US Positive  37  11  48  US Negative  20  22  42  TOTAL  57  33  90  The absolute clinical diagnosis (e.g. tendinosis, partial rupture, peritendinitis) did not correlate well to the imaging diagnosis (Table 3.2). Table 3.2. Chart listing clinical diagnosis and U S correlation.  CLINICAL DIAGNOSIS* SYMPTOMATIC Tendinosis+ partial rupture Insertional tendinopathy Bursitis Peritendinitis TOTAL ASYMPTOMATIC Never Prior TOTAL  -*  .  .  .  .  US No. of tendons.  Agree n  Disagree n  45 16 5 0 66  32 2 3  13 14 2  26 7 33  More than one diagnosis is possible. 55  -  -  37  29  19 3 22 (67%)  7 4 11 (33%)  Figure 3.3. Hypoechoic lesion as seen on US (sagittal view).  Appearance o f a thickened tendon o n sagittal v i e w .  Appearance o f a hypoechoic lesion o n sagittal v i e w . (White A r r o w )  56  T h u s U S h a d a sensitivity o f 0.65 and specificity o f 0.67 and an overall a c c u r a c y o f 0.66. T h e positive predictive value w a s 0.77 and negative predictive value 0.52. T h e a d d i t i o n o f c o l o u r a n d p o w e r d o p p l e r interrogation d i d not e n h a n c e the a c c u r a c y o f U S ( T a b l e 3.3).  T a b l e 3.3. R e l a t i o n s h i p b e t w e e n c l i n i c a l findings and c o l o u r and p o w e r doppler f l o w on U S .  Clinical Findings Colour Doppler (US)  Symptomatic  Asymptomatic  Total  positive  32  7  39  negative  25  26  51  Total  57  33  90  Power Doppler (US)  Symptomatic  Asymptomatic  Total  positive  5  1  6  negative  52  32  84  Total  57  33  90  O f those 3 9 tendons w i t h i n c r e a s e d c o l o u r f l o w , 21 w e r e t h i c k e n e d or n o d u l a r clinically (x  2  = 17.9; p < 0 . 0 1 ) ( T a b l e 3.4). T h e r e w a s also a c o r r e l a t i o n b e t w e e n  positive c o l o u r f l o w and age (Spearman's rho = 0.56; p<0.01) but not between onset of symptoms (x  2  = 0 . 1 1 1 ; p = 0.74)(Table 3.5), o r sports participation ( x  2  = 1.05; p =  0.59).  T a b l e 3.4. R e l a t i o n s h i p b e t w e e n p o s i t i v e c o l o u r f l o w o n U S a n d c l i n i c a l t h i c k e n i n g o f the t e n d o n . Colour no  yes  TOTAL  clinical  no  44  18  62  thickening  yes  7  21  28  TOTAL  51  39  90  57  Table 3.5. Relationship between onset o f symptoms and colour doppler flow on U S .  onset o f symptoms  acute chronic TOTAL  Colour yes 5 24 29  no 4 12 16  TOTAL 9 36 45  3.3.1.2. Ultrasound Severity Although arbitrarily defined, the calculated volume o f hypoechoic lesions correlated significantly with the index o f severity suggested by Archambault et al.  60  (Spearman's  rho = 0.87; p<0.01) and both correlated significantly with the V I S A - A score (Spearman's rho = -0.33; p<0.01 and -0.34; p O . O l respectively).  3.3.1.3 MRI M R I (Figure 3.4) correctly identified 19 (56%) o f the 34 symptomatic tendons as being abnormal but 15 symptomatic tendons were falsely identified as being normal (Table 3.6).  Table 3.6. M R I results MRI results  Clinical findings  n=50 tendons  Symptomatic n=34  Asymptomatic n=16  Total  MRI Positive  19  1  20  MRI Negative  15  15  30  TOTAL  34  16  50  58  Figure 3.4. Intratendinous high signal intensity seen on TI-weighted M R I .  MRI Appearand of wmml Achilla tmdcri Tl-w*i#ited finages  MRI Appearance of fotrabmidir^higi sigriil intensity change OKhite Arrow)  59  Sixteen tendons were asymptomatic, and M R I was normal in 15 (94%) o f them. In the sixteenth case M R I showed increased signal intensity within the tendon that had "never" been symptomatic. Thus M R I has a sensitivity o f 0.56, a specificity o f 0.94, a positive predictive value o f 0.95, a negative predictive value o f 0.50 and an overall accuracy o f 0.68.  There was no significant difference in M R I results between those presenting acutely or chronically (x = 0.15; P = 0.69). However the false negative cases were 2  significantly milder than the true positive cases (paired t-test; p<0.01) (Table 3.7), and were less likely to be thickened (Table 3.8)(Figure 3.5).  Table 3.7. Relationship between M R I results and clinical severity.  C l i n i c a l findings  M R I results  VISA-A Scores*  * t-test; p< 0.01  S y m p t o m a t i c n=34  A s y m p t o m a t i c n=16  mean ± S D  MRI Positive  19  1  60.2 ± 19.5  MRI Negative  15  15  86.9 ± 16.1  Table 3.8. Relationship between clinically thickened tendons and positive M R I .  M R I results x = 12.2; P O . 0 0 1  S y m p t o m a t i c n=34 Thickened  Not T h i c k e n e d  Positive  14  5  Negative  2  13  2  60  Figure 3.5. Combined box plot and scatter plot showing relationship between clinical severity and thickening of the tendon in patients with positive MRI results.  61  3.3.1.4. MRI Severity A l t h o u g h arbitrary, the v o l u m e o f intratendinous h i g h s i g n a l intensity lesions c o r r e l a t e s s i g n i f i c a n t l y w i t h a s i m p l e g r a d i n g s c h e m e s u g g e s t e d b y A r c h a m b a u l t et a / . ( S p e a r m a n ' s r h o = 0 . 7 3 6 ; p < 0 . 0 1 ) . T h i s v o l u m e also c o r r e l a t e d s i g n i f i c a n t l y to 6 0  the c l i n i c a l s e v e r i t y ( S p e a r m a n ' s r h o = - 0 . 4 2 4 ; p < 0 . 0 1 ) , a n d the v o l u m e o f hypoechoic lesions on U S (Spearman's rho = 0.673; p<0.05).  3.3.1.5. Follow up In o r d e r to s h o w a s i g n i f i c a n t c h a n g e i n a subject's c o n d i t i o n , a c h a n g e o f 2 5 o r m o r e p o i n t s o n t h e V I S A - A s c o r e i s r e q u i r e d . F r o m t h e test r e t e s t r e l i a b i l i t y d a t a ( S e c t i o n 2 . 3 . 3 , T a b l e 2.6) the standard error o f m e a s u r e m e n t m a y b e c a l c u l a t e d as 2.4 p o i n t s ( 9 5 % C I 5 8 . 9 to 6 8 . 6 ) . T h e r e f o r e a s i g n i f i c a n t d i f f e r e n c e not d u e to m e a s u r e m e n t e r r o r c a n b e c a l c u l a t e d as 0 . 2 5 ( 2 5 % ) ( 2 . 4 / ( 6 8 . 6 - 5 8 . 9 ) ) . A t 3 m o n t h f o l l o w u p 7 o f the 4 5 patients h a d i m p r o v e d b y m o r e t h a n 2 5 p o i n t s o n the V I S A - A scale, 3 7 r e m a i n e d the s a m e a n d 1 h a d w o r s e n e d . In assessing w h e t h e r the s e v e r i t y i n d e x e s ( c l i n i c a l , U S a n d M R I ) a r e p r e d i c t i v e o f o u t c o m e at 3 m o n t h s , w e a s s e s s e d w h e t h e r t h e i m p r o v e m e n t at 3 m o n t h s w a s r e l a t e d t o s e v e r i t y s c o r e s at b a s e l i n e . W h i l e t h e b a s e l i n e c l i n i c a l V I S A - A score d i d correlate w i t h the 3 m o n t h V I S A - A s c o r e (Pearson's r = 0 . 6 1 5 ; p < 0 . 0 1 ) n e i t h e r U S n o r M R I grade o f s e v e r i t y c o r r e l a t e d to o u t c o m e at 3 m o n t h s ( x  2  = 1.98; p = 0.73 a n d x  3.9).  62  2  = 2.56; p = 0.63 respectively) (Table  Table 3.9. Relationship between imaging severity at baseline and clinical outcome at 3 month follow up.  Follow up x = 4.98; p = 0.28 2  US  normal thickening hypoechoic Total  x = 2.74; p = 0.6  normal thickening intensity change  x  MRI  Total  Improved 2 2 3 7  Same 9 2 26 37  worsened 1 0 0 1  Total 12 3. 30 45  1 1 1 3  9 2 10 21  1 0 0 1  11 3 11 25  2 There was no relationship between outcome and onset o f symptoms (x = 2.8; p = 0.24) nor between outcome and thickening o f the tendon (x = 2.6; p = 0.26). 2  3.3.1.6. Correlation between US and MRI A m o n g the 34 symptomatic tendons both U S and M R I were correct in 18 tendons and falsely negative in 10 tendons (Table 3.10).  Table 3.10 Correlation between U S and M R I . Clinical findings n=50 tendons  Ultrasound  Symptomatic n=34  Asymptomatic n=16  Positive  18  0  Negative  1  1  Positive  5  3  Negative  10  12  34  16  Total  20  MRI Positive  30 .  MRI Negative  TOTAL  63  50  On 2 way A N O V A , the V I S A - A scores o f the patients falsely identified as having normal imaging were significantly higher (milder condition) than those with positive imaging (p<0.05) (Figure 3.6; Table 3.11).  Table 3.11. Correlation between U S and M R I and V I S A - A score in 34 symptomatic subjects.  VISA-A Score  n  US RESULTS  mean ± SD positive  18  57.6 ± 18  negative  1  67.3  positive  5  66.4 ± 13.6  negative  10  77.4 ± 11.7  MRI Positive  MRI Negative  A m o n g the 16 asymptomatic tendons, only one tendon was falsely positive on M R I but not U S and 3 tendons were falsely positive on U S but not M R I . The remaining 12 tendons were correctly identified as normal on both imaging modalities.  64  Figure 3.6. Correlation between U S , M R I and V I S A - A Score.  100  -i  90 ' 80 70  < >  1  1  60 1 50  i X  Ultrasound  •  MRI  30 ' 20 J IS abnormal  abnormal  normal  normal  False Negatives  True Positives  65  3.4. DISCUSSION  Because histopathology was unacceptable to the patients, and there are no biochemical markers o f disease severity, this study utilised a clinical gold standard. While this is the first study to stress this in Achilles tendon research, others have utilised a clinical gold standard in patellar tendon research. L i a n et a l . and Almekinders  36  35  and Shalaby  showed convincing evidence that clinical findings are indeed a  preferable standard than imaging in research in the patellar tendon.  37  W e were unable to show a difference in accuracy between either imaging modalitiy. These findings, among a cohort o f nonoperative cases, complement those o f Astrom et al. who found little difference between U S and M R I among a group o f more 69  severe cases. This lack o f sensitivity would suggest that U S and M R I are inadequate as an outcome measurement.  The value o f U S was not enhanced by the addition o f colour and power doppler interrogation. Colour and power doppler sonography have been used successfully in depicting high volume flow as in large vessels, and only recently has been used in identifying change o f perfusion in low velocity areas such as the musculoskeletal soft tissues.  88 1 0 4  Because grey scale and colour sonography is operator dependant, it was  hoped the addition o f power doppler assessment would add objective evidence o f pathology. But like Weinberg et al.* we found all tendons with positive colour flow 89  9  also had positive findings on grey scale. W e also found colour doppler to be significantly more sensitive and more visible than power doppler, in contrast to the suggestion o f Breidahl et al.  m  who thought that power doppler may be more suitable. 6 6  C o l o u r doppler unlike p o w e r doppler is dependant o n angle. U n t i l the histology is identified, o f tendon w i t h positive colour and p o w e r doppler sonography, the m e c h a n i s m f o r i n c r e a s e s i n flow a r e s p e c u l a t i v e . F u r t h e r r e s e a r c h i s n e e d e d i n t h i s regard.  T h i s study used the v o l u m e o f intratendinous abnormalities seen o n U S and M R I to q u a n t i f y i m a g i n g a b n o r m a l i t y . A l t h o u g h t h i s h a s a l s o b e e n u s e d b y M o v i n et al.  10  the  r e p r o d u c i b i l i t y a n d v a l i d i t y o f t h i s m e a s u r e m e n t h a s n o t b e e n a s s e s s e d . K h a n et a / .  1 0 5  i n their series a s s e s s i n g p a t e l l a r t e n d o n i m a g i n g f i n d i n g s s u g g e s t e d that c r o s s sectional area i n the a x i a l plane w a s a m o r e reproducible measurement. W h e t h e r this is the case i n the A c h i l l e s tendon remains a subject f o r further research.  D e s p i t e these limitations i m a g i n g grade o f severity correlated w e l l to c l i n i c a l severity. H o w e v e r , n o a d d i t i o n a l i n f o r m a t i o n w a s o b t a i n e d that w a s n o t evident clinically.  I m a g i n g w a s u n a b l e to differentiate b e t w e e n cases that w o u l d i m p r o v e a n d those that w o u l d w o r s e n . D e s p i t e n o r m a l i m a g i n g o n e p a t i e n t w a s w o r s e at f o l l o w u p . T h i s i s i n contrast to the studies o f M a t h i e s o n but m o r e i n k e e p i n g w i t h the  findings  et al.,  49  Nehrer  of Astrom  et al.  et al.  56  69  and Archambault  and M a r c u s  et al.  62  et al.  60  Clinical  i n d e x o f s e v e r i t y at p r e s e n t a t i o n w a s t h e o n l y p r e d i c t o r o f o u t c o m e at 3 m o n t h f o l l o w up.  67  3.5. C O N C L U S I O N  C l i n i c i a n s s h o u l d e x e r c i s e d i s c r e t i o n i n o r d e r i n g i m a g i n g tests a n d i n i n t e r p r e t i n g their f i n d i n g s . B e c a u s e o f the cost, a c c e s s i b i l i t y a n d c o n v e n i e n c e o f U S this s h o u l d b e the i m a g i n g m o d a l i t y o f c h o i c e . I m a g i n g m a y b e best suited to a n s w e r s p e c i f i c d i a g n o s t i c q u e s t i o n s , s u c h as t h e l o c a t i o n o f h y p o e c h o i c r e g i o n s i n a d i f f u s e l y t h i c k e n e d t e n d o n ; t h e p r e s e n c e o f a d d i t i o n a l l e s i o n s s u c h as x a n t h o m a  a n d as a n  a d j u n c t to a n U S d i r e c t e d b i o p s y . W h e r e i m a g i n g i s o r d e r e d o n e w o u l d stress the n e e d for c o m m u n i c a t i o n b e t w e e n the c l i n i c i a n and r a d i o l o g i s t .  68  7 3  CONCLUSION AND RECOMMENDATIONS  T h i s study has i n t r o d u c e d a n e w v a l i d and reliable tool for m e a s u r i n g the severity o f A c h i l l e s t e n d o n d i s o r d e r s the V I S A - A q u e s t i o n n a i r e that w i l l b e u s e f u l i n r e s e a r c h and in clinical practice. T h e V I S A - A questionnaire offers a quantifiable measure o f s u b j e c t i v e c l i n i c a l f i n d i n g s that a l l o w for c o m p a r i s o n s o v e r t i m e . In c l i n i c a l trials o f t h e r a p y r e s e a r c h e r s w i l l f i n d t h e i n d e x u s e f u l as a n o u t c o m e m e a s u r e m e n t t o o l . C l i n i c i a n s t o o w i l l f i n d the i n d e x u s e f u l assess patient r e s p o n s e to t h e r a p y a n d changes in clinical condition over time.  T h i s t h e s i s h a s a l s o s h o w n that i m a g i n g f i n d i n g s d o n o t a d d to the c l i n i c a l a s s e s s m e n t o f a patient a n d s h o u l d b e r e s e r v e d for s p e c i f i c cases. W h e r e i m a g i n g is r e q u i r e d U S w a s s h o w n t o b e as a c c u r a t e as M R I , a n d t h e r e f o r e w o u l d b e t h e p r e f e r r e d i m a g i n g m e t h o d . C o l o r a n d P o w e r D o p p l e r s o n o g r a p h y d i d not a d d v a l u e to g r e y scale s o n o g r a p h y and n e e d not be p e r f o r m e d . W h e r e i m a g i n g m a y be o f use is i n the d i a g n o s i s o f u n u s u a l c o n d i t i o n s s u c h as t e n d o n x a n t h o m a ; i d e n t i f y i n g t h e s i t e o f h y p o e c h o i c l e s i o n s p r e s u r g i c a l l y a n d as a n a d j u n c t t o a n U S d i r e c t e d b i o p s y . C o m m u n i c a t i o n b e t w e e n the c l i n i c i a n a n d r a d i o l o g i s t w i l l facilitate appropriate interpretation o f the i m a g i n g f i n d i n g s .  T h i s thesis assessed patients o v e r a short term f o l l o w up p e r i o d . F u r t h e r p r o s p e c t i v e studies to assess the l o n g t e r m p r o g n o s t i c v a l u e o f the V I S A - A s c o r e are n e e d e d . In a d d i t i o n there is a n e e d for p r o s p e c t i v e studies to characterise the natural h i s t o r y o f changes seen in i m a g i n g studies w i t h i n s y m p t o m a t i c and asymptomatic A c h i l l e s tendons.  69  BIBLIOGRAPHY  1.  M y e r s o n M S , Biddinger K. Achilles Tendon Disorders. Practical Management Strategies. T h e P h y s i c i a n and Sportsmedicine 1995;  2.  Jozsa L, K a n n u s P. H u m a n tendons. C h a m p a i g n , IL: H u m a n Kinetics, 1997. 181-190;  3.  460-511  R e n s t r d m P , J o h n s o n R J . 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Br J Sports Med 1997; 31 (4):332-6.  77  APPENDIX A  Investigators in the V I S Tendon study group are: Anderson I; Bartlett J; B e l l S; Bonar F ; Bracy C ; Bradshaw C ; Burke F ; Cladwell B ; Cook J; Crichton K ; Dalziel R ; Desmond P; D o w l i n g R ; Ebeling P; Evans S; Fehrmann M ; Fuller P; Garnham A ; Grant M ; Harcourt P; Hare W ; Henderson I; Kearney C ; Kellaway D ; Khan K ; Kiss Z S ; Larkins P; O ' B r i e n P; O'Sullivan R ; Morris C ; Purdam C ; Quirk R ; Read J; Shnier R ; Tress B ; Visentini P; Wark J; Wilson P; Y o u n g D . The following institutions are represented: Department o f Medicine, University o f Melbourne, Royal Melbourne Hospital; Department o f Radiology, University o f Melbourne, Royal Melbourne Hospital; Australian Institute o f Sport; Victorian Institute o f Sport.  106  7 8