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Assessment of the Visa-A questionnaire for Achilles tendinopathy and its correlation with imaging 2000

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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 University 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 Kinetics) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA July 2000 ® Jennifer Mary Robinson, 2000 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the Un i v e r s i t y of B r i t i s h Columbia, I agree that the Library 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 reference and study. I further agree that permission for extensive copying of t h i s thesis for sc h o l a r l y purposes may be granted by the head of my department or by h i s or her representatives. I t i s understood that copying or p u b l i c a t i o n of t h i s thesis f o r f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of ( T H _ W V \ . g l l / V M ^ ^ C ^ The U n i v e r s i t y of B r i t i s h Columbia Vancouver, Canada Date c9S ft^ O O 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. i i 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 MRI 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 US would be preferred when imaging is required. i i i TABLE OF CONTENTS Abstract i i List of Tables vii i List of Figures x Acknowledgements xi INTRODUCTION 1 C H A P T E R ONE: 3 L I T E R A T U R E R E V I E W 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 MRI 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 THE 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 - THE 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 US and MRI 63 3.4 Discussion 66 3.5. Conclusion 68 C O N C L U S I O N A N D R E C O M M E N D A T I O N S 69 B I B L I O G R A P H Y 70 A P P E N D I X 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 MRI 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 vi i i 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. US 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 MRI 63 Table 3.11. Correlation between US and MRI and V I S A - A score 64 ix LIST OF FIGURES 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. US 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. x i INTRODUCTION Tendon injuries account for a substantial portion of overuse injuries in sports.4 6 Among recreational athletes the Achilles tendon is one of the most common sites of injury. 7 Overuse Achilles injuries occur particularly among athletes involved in running 2 6 8 - 1 0 racquet sports,1 1 jumping sports,9"11 soccer 1 1 1 2 and dancing. 1 2 Among top level runners the incidence of 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 of persistent symptoms, 1 5 recurrences and in 2 % 6 to 16% 1 6 o f athletes abandonment of their sport.7 1 7 Achilles tendinopathy refers to the clinical syndrome of pain in the region of the Achilles tendon with diffuse or nodular swelling in that area. Treatment, typically consists of relative rest, anti-inflammatory medication, 1 8 physical therapy, 1 8 modalities, ice, strengthening exercises, orthotics, heel lifts, stretching and even surgery6 1 5 for persistent cases. However, few controlled studies have tested the efficacy of these forms of 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 of 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 9 S defined but there is a lack of a standardised system of assessing this in orthopaedics. 2 6" 2 8 A standard disease-specific grading system facilitates researchers to 1 better assess efficacy of treatment and compare different methods of treatment. Evidence based treatments may then be used in clinical practice. The purpose of this thesis was to investigate outcome measures of use in Achilles tendinopathy research. In particular attention was focused on clinical measures that may be used to quantify the severity of the patient's condition and to assess changes in condition. Secondly, the value of 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 of the difficulty in assessing differences in treatment results is due to a lack of objective or quantifiable outcome measurement tools. A literature search was done to identify and analyse potential outcome measures which have been used in Achil les tendon research. Potential outcome measurements include: histopathology; biochemical markers; clinical findings; subjective outcome measures and imaging findings. 1.1. H I S T O P A T H O L O G Y While histopathological evidence of 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 of 445 cadaver 3 tendons of healthy individuals with no tendon complaints 3 2 and Astrom and Rausing found histopathological changes in 20% of asymptomatic control tendons. 3 3 1.2. BIOCHEMICAL MARKERS In general, laboratory or biochemical examinations play a minor role in the diagnosis of tendon disorders. There are no measurable markers of 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 of positive clinical findings. 2 5 Without a standard clinical assessment tool it is difficult to quantify clinical findings and there may be observer bias. 2 5 3 7 Patients present mainly because of pain, 2 which is an entirely individual experience and therefore difficult to quantify. 3 8" 4 0 Nevertheless there has been an attempt to quantify subjective information. 1.4. SUBJECTIVE OUTCOME MEASUREMENTS While pain is the usual presenting symptom, 3 8" 4 0 functional status is also an important outcome measure.4 1 There is a surprising low correlation between pain and disability 2 5 and therefore an outcome measurement tool must record pain, function 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 Population Type of Rating system Comments Date intended Percy and Results of Four point descriptive Arbitrary categories derived. Conochie42 surgery of scale of excellent, good, Not validated and reliability not tested. 1978 Achilles fair and poor arbitrarily (Table 2.4) tendinopathy. devised. Curwin and Grading of A 6 point scale, combining Arbitrary categories derived, not specific Stanish43 tendinopathy in the domains of pain and to Achilles tendons. 1984 general. activity in one scale Limited in sensitivity. (Table 2.5) Not validated and reliability not tested The Ankle hindfoot 3 domains of pain, This is non specific for Achilles tendon American scale for function and alignment, disorders, particularly as symptoms such Orthopaedic patients scored over 9 questions on as morning stiffness, pain during and after Foot and undergoing a four point categorical activity and pain with stairs6 7 9 are not Ankle ankle surgery scale totalling 100 possible represented and activity level is not Society. points. documented. Kitaoka, et a/.4 1 4 4 1994 Thermann et Surgically 11 questions scored on All (excepting pain and sports activity treated ruptured mostly a 4 point Likert items) not applicable to Achilles 1997 Achilles Scale. Items include Range tendinopathy. tendons. of Motion, Calf The four point Likert scale has been circumference, Thompon's shown to be insensitive to subtle changes test, Strength testing, Pain, in clinical condition.27 2 8 sports activity, sensitivity The questionnaire was not validated and to weather and subjective reliability not tested. assessment. Leppilahti et al. modified from Boy den et al}61998 Surgically treated ruptured Achilles tendons 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.27 2 8 The questionnaire was not validated and reliability not tested. 1.5. I M A G I N G C o n t r o v e r s y e x i s t s o v e r t he v a l u e o f i m a g i n g i n a s s e s s m e n t 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 . I n p a r t i c u l a r a l i t e ra tu re 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 q u e s t i o n s . (1 ) W h a t i s t he bes t t e c h n i q u e to u s e 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 b e 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 i s t he o v e r a l l v a l u e 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 d i s o r d e r s ? A l i t e ra tu re r e v i e w w a s d o n e u s i n g M E D L I N E d a t a b a s e ( f r o m 1 9 6 6 to the p r e s e n t ) , 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 a r t i c l e s . A t o ta l o f 2 6 o r i g i n a l p a p e r s ( 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 , s o f t - t i s s u e 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 . 2 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 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 c o n t r a s t 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 i n j u r e d t i s s u e . A l t h o u g h x e r o r a d i o g r a p h y , b u r s o g r a p h y , t e n o g r a p h y a n d 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 t i s s u e c o n t r a s t , the i m p o r t a n c e o f t hese m o d a l i t i e s h a s 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 ) h a s a l s o l a r g e l y b e e n r e p l a c e d 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 a n d W e i n s t a b l et al.61 h a v e s h o w n a n i n c r e a s e d a c c u r a c y w i t h U S o r M R I . 6 o o < o 60 60 CS 60 .g "3 T3 & O H g '5b •c o o . 3 (-J cfl 0 0 W 3 OH O T 3 X J B OO fl v a ̂  o 5 C/l CA: o ( , T3 r -a a cs -a :\ a a c o o ! C . CD a CD O en d en d  >s <N en d 1 C/J a - a a • • • • • • • • IS i •y. O' £ i c N ; r. = -a = i r l oo v: • • 0 0 0 0 • O O oo O O o CN — s IS a. S * _ vo C& cfl fe £ • • • • • I t i r-O t— VO CN- VO 3 o 1 •fi o y o p f ' b hp e o c o i o — = B '3 . C j2 O B B v CD OS *•* D . O 0 O cfl . tfl Cfl ' cfl Cfl ' OH ' O t r B i .SJ- o & 5 OV ~ C— ( N /-. cfl " C '' C > ' cfl j SI .Si:.Hi S ^ - o f r i I r-. fl ±: fife c I * cn h-i- fN i fk cfl e f Si = = c u ; O CN = M .vO. X CN ' ^ -si « I cs : ~ D.. 0O 1^ r I I •• a.: o. r- o i , CN CN '—' • B'.B. „ . „ ° S c ^ .S ^ 1 CO C3 G ^ i4 J Z P L H ; Q 2,< O to > 4) O H O o O H O H O O O H CS .b fl o o fl o o O O H < CS O I _o Hi ta fl cs H-» GO "o O on a Table 1.3. List o f review papers dealing with imaging and Achilles tendons Author/ Date Study design Title U/S MR Josza and Kannus 1997 reucw Khan and Kannus72 2000 letter Khan et'al73 1998" ~ " editorial • Jacobson'4 1999 review Panageas etal.75 1990 review Mink et al.'° 1991 Kabbani and Mayer 1993 review O'Reilly and Massouh78 1993 review Human Tendons • >;'" i _ _ :£,_„.' . 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_AnkJê _̂  ' Pictorial review: the sonographic diagnosis of pathology in the Achilles tendon. 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 4 7 5 0 using linear transducers8 1 with a frequency of 5 M H z to 15 M H z 8 5 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. 8 0" 8 2 A thickness of 4.0 - 6.7 mm on transverse images is considered normal 5 4 and a bursa with thickness less than 2-3 on mm is considered normal, but the appearance of the bursa depends on flexion and extension of the ankle. 4 9 A stand off pad is not necessary.6 1 Imaging of the paratendon is unreliable. 6 9 Grading of imaging findings may be possible either on a 3 point scale, (normal, thickened or hypoechoic), 6 0 or by area of hypoechogenicity on axial view. 5 Power and colour doppler have not been studied for the Achil les tendon, but in studies of the patellar tendon colour flow may be increased in abnormal areas, which offers objective evidence of abnormalities that are not operator dependant. Similarly positive power doppler may also offer objective evidence of tendon 88 abnormality on U S , although these two techniques are as yet experimental. Table 1.4. Technical factors in performing U S on tendons. A u t h o r / D a t e T e c h n i c a l a d v a n c e F o r n a g e 1 9 8 7 s M a t h i e s o n et a l . 1 9 8 7 4 y B a r b o l i n i etal. 1 9 8 8 5 0 a n d F o r n a g e 1 9 8 6 4 7 F o r n a g e 1 9 8 8 8 1 C r a s s e r a l . 1 9 8 8 s K a i n b e r g e r et a l . 1 9 9 0 s K a l l i n e n a n d S u o m i n e n 1 9 9 4 K o i v u n e n - N i e m e l a et a l . 1 9 9 5 s 4 B e r t o l o t t o et a l . 1 9 9 5 8 5 A s t r o m etal. 1 9 9 6 6 9 M o v i n etal. 1 9 9 7 s 6 G i b b o n a n d C o o p e r 1 9 9 8 6 1 A r c h a m b a u l t et a l . 1 9 9 8 6 0 F e s s e l etal. 1 9 9 8 s 7 C O L O U R A N D P O W E R D O P P L E R N e w m a n etal. 1 9 9 4 s 8 W e i n b e r g et a l . 1 9 9 8 s 9 T h e o b l i q u i t y o f t h e s u p e r f i c i a l t e n d o n r e s u l t s i n a f a l s e h y p o e c h o g e n i c i t y d u e t o r e f l e c t i o n a n d r e f r a c t i o n o f t h e U S b e a m s . T h e r e f o r e t h e p r o b e s h o u l d b e p l a c e d s t r i c t l y p a r a l l e l t o t h e t e n d o n f i b r e s i n l o n g i t u d i n a l s c a n s a n d s t r i c t l y p e r p e n d i c u l a r i n t r a n s v e r s e s c a n s . D e s c r 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 f l e x i o n a n d e x t e n s i o n o f t h e a n k l e . R e a l t i m e u l t r a s o u n d r a t h e r t h a n B - m o d e s t a t i c U S . L i n e a r t r a n s d u c e r s w i t h b e a m s p e r p e n d i c u l a r t o t h e s u p e r f i c i a l t e n d o n p r e f e r a b l e . F r e q u e n c y o f t h e p r o b e f r o m 5 M H z t o 1 0 M H z a l l o w s a n o v e r v i e w o f t h e e n t i r e t e n d o n a t t h e l o w e r f r e q u e n c i e s a n d t h e n o p t i m a l s p a t i a l r e s o l u t i o n a t t h e h i g h e r f r e q u e n c i e s . B o t h l o n g i t u d i n a l a n d t r a n s v e r s e v i e w s r e q u i r e d . U s e o f a s t a n d o f f p a d i m p r o v e s c o n t a c t b e t w e e n t h e s u r f a c e o f t h e p r 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 s a l l o w i n g v i s u a l i s a t i o n o f t h e s u b c u t a n e o u s t i s s u e . C o n f i r m e d t h e a n g l e d e p e n d e n c e o f t h e e c h o g e n i c i t y o f t e n d o n ( a n i s o t r o p h y ) i n a c o n t r o l l e d e x v i v o s e t t i n g . D e s c r 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 s t e n d o n s t h i c k e r t h a n 6 m m . S h o w e d w i d t h o f t e n d o n l a r g e r i n e l d e r l y a t h l e t e s t h a n e l d e r l y s e d e n t a r y c o n t r o l s . T h e r e w e r e n o d i f f e r e n c e s i n e c h o g e n i c i t y a m o n g a t h l e t e s a 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 i d t h o f t e n d o n d u r i n g t r a n s v e r s e i m a g i n g b e t t e r d i m e n s i o n t o u s e f o r d e t e c t i n g i n t e r t e n d o n d i f f e r e n c e s . T h e r e i s a l a r g e v a r i a t i o n i n s h a p e o f t h e t e n d o n c a u s i n g u p t o 2 5 % v a r i a t i o n i n t h e m e a s u r e d t h i c k n e s s v a l u e s . T h e t e n d o n t h i c k n e s s c o r r e l a t e s w i t h b o d y h e i g h t . S u g 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 a n a t o m i c a l l y d i s t i n c t t e n d o n p o r t i o n s a r i s i n g f r o m t h e s o l e u s a n d g a s t r o c n e m i u s m u s c l e s . I m a g i n g o f p a r a t e n d o n u n r e l i a b l e . 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 y f e a s a b l e . N o s t a n d o f f p a d u s e d . G r a d e d U S f 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 = t e n d o n w i t h h y p o e c h o i c l e s i o n s r e g a r d l e s s o f s i z e . R e v i e w o f U S t e c h n i q u e . C o n f i r m e d m e a s u r e m e n t i n a x i a l p l a n e . D e f i n e d a b n o r m a l r e t r o c a l c a n e a l b u r s a a s t h i c k e r t h a n 2 - 3 m m a t i n s e r t i o n . A s s e s s e d v a l u e o f p o w e r d o p p l e r a m o n g a v a r i e t y o f m u s c u l o s k e l e t a l c o m p l a i n t s i n c l u d i n g s h o u l d e r , e l b o w " t e n d o n i t i s , 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 s c a l e . I n 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 o n g r e y s c a l e . 9 1.5.1.2. Magnetic Resonance Imaging: On M R I (Table 1.5) normal tendons appear black on all sequences due to dense collagen. 9 0 On T l -weighted and T2-weighted M R I tissue contrast is enhanced and fluid and pathological processes appears grey (low signal intensity) on T l - weighted images and white (high signal intensity) on T2 -weighted images. 9 1 Other pulse sequences have been developed including partial flip angle, gradient reversal, fat suppression, chemical shift and three-dimensional volumetric imaging. 9 1 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.7 6 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. 9 2 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. 5 Similarly contrast enhanced imaging may increase sensitivity of detecting abnormalities in the Achilles tendon. 7 0 A head coil may be used to assess bilateral tendons 6 3 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. 7 6 Imaging o f paratendon is unreliable 6 6 6 9 and the dimensions of the retrocalcaneal bursa are variable. Although generally a dimension of more than 1 mm in the anteroposterior plane, 11 mm in the transverse plane and 7 mm in the craniocaudal plane may be considered abnormal. 6 5 The appearance of normal tendon is also variable, with 45% of asymptomatic tendons showing heterogenous signal intensity with distal stripes or punctate foc i . 6 6 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 MRI among the same group of patients. Weinstabl et al.67 and Neuhold et a/. 6 8 were able to confirm the 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 of Achilles tendons. Author / Date Technical advances Beltranera/. 1987y Quinn etal. 1987 Kerr era/. 1990y 63 Mink etal. 1991' Erickson et al. 1993y Brandser et al. 1995y Astrome/a/. 1996" Bottger er a/. 19976 Khan etal. 19985 Movin etal. 1998 Soila etal. 19996 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. Utilised 1.5T superconductive M R unit. Use of head coil. T l weighted spin density and T2-weighted spin echo images obtained. 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. 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. Described magic angle phenomenon in tendons that become artefactually hyperintense on short-TE and GRE images due to T2 augmentation. Review of MRI appearance of normal and injured tendons. Reinforced importance of magic angle. Suggested using Spin-Echo Tl-weighted and T2- weighted 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 GRE 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 1 IS a : < - M fl ! ~a . £ T3 Q 3 C P j CQ ic 3 fl rV 8.1 s s ^ 'S o u t t? 2 S- tn w E i cn I f oo OO B tu 3 3 O « — ra a. c to tn D D a. c S S bfj ~P « 5 E a. E c 2 c fl -o o E 3 1 5 ™«g DO >> c ra 3 o i 3 | 5 ™ > o 2 b • Z S S t ? '5 2 i CJ — co DO O cj C - P t/3 C/l - P " P •5 11 s s _P -= "3 W fl tu r s bO bOT3 fl fl C £ £ (2 m — r - tN I N r » ^ <N N—' (N ' (N O w ( N ^1 M - O N f a a i H ' € 1 &I §"1 n c " » S t o o l g g 5 -3 D D S S tn o i r= tn S tn H 3 o ^ C — ^ ra - ai ai 2 t i § S tn N O N O 1 — ' CN 1 — ' C N © ^ a. w N O - " a e ~ ~ cn <n £ D D S S fl — r£i to o - g S . 2 (N ca U J i &0 £ T3 ( N s o E e CJ .5 - 5 a, SJ _: S « cn 2 g-E , CJ • — « T3 ^ o E 5 I i - s l l : o - £ o O CT\ O CTi O ON O 0\ — © — o Z 33 2 - „ o o 9 o fl -B •% I 'fi 1 c f | D D S S w o U U M 5 5 ° 2 a o u P bo 8 - | = ' t n O m O f_ ~ ON One is unable to draw any conclusions from these studies regarding which imaging technique is more effective. On the other hand, in a 1996 study by 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 of 96% and specificity of 86%. Overall accuracy of U S was 95% and of 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 of intratendinous signal abnormality on Tl-weighted images. They also showed that when compared to U S the volume of 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. 7 0 Karjalainen et al.71 assessed a group of post operative patients and showed thickening of 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: No studies were identified, that classified tendon disorders by clinical severity prior to imaging. However, Kainberger et al.54 classified their 73 symptomatic patients with Achilles tendon disorders into duration of 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 in each group. Nevertheless, they found that U S was normal in 20 of the 73 patients of whom 14 cases had symptoms for less than 2 months (Table 1.7). Maffulli et al.59 and Mathieson et al.49 similarly suggested that their false negative U S 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.,57 Kalebo et al.52 and Astrom et al.69 who found that in patients severe enough to undergo surgery, there were some false negative U S findings. Paavola et al.57 for example found among 80 symptomatic 53 tendons 3 that were normal on U S yet abnormal at surgery and Kalebo et al. found, in their series of 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.69 who operated on one false negative U S patient still found pathology on histology although the grading of 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.10 were able to obtain a histological grade of severity for all 20 of their subjects with Achilles tendon pain. Clinical ly all patients had a painful, swollen tendon and all had U S directed biopsy of any hypoechoic lesions as well as biopsy of 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.70 acknowledged that all o f their cases were severe 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 of false negative imaging, however, in neither o f these studies was the clinical outcome reported and the clinical significance of 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 Rate of false Comment on Modality negatives severity Acute or mild cases only Maffulli et al."911987 US 8/55 (20%) Possible acute cases Mathieson et a/. 4 9 A988 US 8/20 (40%) Resolved in 4-6 months. Kainberger et a/.5 4/1990 US 20/73 (27%) 14 acute cases with no swelling. Severe surgical cases Lehtinene?a/.5 3/1994 u s 2/34 (3%) One normal on Astrom et al.6911996 surgery as well. u s 5/26 (19%) Severe enough to Paavola et al.51 /1998 warrant surgery. u s 3/79 (4%) 2 surgery positive; one negative. Severity undefined. Kalebo et a/. i2/1990 u s 2/62 (2%) Not Stated Weinstabl et al67 /1991 u s 1/10 (10%) Not Stated Nehrer et a/. 5 6 /1997 u s 20/48 (42%) US graded not clinical findings. Archambault et al.60 /1998 u s 11/33 (33%) US graded not clinical findings. Table 1.8: Studies reporting false negative MRI results. Author / Date Imagin g Modality Rate of false Comment on negatives severity Astrom etal.69 1996 MRI 1/27 (4%) Severe enough to 27 patients warrant surgery. Movin et al.10 1998 Contrast enhanced 1/20 (5%) Severe enough to MRI warrant surgery. 20 patients 17 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 of tendon disorder. This is reinforced by the number of false positive imaging findings in asymptomatic tendons (Table 1.9). However no one single study has assessed the correlation of imaging findings among a spectrum of cases of 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 of Ultrasound or Magnetic resonance imaging in assessing Achil les tendinopathy, the usefulness of imaging as a predictive determinant remains controversial. Khan and Kannus remind us that only prospective controlled studies provide evidence of causality while cross sectional studies offer only descriptive information. 7 2 Four studies (Table 1.10) have been identified that prospectively assessed outcome of 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. Name / Date Imaging False positives Comment US Kalebo et «/.5 2/1990 US 16 contralateral asymptomatic tendons 7/16(43.8%) US presumed Gold Standard. Insufficient data - outcome not reported. Unknown significance. Gibbon et fl/.61/1999 US 38 tendons of healthy volunteers occasional small hypoechoic foci. US presumed Gold Standard. Insufficient data - outcome not reported. Unknown significance. Astrom et al69/ 1996 US 13 asymptomatic contralateral tendons 1/13 (7.7% ) Thickening and hypoechoic lesion. Insufficient data - outcome not reported. Unknown significance. Kainberger54 /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/.56/1997 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/.95 /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 Imaging False positives Comment MRI Astrom et n/. 6 9/ 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.66 / 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 Only a single sequence done, most other studies report MRI as positive if on more than one sequence. Description of normal variants. 4/100 small areas of intratendinous ground glass intermediate 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 US 8 normal 8 resolved 8 normal Thickening or al*'! 1988 20 symptomatic 3 fluid around tendon 3 resolved 3 normal hypoechoic changes 4-6 months 3 bursa 2 resolved 2 normal on US would suggest 3 indistinct border 3 resolved 2 normal. a poorer prognosis. 6 thickened or hypoechoic 5 surgery 6 thickened Nehrer el US 20 true negative No ruptures Normal or low grade . o/.56/1997 36 patients 20 false negative No ruptures US had better clinical 2-5 years (48 symptomatic 14 good, 6 fair outcome, and less 24 asymptomatic 5 false positives No ruptures likely to have US tendons) 28 true positives worsen. 17 grade 1 (6-8mm) 1 rupture; 0 better; Incidence of rupture 6 good, 11 fair 13% worse high compared to the 6 grade 2 (8-10mm) 2 ruptures; 18% improved reported prevalence of 2 good, 4 fair 14% worse 0.01%. 9 6 Possibly 5 grade 3 (10-12mm) 4 ruptures 0 better; influenced by the 3 1 good, 4 fair 80% worse. patients who had infiltrations preruture. Outcome possibly confounded by treatments, which were not stated. Archambault us 11 grade 1 (normal) 8 recovered Not done Outcome among the 3 et al.60/ 33 patients 3 symptomatic grades the same, 1998 11 grade 2 (enlarged 5 recovered although rate of retros- tendon) 6 symptomatic recovery different pective 11 grade 3 (hypoechoic 5 recovered among grades, with a 1 year changes) 6 symptomatic higher likelihood of recovery if grade 1. Astrom et us 5 normal US Not correlated Not done Tendency towards nl69/ 1996 26 patients 1 hypoechoic to imaging: better clinical 1 year chronic severe 20 thickened and 20 excellent response in 6 cases tendinopathy hypoechoic 2 good that were not All underwent 2 fair thickened. surgery 3 poor Excellent outcome in those with abnormal imaging. MRI 1 normal Not correlated Not done Outcome of those 27 patients 4 low signal & thickened to imaging: with normal or chronic severe 22 high signal & 20 excellent thickened MRI the tendinopathy. thickened 2 good same as those with All underwent 2 fair high signal intensity. surgery. 3 poor Marcus et MRI Not done MRI presumed gold n/.6 2 /1989 7 patients standard. 3 months (4 total rupture; 3 total rupture; 1 partial 4 good results 6 good results with tear. (1 surgery) only one total rupture 2 possible total 1 normal continuity; 1 2 good results undergoing surgery. rupture; total rupture. Results at follow up 1 chronic 1 tendinopathy. poor result. biased as non tendinopathy) randomised, open study. Prognostic value of MRI unclear. 20 1.5.4.1. Ultrasound: The findings of Mathieson et al.,49 Nehrer et al.56 and Archambault et al.60 would have us believe that imaging may be predictive of 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.69 found that among their 27 surgically treated patients the outcome at 1 year follow up was the same for those with normal or thickened tendon as for those with intratendinous high signal intensity. Marcus et al.62 similarly had mostly good 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 of U S could be calculated (Table 1.11). The overall accuracy of U S ranged from 0.65 5 6 to 0.95. 5 3 O f these studies only four (Table 1.12)4 9 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 of 0.72. The positive predictive value of 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 of M R I is 0.92 6 9 to 0.93. 7 0 If a meta-analysis is done combining these two studies, a sensitivity of 0.95 and specificity of 0.88 is calculated, for an overall accuracy of 0.92. The positive predictive value of M R I is calculated as 0.93 and negative predictive value as 0.88. 22 T a b l e 1.11. S e n s i t i v i t y a n d S p e c i f i c i t y o f U S a n d M R I Author/ Date Subjects (tendons) Gold standard Sensitivity Specificity Overall accuracy Comment US Maffulli et al. 198759 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. 198849 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. 199052 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 54 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. 199669 Nehrer et al.56/1997 35 symptomatic tendons 13 asymptomatic tendons 36 patients, 48 symptomatic tendons, 24 asymptomatic contralateral 26 surgery 26 clinical Clinical 0.69 0.58 0.92 0.72 0.75 0.65 Radiologists blinded. Control group adequate & sufficient data reported. Not stated whether blinded or not. Control group adequate & sufficient data reported. MRI Astrom et al. 199669 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 .0.9 0.93 Radiologists blinded. Control group adequate & sufficient data reported. 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 . Author / Date Imaging Symptomatic Asymptomatic Total US Kainberger et al. 1990 5 4 US positive US negative TOTAL 53 20 73 4 20 24 57 40 97 Mathieson et al. 19884 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 MRI Astrom et al. 199669 MR positive 34 2 36 MR negative 2 12 14 TOTAL 36 14 50 Movin etal. 199870 MR positive 19 2 20 MR negative 1 18 20 TOTAL 20 20 40 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.1 4 Further 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 MRI 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. 7 2 There is therefore clearly a need for further research in this area, utilising a 72 69 79 prospective study design and testing patients of varying severity including non operative cases.69 25 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 VISA-A Questionnaire (Table 2.1). The VISA-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. An 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 m m s 0 mins POINTS • 0 1 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 severe pain • no 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 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 POINTS • POINTS • no pain 0 1 2 3 4 5 6 7 8 9 10 5. Do you have pain during or immediately after doing 10 (single leg) heel raises from a flat surface? strong severe pain 0 1 2 3 4 5 6 7 6. How many single leg hops can you do without pain? POINTS • no pain 10 strong severe pain/unable no pain POINTS • 0 1 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 POINTS • 27 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? POINTS NIL 1-10 mins l l -20mins 21-30mins >30 mins • • • • • • 0 7 14 21 30 OR B. 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? POINTS NIL 1-10 mins 11-20 mins 21-30mins >30 mins • • • • • • 0 4 10 14 20 OR C. If you have pain that stops you from completing your training/practice, for how long can you train/practise? NIL 1-10 mins 11-20 mins 21-30mins >30 mins POINTS • • • • • • 0 2 5 7 10 TOTAL SCORE (/100) • % 28 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.97 For the purposes of this study we used patients with a spectrum of 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 i f they had a diagnosis of Achilles tendinosis, paratendinitis or partial rupture with or without a retrocalcaneal or Achilles bursitis. Patients were excluded i f 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 of 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 of 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 of 57 symptomatic and 33 asymptomatic tendons. Five of the latter had previous symptoms, while twenty eight were never symptomatic. None of 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. Activi ty of patients before and after onset of symptoms. Hours of activity per week Number of subjects exercising at each level prior to symptoms.* Number of subjects exercising at this level after onset of symptoms. 0 0 0 > 0 - 3 8 18 > 3 - 7 19 14 >7 18 13 *x2=22;p<0.01 30 Ten patients had stopped their running sports because of their Achilles tendinopathy. The usual complaint was pain with activity and morning stiffness. Tenderness was found at the mid 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 of motion and power testing of the ankle muscles was assessed with patients' knees flexed at 90 degrees. Patients were then examined lying prone. Both Achil les 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 of transverse diameter of the Achilles tendon was done using a "Value Power" plastic calliper. Measurements were made in millimetres. The tendon was measured first at 1 cm 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.98 Following this a questionnaire was developed for use in 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, 3 8" 4 0 functional status41 and activity2 5 with equivalent of three 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. 3 7 4 0 9 9 " 1 0 2 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 pa t i en t m a y d e s c r i b e the m a g n i t u d e o f a s u b j e c t i v e e x p e r i e n c e o f s y m p t o m s . 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 s u g g e s t e d that a c t i v i t y m i g h t bes t b e a s s e s s e d o n a c a t e g o r i c a l r a t i n g s y s t e m b a s e d o n i n c r e m e n t a l r a n g e 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 V A S . 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 fe l t w e r e i m p o r t a n t i n a s s e s s i n g 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 p h y s i o t h e r a p i s t s , 4 p r i m a r y c a r e p h y s i c i a n s , o n e o r t h o p a e d i c s u r g e o n a n d o n e r e h a b i l i t a t i o n s p e c i a l i s t f r o m the A l l a n M c G a v i n S p o r t s 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 the V I S A - A s c o r e a n d a s k e d to e v a l u a t e the q u e s t i o n n a i r e . 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 t he re 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 a d d , a n d i f t he re 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 r e m o v e o r c h a n g e . F o u r t e e n o f the p a r t i c i p a n t s 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 n o n e w a n t e d a n y c h a n g e d . 34 Table 2.3. Questions identified by "Experts" as important in assessing Severity of Achilles tendinopathy. Ques t ion N u m b e r of T i m e s a s k e d C o m m e n t D iagnost ic : e .g . Ru le out back pa in , hip pa in , locat ion of pa in , prev ious t reatments. A m b i g o u s : e .g . A r e there any aggravat ing o rel ieving factors , A r e you limited act iv i t ies. or in T im ing of pa in : Morn ing pain St i f fness & P a i n with stretching Pa in after activity Pa in dur ing activity Act iv i t ies of dai ly L iv ing Pa in at rest Pa in wa lk ing Pa in up and down stairs Spor ts Act iv i t ies jogg ing hee l ra ises jumping Quant i f ied spor ts disabi l i ty H o w long c a n you p lay? H o w far c a n you run? H a v e you m i s s e d p rac t i ces? 30 11 24 6 6 7 4 29 8 9 5 2 5 9 3 8 5 3 1 1 Not pert inent for sever i ty; C o v e r e d in d iagnost ic interview. Unab le to quanti fy a n s w e r s to open e n d e d ques t ions . Usefu l in initial d iagnost ic interview. Ques t i on one Ques t i on one and two Ques t i on three Ques t i on three Ques t i on one Ques t i on three Ques t i on four Ques t i on s e v e n and eight Ques t i on s e v e n and eight Ques t i on f ive Ques t i on six Ques t i on s e v e n and eight Ques t i on eight Ques t i on eight Ques t i on eight 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 the l i t e ra tu re r e v i e w i t h a s b e e n s h o w n that t he 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 to a pa t i en 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). S i m i l a r l y t h e r e a re n o l a b o r a t o r y o r b i o c h e m i c a l m a r k e r s 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 the 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 g o l d s t a n d a r d . 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 t he 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 t he 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 C o n o c h i e 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 4 3 ( T a b l e 2 .5 ) . T h e s c o r e s f r o m the th ree 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 c o e f f i c i e n t a n d S p e a r m a n ' s R a n k c o r r e l a t i o n c o e f f i c i e n t . S e c o n d l y , a c l a s s o f 6 6 h e a l t h y U n i v e r s i t y s t u d e n t s , w h o w e r e n o t i n v o l v e d i n t h i s s t u d y i n a n y o t h e r 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 ( a g e d 2 0 - 3 2 y e a r s , m e a n 2 3 y e a r s ± 2 . 8 6 ) a n s w e r e d the q u e s t i o n s . 36 T a b l e 2 . 4 . P e r c y a n d C o n o c h i e ' s g r a d i n g s c h e m e f o r r e s u l t s o f s u r g e r y o f A c h i l l e s t e n d i n o p a t h y a n d a m o d i f i c a t i o n f o r n o n s u r g i c a l p a t i e n t s . P e r c y a n d C o n o c h i e ' s g r a d i n g s c h e m e ' M o d i f i c a t i o n f o r n o n s u r g i c a l p a t i e n t s ( N e h r e r et al)56 E x c e l l e n t A p a t i e n t w h o h a d f u l l f u n c t i o n w i t h n o r e s i d u a l d i s a b i l i t y w h a t s o e v e r . A m e l i o r a t i o n o f s y m p t o m s , a n d r e t u r n to f u l l s p o r t i n g a c t i v i t y G o o d A p a t i e n t w i t h s l i g h t l y q u e s t i o n a b l e w e a k n e s s , a n a d h e r e n t s c a r , a n d m i n o r s e n s o r y d e f i c i t , b u t n o r e a l l i m i t a t i o n o f a c t i v i t i e s a n d f u l l r e t u r n to f u n c t i o n as i n the p r e r u p t u r e p e r i o d . F a i r A d e f i n a t e w e a k n e s s a n d s o m e l i m i t a t i o n o f a c t i v i t i e s a n d a s l i g h t l i m p . A m e l i o r a t i o n o f s y m p t o m s , m i n o r l i m i t a t i o n s i n s p o r t i n g a c t i v i t y L i m i t e d s p o r t i n g a c t i v i t i e s . P o o r A p a t i e n t i n w h i c h the re w a s a r e - r u p t u r e o r c o m p l e t e f a i l u r e w i t h s e v e r e w e a k n e s s a n d a m a r k e d l i m p . A b a n d o n m e n t o f t h e i r spo r t . T a b l e 2 . 5 . T e n d i n o p a t h y g r a d i n g s y s t e m o f C u r w i n a n d S t a n i s h . G r a d i n g s y s t e m o f C u r w i n a n d S t a n i s h 4 3 G r a d e D e s c r i p t i o n o f P a i n D i s a b i l i t y 1 N o p a i n N o e f f ec t o n a c t i v i t y 2 P a i n o n l y w i t h e x t r e m e e x e r t i o n ; p a i n r e s o l v e s w h e n a c t i v i t y c e a s e s . N o e f f ec t o n a c t i v i t y 3 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 h o u r s a f t e r w a r d s . L i t t l e e f f ec t o n a c t i v i t y , m a y l i m i t m o r e i n t e n s e p h y s i c a l a c t i v i t i e s . 4 P a i n d u r i n g a n d a f te r v i g o r o u s a c t i v i t y . P e r f o r m a n c e l e v e l d e c r e a s e d ; U n a b l e to p e r f o r m s o m e n e c e s s a y t a s k s . 5 P a i n d u r i n g a c t i v i t y f o r c i n g t e r m i n a t i o n . C a u s e s i m m e d i a t e w i t h d r a w a l f r o m a c t i v i t y . 6 P a i n w i t h d a i l y a c t i v i t i e s . U n a b l e to p a r t i c i p a t e i n a n y s p o r t s ; d a i l y a c t i v i t i e s m a y a l s o b e r e s t r i c t e d . 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 c o h o r t o f 4 5 s u b j e c t s w i t h A c h i l l e s t e n d o n d i s o r d e r s w a s u s e d to assess the r e l i a b i l i t y o f the V I S A - A q u e s t i o n n a i r e . T h e V I S A - A q u e s t i o n n a i r e w a s a d m i n i s t e r e d th ree t i m e s to e a c h pa t i en t . I n o r d e r to e x a m i n e the tes t - re tes t r e l i a b i l i t y o f the q u e s t i o n n a i r e t w o q u e s t i o n n a i r e s w e r e a d m i n i s t e r e d a n h o u r apar t , e i t h e r o n the f i rs t o r s e c o n d p a t i e n t v i s i t ( th i s w a s r a n d o m l y a s s i g n e d ) . A t h i r d q u e s t i o n n a i r e w a s a d m i n i s t e r e d o n e w e e k a f te r the f i r s t to assess sho r t t e r m r e l i a b i l i t y . F o r 16 o f the s u b j e c t s o n o n e o c c a s i o n t he V I S A - A q u e s t i o n n a i r e w a s a d m i n i s t e r e d b y e i t h e r a d i f f e r e n t spo r t s 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 s tuden t . 2.3. RESULTS 2.3.1 Validity T h e c o n s t r u c t v a l i d a t i o n i s s h o w n i n F i g u r e s 2 .2 a n d 2 . 3 . W h i l e t he V I S A - A s c o r e w a s s i g n i f i c a n t l y c o r r e l a t e d to the b o t h g r a d e s o f s e v e r i t y ( p < 0 . 0 0 1 ) t he re w a s a w i d e v a r i a b i l i t y i n the s c o r e s . A s s h o w n i n F i g u r e 2 .4 the V I S A - A s c o r e s a p p r o x i m a t e a n o r m a l c u r v e (a l be i t s k e w e d to t he right, r e f l e c t i n g t he 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 c a s e s ) . 38 I n t he s e c o n d pa r t o f c o n s t r u c t v a l i d i t y t e s t i n g , p a t i e n t s w h o a re 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 t h o s e k n o w n n o t 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 s tuden ts h a d a V I S A - A s c o r e o f 1 0 0 ( 6 8 % ) . O f t he t w e n t y - o n e w i t h V I S A - A s c o r e s l e s s t h a n 1 0 0 - n i n e s tuden ts had . s c o r e s b e t w e e n 9 0 a n d 9 9 ( th ree 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 ) , t e n h a d s c o r e s b e t w e e n 8 0 a n d 8 9 ( t w o w h o h a d l o w e r b o d y i n j u r i e s a n d t w o 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 t w o s c o r e d l e s s t h a n 8 0 ( o n e 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 o t h e r w i t h c a l f p a i n ) . N o s tuden t s w h o s c o r e d 1 0 0 o n the q u e s t i o n n a i r e 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 e i t he r i n t he pas t o r c u r r e n t l y . A c h i l l e s t e n d o n p a i n w a s a s i g n i f i c a n t p r e d i c t o r o f V I S A - A s c o r e ( p = 0 . 0 0 4 ) w h e r e a s o t h e r i n j u r i e s w a s n o t ( p = 0 . 1 1 4 ) . A g e d i d n o t c o r r e l a t e w i t h V I S A s c o r e ( p > 0 . 0 5 ) . N e i t h e r s e x ( p = 0 . 3 7 1 ) n o r s p o r t i n g a c t i v i t y ( p=0 .21 ) w e r e p r e d i c t o r s o f V I S A - A s c o r e . W h e n c o m p a r i n g the V I S A - A s c o r e s o f t he 6 3 s tuden ts 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 t he V I S A - A s c o r e o f t he 4 5 s u b j e c t s i n the s t u d y g r o u p ( M e a n S c o r e 6 3 . 8 ± 16 .8 ) t he re w a s a s i g n i f i c a n t d i f f e r e n c e 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 Conochie '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 1 80 1 < <fc > 70 ' 60 1 50 ' 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 h i s tog ram o f V I S A - A scores a m o n g n o n s u r g i c a l pat ients ( n o r m a l cu r ve supe r imposed ) . 10 T Cl i— i 6:4 30:0 40.0 50.0 60.0 70.0 80.0 90.0 VISA-A .Scpres . 42 Figure 2.5. Box Plot showing V I S A - A scores among asymptomatic students and symptomatic subjects. n = 60 n = 45 Asymptomatic Students* Symptomatic "Subjects; 43 2.3.2. Rel iabi l i ty 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 of Reliability of V I S A - A score Reliability Description Pearson's Correlation Co-efficient Test-retest reliability This measures whether an instrument is capable of 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. 0.93 Intrarater reliability This refers to the stability of 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 of subjects. 0.90 Short term reliability Tests whether the measurement remains the same over a short period of time. 0.81 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 of severity of Achilles tendinopathy, across a wide spectrum of 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, 4 1 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 that 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 i s 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 la t ter 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 , 4 2 4 3 w h i c h 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 2 8 W h i l e the re i s a w i d e v a r i a b i l i t y i n the s c o r e s as m e a s u r e d o n the c a t e g o r i c a l r a t i n g s c a l e s , t h i s 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 7 4 0 9 9 - 1 0 2 N o t r a i n i n g i s r e q u i r e d to a d m i n i s t e r t he V I S A - A q u e s t i o n n a i r e . T h e s c o r e s w e r e the s a m e w h e t h e r a d m i n i s t e r e d b y a n u n t r a i n e d s tuden t o r b y a spo r t s m e d i c i n e t r a i n e d p h y s i c i a n . T h e a d v a n t a g e t h e r e f o r e o f the V I S A - A q u e s t i o n n a i r e i s i n a s i m p l e a s s e s s m e n t o f s u b j e c t i v e d a t a . U n t i l a n o b j e c t i v e m a r k e r o f d i s e a s e s e v e r i t y i s 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 s u b j e c t i v e o u t c o m e m e a s u r e m e n t t o o l i s i n r e p e a t e d m e a s u r e s b e f o r e a n d a f te r a n i n t e r v e n t i o n . T h e u s e 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 s t a t i s t i c a l 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 s e t t i n g b o t h f o r c o n s e r v a t i v e a n d s u r g i c a l t h e r a p i e s . S t u d i e s m a y b e d o n e i n v a r i o u s c e n t r e s a n d r e s u l t s c o m p a r e d . T h e V I S A - A q u e s t i o n n a i r e i s n o t a d i a g n o s t i c t o o l , o t h e r 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 pa t i en t 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 t he f u n c t i o n a l tes ts . N e v e r t h e l e s s the V I S A - A s c o r e o f f e r s c l i n i c i a n s a n i n d i c a t o r o f s e v e r i t y o f t h e i r pa t i en t s ' 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 t h e r a p y . 45 2.5 CONCLUSION The V I S A - A index of 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 of 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 he l i t e ra tu re 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 as to the b e n e f i t 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 d i s o r d e r s . T h e r e i s a n e e d f o r a p r o s p e c t i v e 72 c o n t r o l l e d s t u d y i n t o 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 . I n the p r e s e n t s t u d y , a g r o u p o f p a t i e n t s 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 he art U S a n d M R I . T h e p u r p o s e w a s to c o m p a r e the t w o m o d a l i t i e s w i t h r e g a r d to t h e i r u s e i n m i l d c a s e s , 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 t he c o n d i t i o n c o r r e l a t e d w i t h the s e v e r i t y o f t he 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 , e i t he r m e t h o d w a s p r e d i c t i v e 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 in i ca l 3.2.1.1. Patients. The forty-five consecutive patients recruited for the assessment of the V I S A - A questionnaire (Section 2.2.1) also provided informed written consent to participate in the imaging part of the study. Ethics approval was similarly obtained. The demographics of the forty five subjects was: Age range: 20 and 66 years (mean 42.35 ± S.D.I 1.35); Onset of 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 of 57 symptomatic tendons and 33 asymptomatic tendons. The symptoms were usually pain with activity and morning stiffness, and signs were mid tendon tenderness (41 tendons), insertional tenderness (12 tendons) or diffuse tenderness (4 tendons.) 3.2.1.2. Clinical Severity The severity of the clinical condition was ranked according to the V I S A - A questionnaire'discussed in 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 of 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 high- resolution 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 of or within one week of the clinical examination. Patients were positioned prone with their feet hanging over the end of 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 of the entire length of both tendons, as well as transverse sections. Particular care was taken to ensure the scan plane was parallel to sn 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 of the talocrural joint . 5 4 5 6 8 3 8 7 A thickened tendon was defined as one that was greater than 6 mm. 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 of 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 of each hypoechoic lesion was calculated using the product of length, width and height. 7 0 The tendons were also graded according to a grading scheme developed by Archambault et al.60 Grade 1 was assigned i f the tendon appeared normal; Grade 2 was assigned i f the tendon showed evidence of thickening, with a homogeneous echotexture; Grade 3 51 w a s a s s i g n e d i f t he re w e r e a n y h y p o e c h o i c a r e a s , 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 o r w i t h o u t t h i c k e n i n g . 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 f i r s t 2 5 c o n s e c u t i v e p a t i e n t s w h o e n r o l l e d i n t he s t u d y 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 pa t i en t s u p i n e m u l t i p l e sag i t t a l a n d a x i a l s e q u e n c e s w e r e o b t a i n e d u s i n g a q u a d r a t u r e 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 s e q u e n c e s w e r e u s e d : F o r T l - w e i g h t e d s a g i t t a l s p i n e c h o i m a g i n g a n d a x i a l s p i n e c h o T l i m a g i n g , r e p e t i t i o n t i m e w a s 5 0 0 m s e c , e c h o t i m e 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 , 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 2 a n d i m a g i n g t i m e w a s 4 m i n u t e s 2 4 s e c o n d s . F o r s a g i t t a l fast sho r t 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 w a s 3 2 m s e c , r e p e t i t i o n t i m e w a s 4 , 0 0 0 m s e c , i n v e r s i o n t i m e w a s 1 5 0 m s e c , f i e l d 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 1 9 2 , n u m b e r o f e x c i t a t i o n s w a s 3 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 3 6 s e c o n d s . 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 s a g i t t a l g r a d i e n t - r e c a l l e d e c h o ( G R E ) i m a g i n g : r e p e t i t i o n t i m e w a s 8 0 0 m s e c , e c h o t i m e w a s 3 0 m s e c , f l i p a n g l e w a s 7 0 ° , f i e l d 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 10 s e c o n d s . M R I w a s r e a d b y t w o r a d i o l o g i s t s a n d c o n c u r r e n c e w a s o b t a i n e d f o r a l l 5 0 t e n d o n s . 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 s i z e o f a n y i n t r a t e n d i n o u s p a t h o l o g y w a s m e a s u r e d a n d the a p p r o x i m a t e v o l u m e o f the 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 he 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 l o n g i t u d i n a l p l a n e ) , w i d t h ( m e d i o l a t e r a l d i m e n s i o n o n a x i a l p l a n e ) a n d h e i g h t 70 ( a n t e r o p o s t e r i o r d i m e n s i o n o n a x i a l p l a n e ) . F o r c o m p a r i s o n p u r p o s e s 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 to the U S g r a d i n g as - 1: n o r m a l , 2 : t h i c k e n e d o r 3 : i n t r a t e n d i n o u s s i g n a l i n t e n s i t y c h a n g e . 3.2.3. Data Analysis S t a t i s t i c a l 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 S t a t i s t i c a l 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 s o f t w a r e ( S P S S ) f o r w i n d o w s ( v e r s i o n 7 .0 ) . P a t i e n t c h a r a c t e r i s t i c s 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 d a t a . 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 ar id M R I w e r e c o m p a r e d u s i n g P e a r s o n ' s c o r r e l a t i o n c o - e f f i c i e n t a n d S p e a r m a n ' s r a n k c o r r e l a t i o n . f o r n o n p a r a m e t r i c d a t a . 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 f i n d i n g s a n d i m a g i n g f i n d i n g s w a s a n a l y s e d u s i n g a C h i - s q u a r e d a n a l y s i s w i t h 2 X 2 c o n t i n g e n c y t a b l e s . F o l l o w u p d a t a w a s a n a l y s e d u s i n g a C h i - s q u a r e d a n a l y s i s w i t h 3 X 3 c o n t i n g e n c y t a b l e s . 54 3.3 R E S U L T S 3.3.1 Imaging 3.3.1.1. Ultrasound Ultrasound (Figure 3.3) correctly identified 37 of the 57 (65%) symptomatic tendons as being abnormal and 22 of 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 T O T A L 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* US S Y M P T O M A T I C No. of tendons. Agree n Disagree n Tendinosis+ partial rupture 45 32 13 Insertional tendinopathy 16 2 14 Bursitis 5 3 2 Peritendinitis 0 - - T O T A L 66 37 29 A S Y M P T O M A T I C Never 26 19 7 Prior 7 3 4 T O T A L -* . . . . 33 22 (67%) 11 (33%) More than one diagnosis is possible. 55 Figure 3.3. Hypoechoic lesion as seen on US (sagittal view). Appearance o f a thickened tendon on sagittal v iew. Appearance o f a hypoechoic lesion on sagittal v iew. (White Arrow) 56 T h u s U S h a d a s e n s i t i v i t y o f 0 . 65 a n d s p e c i f i c i t y o f 0 . 6 7 a n d a n o v e r a l l a c c u r a c y o f 0 . 6 6 . T h e p o s i t i v e p r e d i c t i v e v a l u e w a s 0 . 7 7 a n d n e g a t i v e p r e d i c t i v e v a l u e 0 . 5 2 . 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 i n t e r r o g a t i o n d i d n o t 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 f i n d i n g s a n d c o l o u r a n d p o w e r d o p p l e r f l o w o n U S . C l i n i c a l F i n d i n g s C o l o u r D o p p l e r ( U S ) p o s i t i v e n e g a t i v e S y m p t o m a t i c 3 2 2 5 A s y m p t o m a t i c 7 2 6 T o t a l 3 9 51 T o t a l 5 7 3 3 9 0 P o w e r D o p p l e r ( U S ) p o s i t i v e n e g a t i v e S y m p t o m a t i c 5 5 2 A s y m p t o m a t i c 1 3 2 T o t a l 6 8 4 T o t a l 5 7 3 3 9 0 O f t h o s e 3 9 t e n d o n s 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 o r n o d u l a r c l i n i c a l l y ( x 2 = 1 7 . 9 ; p < 0 . 0 1 ) ( T a b l e 3 .4 ) . T h e r e w a s a l s o a c o r r e l a t i o n 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 a n d age ( S p e a r m a n ' s r h o = 0 . 5 6 ; p < 0 . 0 1 ) b u t n o t b e t w e e n o n s e t o f s y m p t o m s ( x 2 = 0 . 1 1 1 ; p = 0 . 7 4 ) ( T a b l e 3 .5 ) , o r spo r t s p a r t i c i p a t i o n ( x 2 = 1 .05 ; p = 0 . 5 9 ) . 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 . n o C o l o u r y e s T O T A L c l i n i c a l n o 4 4 18 6 2 t h i c k e n i n g y e s 7 21 2 8 T O T A L 51 3 9 9 0 57 Table 3.5. Relationship between onset of symptoms and colour doppler flow on U S . no Colour yes T O T A L onset of acute 4 5 9 symptoms chronic 12 24 36 T O T A L 16 29 45 3.3.1.2. Ultrasound Severity Although arbitrarily defined, the calculated volume of hypoechoic lesions correlated significantly with the index of 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%) of 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 MRI Appearance of fotrabmidir^higi Tl-w*i#ited finages sigriil intensity change OKhite Arrow) 59 Sixteen tendons were asymptomatic, and M R I was normal in 15 (94%) of 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 of 0.56, a specificity of 0.94, a positive predictive value of 0.95, a negative predictive value of 0.50 and an overall accuracy of 0.68. There was no significant difference in M R I results between those presenting acutely or chronically (x 2 = 0.15; P = 0.69). However the false negative cases were 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. MRI resul ts C l in ica l f indings V I S A - A S c o r e s * * t-test; p< 0.01 Symp toma t i c n=34 Asymp toma t i c n=16 mean ± S D MRI Pos i t i ve 19 1 60.2 ± 19.5 MRI Negat i ve 15 15 86.9 ± 16.1 Table 3.8. Relationship between clinically thickened tendons and positive M R I . MRI results Symptomat i c n=34 x 2 = 12.2; P O . 0 0 1 T h i c k e n e d Not T h i c k e n e d Pos i t i ve 14 5 Negat i ve 2 13 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 a r b i t r a r y , t he v o l u m e o f i n t r a t e n d i n o u s h i g h s i g n a l i n t e n s i t y l e s i o n s 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 / . 6 0 ( 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 a l s o c o r r e l a t e d s i g n i f i c a n t l y to 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 h y p o e c h o i c l e s i o n s o n U S ( S p e a r m a n ' s r h o = 0 . 6 7 3 ; p < 0 . 0 5 ) . 3.3.1.5. Follow up I n 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 sub jec t ' 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 the V I S A - A s c o r e i s r e q u i r e d . F r o m the test retest 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 ) t he s t a n d a r d e r r o r 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 no t 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 .25 ( 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 p a t i e n t s 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 s c a l e , 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 . I n a s s e s s i n g w h e t h e r t he 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 re 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 the 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 to 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 he b a s e l i n e c l i n i c a l V I S A - A s c o r e d i d c o r r e l a t e w i t h the 3 m o n t h V I S A - A s c o r e ( P e a r s o n ' 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 g r a d e 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 . 7 3 a n d x 2 = 2 . 5 6 ; p = 0 . 6 3 r e s p e c t i v e l y ) ( T a b l e 3 .9 ) . 62 Table 3.9. Relationship between imaging severity at baseline and clinical outcome at 3 month follow up. Follow up x 2 = 4.98; p = 0.28 Improved Same worsened Total U S normal 2 9 1 12 thickening 2 2 0 3. hypoechoic 3 26 0 30 Total 7 37 1 45 x x = 2.74; p = 0.6 normal 1 9 1 11 M R I thickening 1 2 0 3 intensity change 1 10 0 11 Total 3 21 1 25 2 There was no relationship between outcome and onset of symptoms (x = 2.8; p = 0.24) nor between outcome and thickening of the tendon (x 2 = 2.6; p = 0.26). 3.3.1.6. Correlation between US and MRI Among 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 . n=50 tendons Ultrasound Symptomatic n=34 Clinical findings Asymptomatic n=16 Total Positive 18 0 MRI Positive 20 Negative 1 1 Positive 5 3 MRI Negative 30 . Negative 10 12 T O T A L 34 16 50 63 On 2 way A N O V A , the V I S A - A scores of 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 US RESULTS n mean ± SD positive 18 57.6 ± 18 MRI Positive negative 1 67.3 positive 5 66.4 ± 13.6 MRI Negative negative 10 77.4 ± 11.7 Among 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 1 7 0 1 60 1 50 i 30 ' X Ultrasound • MRI 20 J abnormal abnormal normal IS normal True Positives False Negatives 65 3.4. DISCUSSION Because histopathology was unacceptable to the patients, and there are no biochemical markers of 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. Lian et a l . 3 5 and Shalaby and Almekinders 3 6 showed convincing evidence that clinical findings are indeed a preferable standard than imaging in research in the patellar tendon. 3 7 We were unable to show a difference in accuracy between either imaging modalitiy. These findings, among a cohort of nonoperative cases, complement those of Astrom et al.69 who found little difference between U S and M R I among a group of more severe cases. This lack of sensitivity would suggest that U S and M R I are inadequate as an outcome measurement. The value of U S was not enhanced by the addition of 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 of perfusion in low velocity areas such as the musculoskeletal soft tissues. 8 8 1 0 4 Because grey scale and colour sonography is operator dependant, it was hoped the addition of power doppler assessment would add objective evidence of pathology. 8 9 But like Weinberg et al.*9 we found all tendons with positive colour flow also had positive findings on grey scale. We also found colour doppler to be significantly more sensitive and more visible than power doppler, in contrast to the suggestion of Breidahl et al.m who thought that power doppler may be more suitable. 6 6 C o l o u r d o p p l e r u n l i k e p o w e r d o p p l e r i s d e p e n d a n t o n a n g l e . U n t i l the h i s t o l o g y i s i d e n t i f i e d , o f t e n d o n w i t h p o s i t i v e c o l o u 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 , 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 are 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 r e g a r d . T h i s s t u d y u s e d the v o l u m e o f i n t r a t e n d i n o u s a b n o r m a l i t i e s s e e n o n U S a n d 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 t he 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 t h e i r se r i es 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 s e c t i o n a l a r e a i n the a x i a l p l a n e w a s a m o r e r e p r o d u c i b l e m e a s u r e m e n t . W h e t h e r t h i s i s the c a s e i n the A c h i l l e s t e n d o n r e m a i n s a s u b j e c t f o r f u r t h e r r e s e a r c h . D e s p i t e t hese l i m i t a t i o n s i m a g i n g g r a d e o f s e v e r i t y c o r r e l a t e d w e l l to c l i n i c a l s e v e r i t y . 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 tha t w a s n o t e v i d e n t c l i n i c a l l y . I m a g i n g w a s u n a b l e to d i f f e r e n t i a t e b e t w e e n c a s e s that w o u l d i m p r o v e a n d t h o s e 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 pa t i en 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 c o n t r a s t to the s t u d i e s o f M a t h i e s o n et al.,49 N e h r e r et al.56 a n d A r c h a m b a u l t et al.60 b u t m o r e i n k e e p i n g w i t h the findings o f A s t r o m et al.69 a n d M a r c u s et al.62 C l i n i c a l 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 he 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 u p . 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 t h e i r f i n d i n g s . B e c a u s e o f the c o s t , 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 t h i s 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 bes t s u i t e d 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 the 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 ; the 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 s t ress the n e e d f o r 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 . 7 3 68 CONCLUSION AND RECOMMENDATIONS T h i s s t u d y h a s i n t r o d u c e d a n e w v a l i d a n d r e l i a b l e t o o l f o r m e a s u r i n g 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 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 a n d i n c l i n i c a l p r a c t i c e . T h e V I S A - A q u e s t i o n n a i r e o f f e r s a q u a n t i f i a b l e m e a s u r e 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 f o r c o m p a r i s o n s o v e r t i m e . I n c l i n i c a l t r i a l s 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 the 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 pa t i en t r e s p o n s e to t h e r a p y a n d 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 o v e r t i m e . 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 t he c l i n i c a l a s s e s s m e n t o f a pa t i en t a n d s h o u l d b e r e s e r v e d f o r s p e c i f i c c a s e s . W h e r e i m a g i n g i s r e q u i r e d U S w a s s h o w n to 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 the 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 n o t a d d v a l u e to g r e y s c a l e s o n o g r a p h y a n d n e e d no t b e p e r f o r m e d . W h e r e i m a g i n g m a y b e o f u s e i s i n t he 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 the s i te 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 to 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 f a c i l i t a t e a p p r o p r i a t e i n t e r p r e t a t i o n o f t he i m a g i n g f i n d i n g s . T h i s t hes i s a s s e s s e d p a t i e n t s o v e r a sho r t t e r m f o l l o w u p p e r i o d . F u r t h e r p r o s p e c t i v e s t u d i e s 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 t he V I S A - A s c o r e are n e e d e d . I n a d d i t i o n the re i s a n e e d f o r p r o s p e c t i v e s t u d i e s to c h a r a c t e r i s e the n a t u r a l h i s t o r y o f c h a n g e s s e e n i n i m a g i n g s t u d i e s w i t h i n s y m p t o m a t i c a n d a s y m p t o m a t i c A c h i l l e s t e n d o n s . 69 BIBLIOGRAPHY 1. M y e r s o n M S , B i d d i n g e r K . A c h i l l e s T e n d o n D i s o r d e r s . P r a c t i c a l M a n a g e m e n t S t r a t e g i e s . T h e P h y s i c i a n a n d S p o r t s m e d i c i n e 1 9 9 5 ; 2 3 ( 1 2 ) : 4 7 - 5 4 . 2 . J o z s a L , K a n n u s P . H u m a n t e n d o n s . C h a m p a i g n , I L : H u m a n K i n e t i c s , 1 9 9 7 . 1 8 1 - 1 9 0 ; 4 6 0 - 5 1 1 3 . R e n s t r d m P , J o h n s o n R J . O v e r u s e i n j u r i e s i n s p o r t s . A r e v i e w . S p o r t s M e d 1 9 8 5 ; 2 ( 5 ) : 3 1 6 - 3 3 . 4 . J a r v i n e n M . E p i d e m i o l o g y o f t e n d o n i n j u r i e s i n s p o r t s . C l i n S p o r t s M e d 1 9 9 2 ; l l ( 3 ) : 4 9 3 - 5 0 4 . 5 . K h a n K M , M a f f u l l i N , C o l e m a n B D , C o o k J L , T a u n t o n J E . P a t e l l a r t e n d i n o p a t h y : s o m e a s p e c t s o f b a s i c s c i e n c e a n d c l i n i c a l m a n a g e m e n t . B r J S p o r t s M e d 1 9 9 8 ; 3 2 : 3 4 6 - 5 5 . 6 . K v i s t M . A c h i l l e s t e n d o n i n j u r i e s i n a th le tes . S p o r t s M e d 1 9 9 4 ; 1 8 ( 3 ) : 1 7 3 - 2 0 1 . 7. G a l l o w a y M T , J o k l P , D a y t o n O W . A c h i l l e s t e n d o n o v e r u s e i n j u r i e s . C l i n S p o r t s M e d 1 9 9 2 ; 1 1 ( 4 ) : 7 7 1 - 8 2 . 8 . B r u k n e r P . S p o r t s m e d i c i n e . P a i n i n the A c h i l l e s r e g i o n . A u s t F a m P h y s i c i a n 1 9 9 7 ; 2 6 ( 4 ) : 4 6 3 - 5 . 9 . C l e m e n t D B , T a u n t o n J E , S m a r t G W , et al. A s u r v e y o f o v e r u s e r u n n i n g i n j u r i e s . 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Br J Sports Med 1997; 31 (4):332-6. 77 A P P E N D I X A Investigators in the VIS Tendon study group are: Anderson I; Bartlett J; Be l l S; Bonar F; Bracy C; Bradshaw C; Burke F; Cladwell B ; Cook J; Crichton K ; Dalziel R; Desmond P; Dowling 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 'Br ien P; O'Sul l ivan R; Morris C ; Purdam C; Quirk R; Read J; Shnier R; Tress B ; Visentini P; Wark J; Wilson P; Young D . The following institutions are represented: Department of Medicine, University of Melbourne, Royal Melbourne Hospital; Department of Radiology, University of Melbourne, Royal Melbourne Hospital; Australian Institute of Sport; Victorian Institute of Sport. 1 0 6 7 8

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