The role of ultrasound imaging in the diagnosis of Achilles tendinopathy

Student thesis: Doctoral Thesis

Abstract

Aim
The overarching research question guiding this thesis was: What is the role of an ultrasound imaging-based criteria for staging Achilles tendinopathy? To answer this question, four key research aims were identified; 1) to review the current, commonly used criteria for diagnosing, staging and measuring tendon structural change using ultrasound imaging, 2) to develop a criteria for staging tendinopathy using ultrasound imaging and assess the validity, intra and inter-rater reliability of the criteria, 3) to review the current, commonly used clinical tests for diagnosing Achilles tendinopathy,4) to assess the relationship between clinical tests and the developed ultrasound imaging criteria.

Methods
Several approaches were utilised to explore the role of ultrasound imaging in the diagnosis of Achilles tendinopathy. These methods aimed to expand upon existing knowledge and devise new, reliable techniques for diagnosing Achilles tendinopathy consistently in the clinical setting. A narrative review was completed to review the pathophysiology of tendinopathy and provide an understanding of the common features seen on ultrasound imaging and their potential effect on clinical symptomology. Following this, a systematic review was conducted to identify the common methods with which tendinopathy is currently assessed using ultrasound imaging. Using the results of the systematic review, an ultrasound imaging-based criteria was developed, and content validity was assessed via an expert panel. Once the content validity had been established, the reliability of the criteria was assessed using a retrospective analysis of ultrasound images to determine intra and inter-rater reliability. To establish the role of ultrasound imaging in the diagnosis of Achilles tendinopathy in the clinical setting, an understanding of the current clinical tests utilised to determine the diagnosis was required. Thus, a scoping review was undertaken to identify the most common methods for clinically diagnosing Achilles tendinopathy. Finally, the previously developed ultrasound imaging criteria was compared to the clinical tests identified in the scoping review, and a pilot case series study was completed to assess the relationship between clinical tests and the developed USI criteria.

Results
The narrative review illustrated the pathophysiological relationship between tendon structure and features identified on ultrasound imaging. It also highlighted heterogeneity in the assessment methods used to diagnose tendinopathy. The systematic review identified that the most common ultrasound imaging-based parameters used to assess tendon matrix change included tendon thickness, echogenicity, and vascularity, while also illustrating that pathology identified on USI was predictive of developing future clinical symptoms in asymptomatic tendons. An ultrasound imaging-based criteria was developed using the results of the systematic review that demonstrated both intra-rater and inter-rater reliability was ‘substantial’ to ‘almost perfect’ for diagnosing Achilles tendinopathy using ultrasound imaging. The scoping review identified significant variability in the current methods employed to clinically diagnose Achilles tendinopathy. As such, an assessment method was presented that utilised the most common clinical tests for Achilles tendinopathy. The pilot case series revealed that clinical tests can differentiate between Achilles tendinopathy with and without structural change on ultrasound imaging, however, were unable to subcategorise Achilles tendinopathy according to the continuum model of tendon pathology when structural change on USI has occurred.

Conclusions
The findings of this thesis can be translated into practical recommendations regarding the diagnosis of Achilles tendinopathy and the assessment of tendon structural change using ultrasound imaging. Structural changes seen on ultrasound imaging increase the risk of developing clinical symptoms in tendinopathy and an ultrasound-based criteria that utilises the continuum model of tendon pathology is a reliable method with which to assess Achilles tendinopathy. There is significant variability in the clinical diagnosis of Achilles tendinopathy with clinical tests able to differentiate between Achilles tendinopathy with and without structural changes but not subcategorise tendinopathy with structural change according to the continuum model of tendon pathology. Ultrasound Imaging is not required where clinical tests identify a patient with Achilles tendinopathy as potentially having a structurally normal Achilles tendon. However, ultrasound imaging may be beneficial when clinical tests identify a patient with Achilles tendinopathy with potential structural changes, where the stage of tendinopathy may affect clinical decision-making regarding treatment selection.
Date of Award2024
Original languageEnglish
SupervisorWayne Hing (Supervisor), Richard Ellis (Supervisor) & James Furness (Supervisor)

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