Ultrasonography as a prognostic and objective parameter in Achilles tendinopathy: A prospective observational study
Introduction
Achilles tendinopathy (AT) is a very common injury in sports and a difficult condition to treat [1], [2]. The exact mechanisms behind AT and the source of pain has not yet been clarified [3]. At the moment there is no consensus on the treatment regime. Eccentric exercises have proven effect on AT [4], [5] as well as stretching exercises [6], [7]. In these efficacy training studies on motivated patients 60–90% are cured, and we cannot expect as high cure rate in the daily clinic, in fact one clinical effectiveness study found only 10% cure rate from a home exercise program consisting of eccentric exercises [8]. Glucocorticosteroid (GCS) injection is also found to have a good short term effect on chronic AT [9], but we have found no studies that combine exercises and GCS injections. Ultrasonography (US) is increasingly used in the diagnosis of soft tissue diseases such as tendinopathy. However there is no consensus on what is defined as normal, abnormal or a pathological US. In a study by Fredberg and Bolvig on high level soccer players, asymptomatic Achilles tendons were investigated [9]. They found US changes (tendon thickness >7 mm) in 11% of the asymptomatic Achilles tendons and demonstrated that the risk of developing symptoms within 1 year was very high in the group of players with increased thickness on US (45%) when continuing playing soccer. This means that increased thickness probably is a precursor for developing AT. It has been suggested, that increased tendon thickness and the presence of Doppler signals are correlated with the level of discomfort and dysfunction and that reduction in symptoms is accompanied with a decrease in US changes [10]. On the other hand neovascularisation is also found in asymptomatic tendons [11]. In the present study we evaluated whether different US changes can be prognostic markers for patients with symptomatic Achilles tendinopathy undergoing a conservative treatment protocol. The hypothesis was that increased tendon thickness, increased peri- and intratendinous flow and heterogeneity (hypo-, hyperechogenicity and calcifications) at the initial examination were associated with a poor outcome at follow-up 6 months later measured by visual analog scale (VAS) and a general assessment score (GA). Furthermore we investigated whether a correlation between symptoms (VAS and GA) and US findings can be determined pointing towards objective signs of AT severity and AT improvement.
Section snippets
Materials and methods
Over an 8 month period 113 consecutive patients (52 women and 61 men) with AT from two outpatient clinics in rheumatology in Denmark were recruited for this prospective study. AT was defined as tenderness at palpation of the tendon, tenosynovium or tendon insertion impairing the daily activities of the patient. A total of 21 (18.6%) patients were excluded; 2 patients were diagnosed with a rupture of the Achilles tendon and in 5 patients erosions were found. 14 patients were excluded due to
Results
92 patients completed the study, 42 women and 50 men with a mean age of 46.9 (SD 15.7) years, symptoms for 13.2 (SD 15.5) months and a symptomatic and asymptomatic Achilles tendon mean maximal thickness of 7.4 (SD 2.3)mm and 5.5 mm (SD 1.1), respectively. The US findings at entry are shown in Table 1. Eight (9%) symptomatic tendons were found with no US changes and 23 (30.7%) asymptomatic tendons were found with US abnormalities. Patients with or without heterogeneity at entry were compared with
Discussion
The primary aim of this study was to find US changes that could be prognostic markers for the outcome. We found US heterogeneity (hyper- and/or hypoechogenicity) at entry to be a prognostic marker for poor outcome at 6 months. Our findings are in contrast to a 2 year prospective study where they found no US changes that could predict the 12 months outcome [14]. This could be explained partly in the difference in follow up time. In another prospective study clinical outcome, after a conservative
Conflict of interest statement
None.
Acknowledgements
Thanks to Arne Gam, MD, specialist in rheumatology, private rheumatology clinic, Brønshøj for including patients into this project. Thanks to Ditte Sæbye, Cand. Scient. in Statistics, Institute of Preventive Medicine, Frederiksberg Hospital for statistical advice.
References (20)
Achilles tendon injuries in athletes
Sports Med
(1994)- et al.
Management of tendinopathy
Am J Sports Med
(2009) - et al.
Achilles tendinopathy: aetiology and management
J R Soc Med
(2004) - et al.
The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up
Am J Sports Med
(2011) - et al.
Chronic Achilles tendon pain treated with eccentric calf-muscle training
Knee Surg Sports Traumatol Arthrosc
(2003) - et al.
The effects of duration and frequency of Achilles tendon stretching on dorsiflexion and outcome in painful heel syndrome: a randomized, blinded, control study
Foot Ankle Int
(2002) - et al.
Eccentric exercise in treatment of Achilles tendinopathy
Scand J Med Sci Sports
(2007) - et al.
The limited effectiveness of a home-based eccentric training for treatment of Achilles tendinopathy
Clin Invest Med
(2013) - et al.
Significance of ultrasonographically detected asymptomatic tendinosis in the patellar and achilles tendons of elite soccer players: a longitudinal study
Am J Sports Med
(2002) - et al.
Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis?
Knee Surg Sports Traumatol Arthrosc
(2004)
Cited by (32)
Current advances and research in ultrasound imaging to the assessment and management of musculoskeletal disorders
2021, Disease-a-MonthCitation Excerpt :This injury was determined by the presence of pain, inflammation and functional deficit in gait and running.167 USI imaging of a pathological tendon usually shows hypoechoic areas, increased CSA and neovascularization.168,169 In this context, Romero et al. reported an increase of Achilles tendon thickness and CSA (Fig. 3), a CSA decrease in the extensor digitorum longus, peroneus muscles and tibialis anterior in individuals with AT.25,170
Nonsurgical Management of Midsubstance Achilles Tendinopathy
2017, Clinics in Podiatric Medicine and SurgeryCitation Excerpt :A lack of recovery of musculotendon function may be consistent with persistent tendon pathoanatomy. Greater tendon heterogeneity on ultrasound examination has been associated with a longer recovery time and poor outcome at 6 months of tendon loading exercise and corticosteroid injections.8,104 Continued improvement in AT can be observed up to 1 year after starting treatment,70 and ultrasound imaging may be useful during this time to monitor structural changes and encourage long-term adherence to tendon loading exercise.
Rehabilitative ultrasound imaging in musculoskeletal and neuromuscular disorders
2017, KinesitherapieUltrasonographic Finding of Contralateral Achilles Tendon in Patients with Acute Achilles Tendon Rupture: A Prospective Observational Study
2023, Clinical Journal of Sport MedicineMusculoskeletal Ultrasound Image-Based Radiomics for the Diagnosis of Achilles Tendinopathy in Skiers
2023, Journal of Ultrasound in Medicine