Ultrasonography as a prognostic and objective parameter in Achilles tendinopathy: A prospective observational study

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Abstract

Objectives

To study prospectively whether structural changes determined by ultrasound scanning (US) can be used as prognostic markers for outcome in patients with symptomatic Achilles tendinopathy (AT) and to investigate whether there exists an association between US findings and pain measured by visual analog scale (VAS) and a general assessment score (GA).

Methods

92 consecutive patients with AT symptoms were recruited from two outpatient clinics in rheumatology. The patients underwent a conservative treatment protocol consisting of reduced activities, controlled rehabilitation including eccentric exercises of the calf muscles and if needed supplemented with corticosteroid injections. The patients were examined clinically and by US (tendon thickness, hyper- and hypoechogenicity, calcification, bursitis, calcaneusspure, tenosynovitis, gray scale and color Doppler focusing on increased flow intra- or peritendinous). The clinical and US examination were performed at entry, 1, 2, 3 and at 6 month.

Results

42 women and 50 men were included (mean age of 47 years). They had symptoms for more than 13 months and a symptomatic Achilles tendon mean thickness of 7.4 ± 2.3 mm. Heterogeneity at the initial examination was found to be a prognostic marker for the clinical outcome. Tendon thickness, hypoechogenicity and increased flow at any time point were significantly correlated to pain at function, palpatory pain and morning pain at the same time points. A reduction in tendon thickness was statistically associated with a decrease in palpatory pain.

Conclusion

Heterogeneity is a prognostic marker in AT. Tendon thickness, hypoechogenicity and increased Doppler activity can be used as objective outcome parameters for the treatment effect of AT.

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.

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