12 Chapter 1 Achilles tendon is typically viewed in two planes and the maximum anterior-posterior tendon thickness is commonly measured in the transversal plane (Figure 3). Achilles tendinopathy is ultrasonographically characterized by increased tendon thickness (Figure 3), decreased tendon structure and neovascularization.26,30,31 Doppler ultrasonography can detect the increased blood supply.31,32 However, a significant drawback of imaging is that findings suggestive for tendinopathy are present in 25% of asymptomatic Achilles tendons, which can lead to overdiagnosis and overtreatment.33 Another problem with imaging is that reference values for tendon geometry and structure are lacking for the general population.33 The current cut-off value of 6 mm in maximum Achilles tendon thickness is accepted as a reference standard, but is based on small crosssectional studies in specific populations, and it is likely that tendon geometry is influenced by personal characteristics.25 Figure 3. Visualisation of the Achilles tendon using Ultrasound Tissue Characterization in a healthy individual (A + B) and a patient with midportion Achilles tendinopathy (C + D), with increased tendon thickness. In image A + C the transversal view is shown and in image B + D the tendon is viewed in the longitudinal plane. The yellow line represents the border of the Achilles tendon. PROGNOSTIC FACTORS The conservative therapy for Achilles tendinopathy consists of load-management, education and exercise therapy. However, this treatment may not be very effective in first line care, as one-thirds of patients with new-onset Achilles tendinopathy continue to experience symptoms at one-year follow-up.34 At ten years of follow-up, even up to a quarter of patients remain symptomatic.35
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