162 Chapter 9 noteworthy that psychosocial outcome measures were not included in the core outcome set for clinical trials in Achilles tendinopathy. This omission may be attributed to the current absence of psychosocial outcome measures tailored specifically to the population of Achilles tendinopathy patients. DIAGNOSTIC IMAGING Clinical diagnosis Achilles tendinopathy is a clinical diagnosis, with 3 key diagnostic criteria.25 Patient history is crucial to diagnose Achilles tendinopathy as patients must have pain in the Achilles tendon region, which worsens on loading.25 A second key diagnostic criterion is the presence of localized Achilles tendon pain, which can be assessed upon palpation of the Achilles tendon.25,26 When evaluating the location of pain it is important to distinguish between the insertional and midportion region as it affects prognosis and treatment.26,27 Our crosssectional study demonstrated that Achilles tendinopathy patients could adequately localize their pain. This study showed that, with the use of a pain map, there was substantial agreement between the localization of the pain by the patient and the diagnosis of insertional/midportion Achilles tendinopathy by the physician. A third important diagnostic criterion is the presence of localized tendon thickening.25 Experts agree that when all three clinical diagnostic elements are present, the clinical diagnosis is straightforward.28 Previous research, using ultrasound as reference standard, indicated that these three findings show high diagnostic accuracy for diagnosing chronic midportion Achilles tendinopathy.26 This leads us to the role of imaging in diagnosing Achilles tendinopathy. Is imaging useful in cases where not all three diagnostic criteria are present (e.g. localized tendon pain which is painful on palpation but without tendon thickening)? And is imaging indeed the reference or ‘golden’ standard? Diagnostic imaging Ultrasound serves as the preferred imaging modality for diagnosing Achilles tendinopathy.3,4,29 Conventional X-rays are generally only used to assess for any potential bone-related abnormalities and in cases where ultrasound is not accessible, prior to potential surgical intervention, or when ultrasound results don’t match with clinical findings, MRI may be considered.3,29 A common finding of Achilles tendinopathy during ultrasound examination is an increase in tendon thickness in the anterior-posterior direction.29 The reliability of measuring Achilles tendon thickness using conventional ultrasound techniques ranges from fair to excellent.30-32 However, there has been a lack of research evaluating the reliability of measurements in the insertional area of Achilles tendinopathy patients. In addition to conventional ultrasound, the adoption of standardized ultrasound procedures is becoming
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