164 Chapter 9 can provide valuable insights into the structural changes in the Achilles tendon, it is now evident that not all patients with clinical symptoms of Achilles tendinopathy exhibit the expected increase in tendon thickness. Conversely, a substantial proportion of individuals without symptoms display morphological changes indicative of tendinopathy on imaging. This disparity raises significant questions regarding the reliance on imaging for diagnosing and assessing Achilles tendinopathy. Experts already agree that imaging is not essential for diagnosing Achilles tendinopathy and current guidelines only recommend imaging in cases where the diagnosis is uncertain.3,4,28 However, randomized control trials frequently (47%) use imaging in the diagnostic process.3,28,39 In these RCTs local thickening of the tendon is often used but predominantly without specifying the criteria for when one speaks of increased tendon thickness.3 Heterogeneous tendon structure with hypoechoic areas and presence of intratendinous/peritendinous Doppler flow are also regularly used for diagnosing Achilles tendinopathy on imaging35,36,40,41, but also these criteria may be absent in patients with Achilles tendinopathy. For example, one study showed that areas of altered echogenicity were seen in 67% of patients and only 47% of the patients exhibited increased Doppler flow.42 While it is hypothesized that radiological findings are similar for midportion and insertional Achilles tendinopathy43 diagnostic criteria in RCTs on insertional Achilles tendinopathy are underreported compared to midportion Achilles tendinopathy.3 We found only one RCT reporting radiologic criteria (solely the presence of calcifications was used) for diagnosing insertional Achilles tendinopathy.44 The heterogeneity in radiologic criteria used for diagnosing Achilles tendinopathy on imaging and the lack of reporting radiologic criteria in these RCTs stress the need for clear diagnostic criteria. These diagnostic criteria (such as tendon geometry and structure, Doppler flow and intratendinous calcifications) should preferably be based on large international studies evaluating imaging findings of the Achilles tendon in both Achilles tendinopathy patients and asymptomatic individuals. Next to this, clinicians and researchers should form clear agreements how these diagnostic criteria are defined and how to reliably assess them, for example through a consensus process/study. Only after such studies we will be able to know if imaging truly has a place in the diagnostic process for Achilles tendinopathy. If imaging does not have a place in the diagnostic process, does it have added value for evaluating response to treatment or as prognostic factor? There have been several studies which used imaging as secondary outcome measure when evaluating the effect of treatment.45,46 It is hypothesized that mild degree of tendon thickening, neovascularization or hypo-echogenicity is indicative of a favourable response to treatment. However, numerous studies have showed that there is no clear relationship between radiographic findings and clinical severity in patients with AT and that imaging findings are not predictive/indicative for the response to treatment.47-51 If imaging is of limited value in the diagnostic process or as prognostic factor, the question arises if there are other potential benefits of using imaging in the management of Achilles
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