10 177 Appendices chronic midportion AT. The primary outcome was the EuroQol questionnaire (EQ-5D), which expresses the percentage of moderate/major problems on the domains self-care, anxiety/depression, mobility, usual activities and pain/discomfort. Secondary outcomes were the number of previous healthcare visits, work performance during the period of symptoms and estimated annual direct medical and indirect costs per patient as a result of AT. The EQ-5D scores were low for the domains self-care (1%) and anxiety/depression (20%), and high for the domains mobility (66%), usual activities (50%) and pain/discomfort (89%). Patients with AT mainly reported an impact on work productivity (38%). Work absenteeism due to AT was present in 9%. The total median (IQR) number of annual healthcare visits was 9 (3–11). The total mean (SD) estimated annual costs were €840 (1420) per patient with AT (mean (SD) US$991 (1675)). We concluded that the impact of Achilles tendinopathy (AT) on quality of life is substantial, with especially the domains mobility, pain/discomfort and usual activities being affected. Next to this, we demonstrated that Achilles tendinopathy also leads to a significant decrease in work productivity and causes substantial costs. Diagnostic imaging As the clinical sign of subjective self-reported pain is a key criteria for establishing the diagnosis of Achilles tendinopathy we wanted to know if patients with pain in the Achilles region could adequately localize their pain. In Chapter 5 we performed a crosssectional study and evaluated the level of agreement between patient-reported pain using a standardized pain map and the physician-determined clinical diagnosis of Achilles tendinopathy. 110 patients with pain in the Achilles region were included and in 102 (93%, Kappa = 0.86, CI 0.78–0.95) patients who indicated pain in the Achilles tendon region on the pain map, the clinical diagnosis of Achilles tendinopathy was made by the sports physician. 82% of the patients had the clinical diagnosis of tendinopathy in the specific region (midportion/insertion) of the tendon they marked on the pain map (Kappa = 0.67, CI 0.54–0.79). This study demonstrated that there was substantial agreement between the localization of the pain selected by the patient and the diagnosis of insertional/ midportion Achilles tendinopathy by the physician. The use of a pain map could be of value to researchers performing large epidemiological studies or aid in self-diagnosis and adequate triage for specialized care. Ultrasound is the preferred imaging method in the diagnostic process of Achilles tendinopathy. Ultrasound Tissue Characterization is a frequently used, standardized method to assess tendon geometry in AT patients, but it has been unknown whether UTC is reliable for measuring Achilles tendon thickness. In Chapter 6 we included 50 Achilles tendinopathy patients and 50 asymptomatic individuals and assessed the intra- and inter-rater reliability of Achilles tendon thickness measurements using UTC. Overall, we demonstrated excellent reliability for measuring tendon thickness using UTC. However,
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