178 Appendices significantly lower intra-class correlation coefficients were observed for the reliability of thickness measurements in the insertional region when compared to the midportion. Next to this, we showed that tendon thickness measurements using UTC can be reliably translated to conventional ultrasound. In Chapter 7 we obtained adjusted ultrasonographic reference values of the Achilles tendon thickness (maximum anterior-posterior distance) in adults without (previous) Achilles tendinopathy and compared these reference values with AT patients. In this large international cross-sectional study we demonstrated that Achilles tendon thickness is influenced by personal characteristics. We found that age and height had the largest influence on maximum anterior-posterior distance. The mean difference in tendon thickness between asymptomatic persons and patients with Achilles tendinopathy was 2.7 mm for the midportion region and 1.4 mm for the insertional region. The majority of the AT patients (73%) had an increased tendon thickening outside the 95% reference interval. Our novel web-based openly accessible calculator for determining normative Achilles tendon thickness (www.achillestendontool.com) will help clinicians distinguish between ultrasonographic features of Achilles tendinopathy and normal morphological changes. Prognostic factors As imaging does not have any prognostic value for Achilles tendinopathy patients, it is important to evaluate other potential patient specific prognostic factors. In Chapter 8 we included 200 Achilles tendinopathy patients who were treated according to the current guidelines and evaluated if socio-economic status had effect on symptom severity and response to standardized treatment. We found that there was a mean difference of 11 points on the VISA-A questionnaire at 24-weeks follow-up in favour of patients with high socioeconomic status compared to patients with low SES. This difference in VISA-A score is larger than the Minimal Clinically Important Difference and thus clinically relevant. We advise healthcare providers to be mindful of the socioeconomic status of their patients while administering treatment. Future research should focus on this subgroup of tendinopathy patients with lower socioeconomic status to better understand the reasons behind the worse treatment response. In Chapter 9, the key findings of this thesis are described in relation to both each other and the existing body of literature on Achilles tendinopathy. Several recommendations for future research are presented, aiming to enhance the knowledge on the impact, diagnostic imaging modalities and prognosis of Achilles tendinopathy.
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