Is Sonographic Assessment of Intratendinous Blood Flow in Achilles Tendinopathy Patients Reliable?

Abstract

Purpose:

The purpose of this study was to investigate the consistency between different Doppler ultrasound (DU) modes as well as the intra- and inter-observer reliability of investigators with different experience level in assessing intratendinous blood flow (IBF) in Achilles tendinopathy patients.

Material and Methods:

18 participants (36 Achilles tendons, AT) with Achilles tendinopathy (24 AT) were examined with power Doppler ultrasound (PDU), colour Doppler ultrasound (CDU) and “Advanced Dynamic Flow” (ADF) (Toshiba Xario SSA-660 A; 14MHz transducer) by 2 investigators (experienced, EI; inexperienced, II) in a test-retest design (M1/M2). A modified Öhberg score was used to quantify IBF. Data was analysed descriptively (absolute and relative). Consistency of the 3 modes was presented by Kendall’s Coefficient of Concordance (Kendall’s W). Intra- and inter-observer reliability were calculated by use of Kendall’s tau b correlation coefficient.

Results:

IBF was detected in 79–92% of symptomatic AT and in 33–50% of contralateral asymptomatic AT. Comparing the 3 modes, Kendall’s W ranged from 0.97–0.98. Analysis of intra-observer reliability resulted in Kendall’s tau 0.90–0.92 for EI and 0.84–0.87 for II. Inter-observer reliability resulted in Kendall’s tau 0.64–0.69 in M1 and 0.68–0.70 in M2.

Conclusion:

The very good consistency between PDU, CDU and ADF indicates a comparable applicability for assessing IBF in ATs. Intra-observer reliability was high for both investigators, independent of experience. The moderate inter-observer reliability reflects the challenge in sonographic detection of intratendinous blood flow (IBF) amount.

Key words

ultrasound-power doppler - ultrasound-color doppler - advanced dynamic flow - achilles tendon - reliability

• References

• 1 Sengkerij PM, de Vos R-J, Weir A et al. Interobserver reliability of neovascularization score using power Doppler ultrasonography in midportion achilles tendinopathy. Am J Sports Med 2009; 37: 1627-1631
• 2 Hirschmüller A, Frey V, Konstantinidis L et al. Prognostic value of Achilles tendon Doppler sonography in asymptomatic runners. Med Sci Sports Exerc 2012; 44: 199-205
• 3 Tol JL, Spiezia F, Maffulli N. Neovascularization in Achilles tendinopathy: have we been chasing a red herring?. Knee Surg Sports Traumatol Arthrosc 2012; 20: 1891-1894
• 4 Hirschmüller A, Frey V, Deibert P et al. Achilles tendon power Doppler sonography in 953 long distance runners – a cross sectional study. Ultraschall Med 2010; 31: 387-393
• 5 Malliaras P, Richards PJ, Garau G et al. Achilles tendon Doppler flow may be associated with mechanical loading among active athletes. Am J Sports Med 2008; 36: 2210-2215
• 6 Boesen MI, Boesen A, Koenig MJ et al. Ultrasonographic investigation of the Achilles tendon in elite badminton players using color Doppler. Am J Sports Med 2006; 34: 2013-2021
• 7 Boesen MI, Koenig MJ, Torp-Pedersen S et al. Tendinopathy and Doppler activity: the vascular response of the Achilles tendon to exercise. Scand J Med Sci Sports 2006; 16: 463-469
• 8 De Vos R-J, Weir A, Cobben LPJ et al. The value of power Doppler ultrasonography in Achilles tendinopathy: a prospective study. Am J Sports Med 2007; 35: 1696-1701
• 9 Pingel J, Harrison A, Suetta C et al. The acute effects of exercise on the microvascular volume of Achilles tendons in healthy young subjects. Clin Physiol Funct Imaging 2013; 33: 252-257
• 10 Richards PJ, Win T, Jones PW. The distribution of microvascular response in Achilles tendonopathy assessed by colour and power Doppler. Skeletal Radiol 2005; 34: 336-342
• 11 Boesen AP, Boesen MI, Torp-Pedersen S et al. Associations between abnormal ultrasound color Doppler measures and tendon pain symptoms in badminton players during a season: a prospective cohort study. Am J Sports Med 2012; 40: 548-555
• 12 Sunding K, Fahlström M, Werner S et al. Evaluation of Achilles and patellar tendinopathy with greyscale ultrasound and colour Doppler: using a four-grade scale. Knee Surgery, Sport Traumatol Arthrosc. 2014
• 13 Weskott HP. Amplitude Doppler US: slow blood flow detection tested with a flow phantom. Radiology 1997; 202: 125-130
• 14 Yang X, Pugh ND, Coleman DP et al. Doppler studies a useful method of assessing neovascularization in human Achilles tendinopathy? A systematic review and suggestions for optimizing machine settings. J Med Eng Technol 2010; 34: 365-372
• 15 Strunk J, Backhaus M, Schmidt W et al. Color Doppler sonography for investigation of peripheral joints and ligaments. Z Rheumatol 2010; 69: 164-170
• 16 Reiter M, Ulreich N, Dirisamer a et al. Colour and power Doppler sonography in symptomatic Achilles tendon disease. Int J Sports Med 2004; 25: 301-305
• 17 Heling KS, Chaoui R, Bollmann R. Advanced dynamic flow – a new method of vascular imaging in prenatal medicine. A pilot study of its applicability. Ultraschall Med 2004; 25: 280-284
• 18 Fittschen M, Reinhard I, Wellek S et al. Advanced dynamic Doppler flow of the pulmonary artery in a normal population: reference values from 18 to 41 weeks of gestation calculated by automatic Doppler waveform analysis. Arch Gynecol Obstet 2014; 289: 973-980
• 19 Ohberg L, Alfredson H. Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment. Br J Sports Med 2002; 36: 173-175 discussion 176–177
• 20 Cook JL, Ptazsnik R, Kiss ZS et al. High reproducibility of patellar tendon vascularity assessed by colour Doppler ultrasonography: a reliable measurement tool for quantifying tendon pathology. Br J Sports Med 2005; 39: 700-703
• 21 Malliaras P, Chan O, Simran G et al. Doppler ultrasound signal in Achilles tendinopathy reduces immediately after activity. Int J Sports Med 2012; 33: 480-484
• 22 Hutchison A, Evans R, Bodger O et al. What is the best clinical test for Achilles tendinopathy?. Foot Ankle Surg 2013; 19: 112-117
• 23 Robinson JM, Cook JL, Purdam C et al. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 2001; 35: 335-341
• 24 Ohrndorf S, Messerschmidt J, Reiche BE et al. Evaluation of a new erosion score by musculoskeletal ultrasound in patients with rheumatoid arthritis. Clin Rheumatol 2014; 1255-1262
• 25 Cassel M, Fröhlich K, John M et al. Belastungsabhängige Prävalenz von Patellasehnen-Tendinopathie und sonographischen Veränderungen junger Nachwuchsathleten. Sport Orthop Traumatol 2014; 30: 145-150
• 26 Cook JL, Malliaras P, De Luca J et al. Vascularity and pain in the patellar tendon of adult jumping athletes: a 5 month longitudinal study. Br J Sports Med 2005; 39: 458-461 discussion 458–461
• 27 Cassel M, Baur H, Hirschmüller a et al. Prevalence of Achilles and patellar tendinopathy and their association to intratendinous changes in adolescent athletes. Scand J Med Sci Sports 2014; 1-9
• 28 Bortz J, Lienert GA. Kurzgefasste Statistik für die klinische Forschung: Leitfaden für die verteilungsfreie Analyse kleiner Stichproben. 3rd ed. Heidelberg: Springer; 2008
• 29 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159-174
• 30 Mukaka MM. Statistics corner: A guide to appropriate use of correlation coefficient in medical research. Malawi Med J 2012; 24: 69-71
• 31 Iversen JV, Bartels EM, Langberg H. The victorian institute of sports assessment – achilles questionnaire (visa-a) – a reliable tool for measuring achilles tendinopathy. Int J Sports Phys Ther 2012; 7: 76-84
• 32 Gellhorn AC, Carlson MJ. Inter-rater, intra-rater, and inter-machine reliability of quantitative ultrasound measurements of the patellar tendon. Ultrasound Med Biol 2013; 39: 791-796
• 33 Knobloch K. The use of a neovascularization score to predict clinical severity in Achilles tendinopathy. Am J Sports Med 2008; 36 395; author reply 395-397
• 34 Weidekamm C, Köller M, Weber M et al. Diagnostic value of high-resolution B-mode and Doppler sonography for imaging of hand and finger joints in rheumatoid arthritis. Arthritis Rheum 2003; 48: 325-333