Rationale and Objectives
We aimed to investigate the diagnostic accuracy with which shear wave elastography (SWE) can be used to monitor response to treatment of tendinopathies, and to compare it to conventional ultrasound (US)-imaging methods (B-mode US (B-US) and power Doppler US (PD-US)).
Materials and Methods
A prospective Institutional Review Board-approved longitudinal study on 35 patients with 47 symptomatic tendons (17 Achilles-, 15 patellar-, and 15 humeral-epicondylar) who underwent standardized multimodal US and standardized clinical assessment before and after 6 months of treatment (tailored stretching exercise, sport break, and local Polidocanol) was carried out. All US studies were performed by radiologists blinded to the clinical symptoms on both tendon sides to avoid biased interpretations, by B-US, PD-US, and SWE, conducted in the same order, using a high-resolution linear 15 MHz probe (Aixplorer). Orthopedic surgeons who were in turn blinded to US imaging results used established orthopedic scores (Victorian Institute of Sports Assessment questionnaire for Achilles, Victorian Institute of Sports Assessment questionnaire for patellar tendons, and Disability Arm Shoulder Hand scoring system) to rate presence, degree, and possible resolution of symptoms. We analyzed the diagnostic accuracy with which the different US imaging methods were able to detect symptomatic tendons at baseline as well as treatment effects, with orthopedic scores serving as reference standard.
Results
B-US, PD-US, and SWE detected symptomatic tendons with a sensitivity of 66% (31 of 47), 72% (34 of 47), and 87.5% (41 of 47), respectively. Positive predictive value was 0.67 for B-US, 0.87 for PD-US, and 1 for SWE. After treatment, clinical scores improved in 68% (32 of 47) of tendons. Treatment effects were observable by B-US, PD-US, and SWE with a sensitivity of 3.1% (1 of 32), 28.1% (9 of 32), and 81.3% (26 of 32), respectively. B-US was false-positive in 68.8% (20 of 32), PD-US in 46.9% (15 of 32), and SWE in 12.5% (4 of 32) (SWE). Clinical scores and B-US, PD-US, and SWE findings correlated poorly (r = 0.24), moderately (r = 0.59), and strongly (r = 0.80).
Conclusion
Unlike B-US or PD-US, SWE is able to depict processes associated with tendon healing and may be a useful tool to monitor treatment effects.
Introduction
Tendinopathies of Achilles, patellar, or epicondylar tendons, characterized by pain, swelling, or function, are some of the most common orthopedic conditions, not only in sportsmen or athletes , but also in individuals with sedentary lifestyle .
To date, B-mode ultrasound (B-US), power Doppler ultrasound (PD-US), and magnetic resonance imaging (MRI) are the main diagnostic tools in detecting and monitoring tendinopathies . Typical US detectable changes, such as tendon thickening, inhomogeneous tendon structure, loss of echogenicity, and hypervascularization are known to be imaging signs associated with or indicative of tendinopathy .
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Materials and Methods
Study Design and Population
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Inclusion Criteria
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Clinical Assessment
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Tendinopathy Treatment
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Imaging Protocol
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B-Mode Ultrasound (B-US)
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Power Doppler Ultrasound (PD-US)
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Shear Wave Elastography (SWE)
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Data Analysis
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Statistical Analysis
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Results
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Table 1
Demographics of Symptomatic Participants at Baseline ( n = 47)
All ( n = 47) Achilles Tendon ( n = 17) Patellar Tendon ( n = 15) Humeral Epicondylar Tendon ( n = 15)Age (years) Mean ± SD 46 ± 18 50 ± 13 26 ± 5 49 ± 15 Median/range 45/20–71 49/31–69 30/20–40 43/24–70Sex Male 37 (78.7%) 11 (64.7%) 15 (100%) 11 (73.3%) Female 10 (23.4%) 6 (35.3%) 0 (0%) 4 (26.7%)Clinical score VISA-A score VISA-P score DASH score \* Baseline (Mean/SD) 40 ± 20 54 ± 16 38 ± 15 48 ± 12
DASH, Disability Arm Shoulder Hand scoring system; SD, standard deviation; VISA-A, Victorian Institute of Sports Assessment questionnaire for Achilles; VISA-P, Victorian Institute of Sports Assessment questionnaire for patellar tendons.
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Table 2
Imaging Findings in Symptomatic Tendons at Baseline and After 6 Months of Therapy ( n = 47)
Baseline 6 Months Following Treatment Measureable Improvement_P_ Value Clinical score 40 ± 20 98 ± 17 +245% <.01 SWE score (kPa) 42 ± 15 106 ± 27 +152.4% <.01 Symptomatic tendons 47/47 (100%) 15/47 (31.9%) +68.1% <.01 Positive B-mode US 31/47 (66%) 29/47 (61.7%) +4.3% >.05 Positive PD-US 34/47 (72.3%) 25/47 (53.2%) +26.5% >.05 Positive SWE 41/47 (87%) 6/47 (12.8%) +85.4% <.01
B-mode US, B-mode ultrasound; PD-US, power Doppler ultrasound; SWE, shear wave elastography.
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Baseline (Pretreatment) Findings
Clinical Scores
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Ultrasound Findings
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After 6 Months of Treatment
Clinical Scores
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B-Mode Ultrasound
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Power Doppler Ultrasound
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Shear Wave Elastography
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Table 3
Sensitivity/Specificity of Different Modalities Prior to and 6 Months After Initiating Tendinopathy Treatment
Baseline 6 Months Following Treatment Modality SENS SPEC PPV NPV SENS SPEC PPV NPV B-mode 0.66 0.83 0.67 0.58 0.05 0.31 0.3 0.13 Power Doppler 0.72 0.79 0.87 0.65 0.47 0.53 0.32 0.32 SWE 0.87 1 1 0.83 0.81 0.88 0.75 0.57
NPV, negative predictive value; PPV, positive predictive value; SENS, sensitivity; SPEC, specificity; SWE, shear wave elastography.
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Quantitative Tendon Assessment by SWE
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Discussion
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Conclusion
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