EVIDENCE INFORMED PRACTICE


EVIDENCE INFORMED PRACTICE


TABLE 1: POSSIBLE DIFFERENTIAL DIAGNOSES FOR DIFFERENT REGIONS OF THE TENDON (J. ANTFLICK, 2014)


Mid portion


Achilles degeneration/ tendinosis


Achilles dysrepair


Achilles intrasubstance partial tear Central/spinal sensitisation Achilles tendinopathy Achilles rupture Achilles paratenonitis


(a) +


excursion of transducer


0


beam axis


- (b)


Figure 2: The image created from the UTC scan indicates healthy or progressively more damaged tissue by a colour classification system: I. Green: intact and aligned bundles and fasciculi, diameter: ≥0.38mm II. Blue: discontinuous wavy bundles and fascicule, diameter: ≥0.38mm


III. Red: mainly smaller fibres (‘fibrillar’), diameter: <<0.38mm IV. Black: mainly amorphous tissue containing cells and/or fluid, diameter <<<0.38mm. (H. van Schie, utcimaging)


Figure 1: The Ultrasound Tissue Characterisation (UTC™) Tracker device provides a more detailed image of the tendon. The UTC Tracker (supplied by utcimaging) (a) is specifically designed to image tendons (b). [(a) Courtesy of utcimaging.com; (b) credit: J. Antflick, Tendon Performance, 2013]


The UTC probe travels automatically over the tendon’s long axis, collecting transverse images at even distances of 0.2mm over a length of 12–20cm. UTC produces a transverse, coronal and longitudinal image and a 3D coronal view. The tendon structure is classified into four discrete echo types: n Echo-type I (green), generated by reflections at intact and aligned tendon bundles (coloured green in


www.sportEX.net processed images)


n Echo-type II (blue), generated by reflections at discontinuous or waving tendon bundles (coloured blue in processed images)


n Echo-type III (red), generated by interfering echoes from mainly fibrillar components (coloured red in processed images)


n Echo-type IV (black), generated by mainly cellular components and fluid in amorphous tissue. These different echo types provide


objective information on the integrity of the tendon matrix from the distal insertion to musculotendinous junction. The scans are analysed to assess for focal areas of echo change and to


Distal tendon


Insertional Achilles tendinopathy Enthesitis


Insertional tendinopathic degenerative change


Insertional calcification Retrocalcaneal bursitis


Medial tendon Plantaris rupture


Plantaris partial tear Plantaris tendinopathy


Plantaris friction syndrome


Lateral tendon Sural neuropathy


establish the overall health of the tendon (Fig. 2).


EXAMPLES OF UTC IMAGES The UTC Tracker produces images that give a clear indication to the health of the tendon. Figure 3 shows an image of a relatively normal healthy tendon. The scan data can also be presented in different types of graphical images. Figure 4 is a graph of the relative amounts of echo-types (and therefore tissue types) along the length of the tendon. Figure 5 is a bar chart, which gives a clear picture of the relative amounts of the healthy and damaged types of tissue as indicated by the different echo-types. The values for a normal healthy Achilles or patella tendon would typically be: green, 80% or greater; blue, 15%; and red and black together, 5%. Figures 6 and 7 show the recovery of a surgically repaired tendon following complete rupture and the healing that takes place over time. UTC plays an important role in monitoring athletes’ tendon health during each phase of the rehabilitation process and for managing in-season tendon pain. Managing tendinopathy in season is particularly challenging as training and competition loads are high and often there is not sufficient time for a full recovery. Tendon pain is provoked by excessive loading; the greater the load, the more pain is experienced (3). UTC is currently being used in British Athletics and Australian Rules Football in symptomatic and asymptomatic tendons to study the effect of load on the tendon matrix. The UTC data combined with


clinical markers assess the tendons tolerance to load, such as 24-hour pain response, morning stiffness,


TO ECHO TYPE, WHICH INDICATES THE HEALTH OF THE TISSUE


UTC IMAGES ARE COLOURED ACCORDING


27


transducer


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