Objective To report the intra- and inter-operator reliability of ultrasound strain elastography measures in the assessment of quadriceps and patellar tendons. Materials and methods Forty tendons were investigated of 20 healthy volunteers. Five anatomical sites were examined and analysed by three operators of differing levels of experience. Ultrasound was performed over two measures, employing three sonoelastography measurement techniques using a GE S8 with linear probe (L6–15 MHz). The percentage of exact agreement, Cohen's kappa and ICC2,1 were performed to assess intra- and inter-operator reliability. Results The patellar tendon is more reliably measured across all techniques compared to the quadriceps tendon, particularly the distal region. Colour scoring was the most reliable method of sonoelastography. Colour scoring intra- and inter-operator reliability was better for patella tendon sites across all operators (60–95% agreement range), and greatest for experienced operators. Elasticity index intra-operator reliability was greatest for the most experienced operator compared with the least (ICC range 0.35–0.72 and ICC 0.17–0.60). Elasticity ratio intra-operator reliability of the patella tendon was fair–excellent for the experienced operator (ICC range 0.43–0.91), excluding the mid patellar region (ICC 0.13). Poor–fair inter-operator reliability was observed for elasticity ratio (ICC range 0.0–0.54) and elasticity index (ICC range 0.0–0.57). Conclusions Strain elastography of the patellar tendon is more reliable than the quadriceps tendon. Intra- and inter-operator reliability was better when undertaken by more experienced operators. Colour scoring was more reliable than elasticity ratio and index methods. Poor–fair intra- and inter-operator reliability of the elasticity ratio and elasticity index was observed.

Objectives: To evaluate inter-machine variation and compare intra-and inter-operator agreement and repeatability characteristics of two ultrasound systems for strain elastography measurements of quadriceps and patellar tendons.Methods: Forty tendons from 20 healthy participants were investigated by operators with different experience (operator 1; 12 years' ultrasound and >50 strain elastography (SE) examinations, operator 2; no ultrasound experience, 1 day SE training). Repeated measures were performed employing GE and esaote ultrasound systems. Percentage agreement, Cohen's kappa, intra-class correlation coefficient, and correlation tests assessed agreement, repeatability and associations of SE measures. Paired T-Test and Wilcoxon signed rank assessed differences in SE measures.Results: The study partipants included 5 males, 15 female volunteers; mean (range) age 29.3 (21-39) years). Better agreement and repeatability characteristics were observed for the patellar compared to the quadriceps tendon, and colour score (CS) method over the elasticity ratio (ER). Intra-operator agreement was better for the experienced operator. Intra-operator repeatability was achieved in 55% of ER (ICC, 0.40-0.91, p<0.05) and 77-85% (k, -0.25-1) of CS measures. Inter-operator repeatability was achieved in 35% (t/z, -2.93-7.94, p, 0.000-0.048) of all ER measures. No significant difference in proximal (z, -0.13--0.78) and distal patellar (z, -1.52-2.26, p>0.5) ER measures were observed. 74-75% mean agreement (k, 0-0.5) for CS measures comparable across both ultrasound systems was observed. Intermachine ER associations were poor (r, -0.39-0.13, p>0.05), whereas greater than 70% agreement (k, -0.87-0.53) for CS was achieved.Conclusions: Reproducibility of knee tendon strain elastography measurements is influenced by operator experience, ultrasound system, and tendon site.

An advanced ultrasound imaging technique, sonoelastography (SE) is used to evaluate tissue elasticity. To determine SE potential to detect pathological-related changes, and characteristics related to tendon pathology we aimed to (1) compare quadriceps and patellar tendon findings in individuals with knee osteoarthritis (KOA) and asymptomatic older adults (AC), and (2) explore associations between SE, participant characteristics (age, BMI, and leg circumference) and KOA status. 84 participants (47; KOA and 37; asymptomatic older adults) underwent SE examination of quadriceps (distal) and patellar (distal, proximal) tendon in a supine position with the knee bent at 30°. Colour score (CS) and Elasticity Ratio (ER) analysis were performed by a blinded experienced operator using Esaote Mylab 70 XVG Ultrasound equipment. Significantly reduced elasticity in the distal quadriceps (median (IQR) 2(2), 3(1), p = 0.033 for KOA and AC, respectively) and proximal patellar (3(1), 3(0), p = 0.001) tendons and more elastic distal patellar (1.50 (0.55), 1.87 (0.72), p = 0.034) tendons were observed in the KOA group. Significant associations) were identified between SE and participant BMI (Rs = − 0.249–0.750, p < 0.05) and leg circumference (Rs = − 0.260–0.903, p < 0.05). Age, BMI and KOA status, were independent explanatory variables of SE CS findings at the distal quadriceps tendon patellar tendon, proximal patellar tendon and distal patellar tendon, explaining 66%, 81% and 64% of variance, respectively. Age, BMI and KOA status were independent explanatory variables of SE ER findings at the distal patellar tendon explaining 19% of variance. Potentially clinically relevant altered tendon stiffness were observed between individuals with KOA and asymptomatic controls. Key KOA risk factors and participant characteristics explained variance in tendon stiffness. Findings provide context for future studies to investigate the potential for targeted SE detected early clinical management based on associated participant characteristics.

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Although patient-reported outcome measures (PROMs) are recommended in clinical practice, their application in routine care is limited. The Rheumatoid Arthritis Foot Disease Activity Index (RADAI-F5) is a validated PROM for assessing foot disease in rheumatoid arthritis (RA). To explore patient and clinician opinions and perceptions of the clinical utility of the Rheumatoid Arthritis Foot Disease Activity Index (RADAI-F5), eight RA patients and eight clinicians routinely involved in the management of RA patients participated in one semi-structured remote video-based interview. They provided their perspectives on the barriers and facilitators to clinical implementation of the RADAI-F5. Three global themes were identified; 'Feet are a priority' as the impact of RA on the feet negatively impacted upon patient quality of life. The second theme was 'Need for a clinically feasible foot PROM' as participants recognised the current lack of a clinically feasible tool to determine RA foot disease. The third global theme of ‘Implementation’ was drawn together to form two subordinate themes: ‘Facilitators to RADAI-F5 implementation’ as the tool can promote communication, guide management, help screen foot symptoms, monitor foot disease status and treatments, and promote patient education and; ‘Barriers to RADAI-F5 implementation’ as there were associated practical difficulties, including lack of appointment time, administrative burdens, IT barriers and preference for further RADAI-F5 validation using imaging. The RADAI-F5 has significant potential as a clinical tool to aid foot disease management. However, implementation challenges must be overcome before broad adoption in rheumatology clinics.

Linking theory to practice is an area of concern for ultrasound students, clinical mentors and academic staff. The link between theory and practice requires a robust clinical mentorship scheme in addition to careful curricula design considerations to improve student outcomes. The introduction of interactive technology in education provides ripe opportunity to improve feedback to students to support the link between theory and practice. A series of three interactive learning and teaching activities were designed and delivered to a PostGraduate Ultrasound cohort, after which, evaluation was performed to answer the research question: Which interactive technologies support the link between theory and practice through improved feedback mechanisms? An action research methodology was adopted involving an enquiry based literature review, planning, design and action process. Data were collected following action of three interactive teaching and learning sessions within the Medical Ultrasound cohort of 2013/2014 at Glasgow Caledonian University via a paper based questionnaire. A 100% response rate was achieved (n ¼ 14). All three interactive learning and teaching sessions were considered with 100% highest point agreement to support the link between ultrasound theory and practice via feedback. Students found all three designed and facilitated sessions valuable and relevant to their learning, which in turn provided positive experiences which were perceived to support the link between theory and practice through feedback. These activities can be considered valuable in Postgraduate Ultrasound education.

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Objectives The Rheumatoid Arthritis Foot Disease Activity Index (RADAI-F5) is a valid, reliable, and clinically feasible patient-reported outcome measure (PROM) for the measurement of rheumatoid arthritis (RA) foot disease activity. Further validation of the RADAI-F5 against musculoskeletal ultrasonography (MSUS) for foot disease activity are necessary prior to clinical implementation. This study aimed to examine the construct validity of the RADAI-F5 in relation to MSUS and clinical examination. Method Participants with RA completed the RADAI-F5. MSUS was employed to evaluate disease activity (synovial hypertrophy/synovitis/tenosynovitis/bursitis) and joint damage (erosion) utilising grayscale (GS) and power Doppler (PD) at 16 regions in each foot, including joints and soft tissues. These same regions were examined clinically for swelling and tenderness. The construct validity of the RADAI-F5 was assessed using correlation coefficients and a priori-specified hypotheses for the strength of associations. Results Of 60 participants, 48 were female, with a mean [standard deviation, ± SD] age of 62.6 ± 9.96 and median disease duration of 15.49 (interquartile range 6–20.5) years. Theoretically consistent associations confirming construct validity [95% CI] were observed between the RADAI-F5 and MSUS GS (0.76 [0.57-0.82]; strong), MSUS PD (0.55 [0.35-0.71]; moderate), MSUS-detected erosions (0.41 [0.18-0.61]; moderate), clinical tenderness (0.52 [0.31-0.68]; moderate), and clinical swelling (0.36 [0.13-0.55]; weak). Conclusion Moderate-to-strong correlations between RADAI-F5 and MSUS demonstrate this instrument's good measurement properties. With greater confidence in the utility of the RADAI-F5, clinical use of this novel instrument as an adjunct to the DAS-28 could help identify RA patients at risk for poor functional and radiological outcomes. Lay summary What does this mean for patients? Rheumatoid arthritis (RA) is a condition that commonly affects the feet. It is important to have a reliable way to measure the activity of RA in the feet. One such measure is called the Rheumatoid Arthritis Foot Disease Activity Index (RADAI-F5), which is a five item questionnaire completed by patients. However, the RADAI-F5 still needs to be validated against other methods of assessing foot disease activity, such as musculoskeletal ultrasonography (MSUS) and clinical examination. In this study, 60 participants with RA were enrolled. Participants completed the RADAI-F5 questionnaire. Thereafter, MSUS was used to evaluate disease activity and joint damage in the participants' feet. Clinical examinations to assess swelling and tenderness were also conducted at this appointment. The results showed that there were strong-to-moderate consistent associations between the RADAI-F5 scores and MSUS grayscale images, MSUS Power Doppler and the presence of joint damage. The RADAI-F5 scores also correlated moderately with clinical tenderness and weakly with clinical swelling. These findings suggest that the RADAI-F5 is a reliable tool for measuring foot disease activity in RA patients. The tools implementation in clinical practice may help better identify RA patients who are at risk for poor outcomes and may require more targeted treatment.