Arc Sign Research Articles

Navigating a Rare Type IV Capitellar fracture: A Case Report and Comprehensive Literature Review.

Capitellar fractures are rare, it accounts 1% of elbow fractures, and can be challenging to diagnose initially. Distinctive "double arc sign" on lateral elbow radiograph is pathogonomic. 3D CT scans is . ORIF is the preferred treatment, but the choice of fixation methods lacks consensus, although headless compression screws are commonly used. This case report presents a Type IV capitellar fracture in a 14-year-old boy resulting from a fall. The patient underwent successful ORIF using 4.0mm cannulated screws inserted posterior to anterior without penetrating joint surface, leading to complete functional recovery. At the 6-month follow-up, the patient exhibited robust healing without signs of capitellar avascular necrosis (AVN).The case underscores the significance of clinical suspicion and meticulous radiographic evaluation to avoid overlooking capitellar fractures. Moreover, it showcases the effectiveness of cannulated screws as a viable alternative in the absence of headless compression screws, offering comparable stability and excellent functional outcomes.

The clinical diagnosis of Achilles tendinopathy: a scoping review.

BackgroundAchilles tendinopathy describes the clinical presentation of pain localised to the Achilles tendon and associated loss of function with tendon loading activities. However, clinicians display differing approaches to the diagnosis of Achilles tendinopathy due to inconsistency in the clinical terminology, an evolving understanding of the pathophysiology, and the lack of consensus on clinical tests which could be considered the gold standard for diagnosing Achilles tendinopathy. The primary aim of this scoping review is to provide a method for clinically diagnosing Achilles tendinopathy that aligns with the nine core health domains.MethodologyA scoping review was conducted to synthesise available evidence on the clinical diagnosis and clinical outcome measures of Achilles tendinopathy. Extracted data included author, year of publication, participant characteristics, methods for diagnosing Achilles tendinopathy and outcome measures.ResultsA total of 159 articles were included in this scoping review. The most commonly used subjective measure was self-reported location of pain, while additional measures included pain with tendon loading activity, duration of symptoms and tendon stiffness. The most commonly identified objective clinical test for Achilles tendinopathy was tendon palpation (including pain on palpation, localised tendon thickening or localised swelling). Further objective tests used to assess Achilles tendinopathy included tendon pain during loading activities (single-leg heel raises and hopping) and the Royal London Hospital Test and the Painful Arc Sign. The VISA-A questionnaire as the most commonly used outcome measure to monitor Achilles tendinopathy. However, psychological factors (PES, TKS and PCS) and overall quality of life (SF-12, SF-36 and EQ-5D-5L) were less frequently measured.ConclusionsThere is significant variation in the methodology and outcome measures used to diagnose Achilles tendinopathy. A method for diagnosing Achilles tendinopathy is proposed, that includes both results from the scoping review and recent recommendations for reporting results in tendinopathy.

Ultrastructural study of closed macular hole- preliminary application of a novel high magnification module combining with OCT

BackgroundAs a novel high magnification module (HMM) combining with OCT (OCT-HMM) is able to detect the microstructure of retina, we apply it to explore the ultrastructure of the macula after closure of the idiopathic macular hole (IMH) by surgery.MethodsThis is an observational case series study in which patients with full-thickness IMHs who had undergone successful macular closure by vitrectomy and internal limiting membrane peeling and healthy subjects were recruited. After comprehensive ophthalmic examinations, the images of macular area were obtained and collected by professional operators using OCT-HMM. Then images were independently analyzed by 4 masked vitreoretinal specialists.ResultsA total of 24 IMH eyes and 42 healthy eyes were examined. HMM images were obtained in 10 IMH eyes. Among them, 4 eyes whose macula closed completely with recovery of photoreceptor layer presented a dark arc nasal to the fovea, oriented to the optic, and the notch of arc faced temporally. Six eyes in which the macula closed incompletely with photoreceptor cells loss revealed a dark ring with uneven bright spots inside. The other 14 eyes failed to obtain clear images by OCT-HMM. The contra lateral eyes of the patients and the healthy subjects’ eyes succeeded to obtain the HMM images which displayed evenly grey background thickly covered with tiny bright dots that was in similar size and evenly and widely distributed and there no dark arc or ring. OCT B-scan and IR images could be acquired in all of the IMH and healthy eyes.ConclusionThe preliminary application of HMM has supplied us a brand-new insight into the microstructure of closed IMH. A dark arc sign could be detected with OCT-HMM in the macula which was functionally closed after surgery that was probably the healing mark on a microstructure photoreceptors level. Its existence and shape indicated that the functional closure followed by a retinal displacement mainly horizontally from temporal side to nasal side but not symmetric centripetally.

Comparison of two surgical methods in the treatment of rotator cuff tendinopathy

Objective To compare the effect of whether rotator cuff pathological tissue cleaning and tendon insertion reconstruction or not under shoulder arthroscopy on the surgical treatment of rotator cuff tendinopathy. Methods From September 2015 to January 2017, the clinical data of forty-one patients with rotator cuff tendinopathy treated by surgical medicine ward in Shengjing Hospital of China Medical University were retrospectively analyzed.According to different surgical methods, 41 patients were divided into A group and B group.In group A, 21 patients were treated with shoulder arthroscopic bursa debridement combined with selective acromioplasty.In group B, 20 patients were treated with cleanup of pathological changes tissue and reconstruction of tendon insertion on the basis of A. All patients were followed up for one year.Constant-Murley shoulder function score, visual analog scale (VAS), University of California Los Angeles (UCLA) and Hawkins sign, arc of pain sign and infraspinatus muscle test were used as the evaluation indexes.The shoulder joint function was evaluated so as to compare the efficacy of two surgical methods for rotator cuff disease. Results Compared with the preoperative, the postoperative VAS score, UCLA score and Constant-Murley score in both groups were significantly improved.In group A, the preoperative in group A (5.0±1.3)points, (15.5±1.4) points, (65.1±5.7) points) were increased to (0.7±0.4) points, (33.0±1.7) points, (90.9±3.1) points.The preoperative scores of group B were (5.2±1.0)points, (15.6±2.0) points, (65.4±5.9) points, and increased to (0.4±0.5) points, (34.3±0.9) points, (93.3±2.3) points respectively, and the differences were statistically significant (group A: t=14.77, P<0.001; t=- 74.44, P<0.001; t=- 29.19, P<0.001; group B: t=23.13, P<0.001; t=- 61.52, P<0.001; t=- 26.38, P<0.001). The UCLA score and Constant-Murley score of shoulder joint in group B were higher than those in group A (t=-3.27, P=0.003; t=-2.90, P=0.007). Postoperative positive rates of Hawkins sign, pain arc sign and infraspinatus muscle test in group A decreased from 90% (18/20), 90% (18/20), 95% (19/20) to 15% (3/20), 10% (2/20) and 15% (3/20) respectively.There was a significant difference between preoperative and postoperative (χ2=13.067, P<0.001). χ2=14.063, P<0.001; χ2=14.063, P<0.001), group B decreased from 90.5% (19/21), 85.6% (18/21), 90.5% (19/21) to 9.5% (2/21), 4.8%(1/21), 9.5% (2/21). There were significant differences between preoperative and postoperative (χ2=15.059, P<0.001; χ2=12.500, P<0.001; χ2=15.059, P<0.001). Conclusion Both group A and group B are effective in the treatment of rotator cuff tendon disease, and group B is more effective than group A in the treatment of rotator cuff tendon disease. Key words: Shoulder joint; Rotator cuff tendinopathy; Arthroscope; Clinical efficacy

Value of the ultrasonography in guiding closed reduction and intramedullary nail fixation for femoral shaft fractures

Objective To study the ultrasonic image characteristics of the displaced femoral shaft fracture before and post reduction, and to explore its clinical significance in guiding the closed reduction and intramedullary nail fixation. Methods Ultrasonic imaging features of 21 cases of femoral shaft fractures were observed.Closed reduction was completed under ultrasound monitoring, and the characteristics of ultrasonic imaging after fracture reduction were observed. Fixation of femoral fractures with intramedullary nails after closed reduction was completed. Results On the long axis of the femoral shaft, the ultrasonograms displayed a gap between two hyperechoic bands(step sign). On the cross section, two short arc hyperechoic bands can be seen(double short arc sign). After the completion of closed reduction, the step sign and double short arc sign disappeared. In the front and rear of the femoral shaft, there were 2 echo lines connected to a straight line. The line in front of the femoral parallel to the rear(continuous parallel sign). Continuous parallel sign indicated that reduction was achieved, the intramedullary nail guide pin could be successfully inserted into the femoral shaft, to complete the intramedullary nail fixation. Conclusions Ultrasound imaging shows step sign and double short arc syndrome when femoral shaft fracture displaced. Post fracture reduction, the imaging shows continuous parallel sign. Observing ultrasonic image characteristics of the displaced femoral shaft fracture is effective in assisting closed reduction and intramedullary nailing for femoral shaft fractures. Key words: Ultrasonography; Femoral fractures; Reduction; Fracture fixation, internal

Outcome of surgical treatment of type IV capitellum fractures in adults

ObjectiveFractures of the capitellum and trochlea constitute less than 1% of all elbow fractures and a shear fracture involving the capitellum and extending medially into most of the trochlea is rarely reported. Type IV capitellum fracture is still controversial in regard to its radiographic appearance, surgical approach and osteosynthesis. We report 10 cases of type IV capitellum fracture with a view to elucidating its clinical features and treatment outcome. MethodsWe treated 10 patients of type IV capitellum fracture with a mean age of 32 years. A uniform surgical approach and postoperative rehabilitation were followed. ResultsNine patients presented to us after a mean of 4 days of injury and one patient was nonunion after 6 months of injury who had been treated conservatively by a bone setter. Double arc sign was absent in 6 cases. Intraopera-tively 6 capitellotrochlear fragments were devoid of soft tissue attachments. By Mayo Elbow Performance Score evaluation, 7 patients got excellent,2 good and 1 fair results. One patient with associated elbow dislocation developed heterotopic ossification. There was no case of avascular necrosis, osteoarthrosis or fixation failures. ConclusionsType IV capitellum fractures are rare and belong to complex articular injuries. A good functional outcome can only be achieved with open reduction and stable internal fixation followed by early mobilization. Preoperative radiographic assessment and computed tomography help surgeons in choosing the right surgical approach and implants. Good surgical technique and stable internal fixation are the keys to early mobilization and good functional outcome.

Characteristic features and progression of abnormalities on MRI for CARASIL.

The objective of this study was to clarify the characteristic brain MRI findings for genetically diagnosed CARASIL (cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy). Seven patients with CARASIL carrying HTRA1 mutations (representing 6 Japanese families) were included in this study. Eighteen brain MRIs were reviewed and evaluated with a new rating scale based on scoring for abnormal hyperintense lesions and atrophy. At the last follow-up MRI, all patients had hyperintense lesions on T2-weighted images of the frontal white matter, anterior temporal lobe, external capsules, and thalami. Patients with longer time from the onset of cognitive impairment had higher MRI severity score. The atrophy advanced, followed by white matter lesion progression. During the early stage, hyperintense lesions were observed in the frontal white matter, external capsule, and pons. During the late stage, the arc-shaped hyperintense lesion from the pons to the middle cerebellar peduncles, which we designated the "arc sign," became evident. The arc sign was a characteristic finding for CARASIL in the advanced stage. These characteristic MRI findings for CARASIL are useful for selecting patients for genetic testing. The rating scale correlates well with disease duration and might be useful for assessing disease progression.

The utility of clinical measures for the diagnosis of achilles tendon injuries: a systematic review with meta-analysis.

To summarize and evaluate the current diagnostic accuracy of clinical measures used to diagnose Achilles tendon injuries. A literature search of MEDLINE, CINAHL, and EMBASE databases was conducted with key words related to diagnostic accuracy and Achilles tendon injuries. Original research articles investigating Achilles tendon injuries against an acceptable reference standard were included. Three studies met the inclusion criteria. Quality assessment was conducted using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. DerSimonian-Laird random-effects models were used to pool sensitivity (SN), specificity (SP), and diagnostic odds ratios with their 95% confidence intervals (CIs). The SN and negative likelihood ratio (-LR) values for Achilles tendon rupture measures ranged from 0.73 (95% CI = 0.65, 0.81) and 0.30 (95% CI = 0.23, 0.40) to 0.96 (95% CI = 0.93, 0.99) and 0.04 (95% CI = 0.02, 0.10), respectively, whereas SP and positive likelihood ratio (+LR) values ranged from 0.85 (95% CI = 0.72, 0.98) and 6.29 (95% CI = 2.33, 19.96) to 0.93 (95% CI = 0.84, 1.00) and 13.71 (95% CI = 3.54, 51.24), respectively, with the highest SN and SP both reported in the calf-squeeze test. The SN and -LR values for Achilles tendinopathy measures ranged from 0.03 (95% CI = 0.00, 0.08) and 0.97 (95% CI = not reported) to 0.89 (95% CI = 0.75, 0.98) and 0.19 (95% CI = not reported), whereas SP and +LR values ranged from 0.58 (95% CI = 0.38, 0.77) and 2.12 (95% CI = not reported) to 1.00 (95% CI = 1.00, 1.00) and infinity, respectively, with the highest SN and SP reported for morning stiffness and palpation for crepitus. Pooled analyses demonstrated similar diagnostic properties in all 3 clinical measures (arc sign, palpation, and Royal London Hospital test), with SN and -LR ranging from 0.42 (95% CI = 0.23, 0.62) and 0.68 (95% CI = 0.50, 0.93), respectively, for the arc sign, to 0.64 (95% CI = 0.44, 0.81) and 0.48 (95% CI = 0.29, 0.80), respectively, for palpation. Pooled SP and +LR ranged from 0.81 (95% CI = 0.65, 0.91) and 3.15 (95% CI = 1.61, 6.18), respectively, for palpation, to 0.88 (95% CI = 0.74, 0.96) SP for the arc sign and 3.84 (95% CI = 1.69, 8.73) +LR for the Royal London Hospital test. Most clinical measures for Achilles tendon injury have greater diagnostic than screening capability.

Characteristics of Shoulder Impingement in the Recreational Weight-Training Population

Despite reports implicating subacromial impingement syndrome (SIS) as an etiologic source of shoulder pain among weight-training (WT) participants, a paucity of case-controlled evidence exists to support this premise. The purpose of this study was to determine whether WT participants present with characteristics of SIS. Additionally, we investigated the role of exercise selection among those identified as having SIS. Seventy-seven (154 shoulders) men (mean age, 28) were recruited, including 46 individuals who engaged in WT a minimum of 2 days per week; and 31 controls with no history of WT participation. Before testing, participants completed a questionnaire summarizing their training patterns. On completing questionnaire, 2 previously validated tests used to identify SIS were performed on both groups and included the painful arc sign and Hawkins-Kennedy test. When clustered, these tests have a positive likelihood ratio of 5.0 for identifying SIS when compared with diagnostic gold standards. Analysis identified significant between-group differences in the combined presence of a positive painful arc and Hawkins-Kennedy (p < 0.001) test. A significant association existed between clinical characteristics of SIS (p ≤ 0.004) and both lateral deltoid raises and upright rows above 90°. Conversely, a significant inverse association was found between external rotator strengthening and characteristics of SIS. Results suggest that WT participants may be predisposed to SIS. Avoiding performance of lateral deltoid raises and upright rows beyond an angle of 90° and efforts to strengthen the external rotators may serve as a useful means to mitigate characteristics associated with SIS.

肩関節屈曲動作時にpainful arc signを認める棘上筋不全断裂の一症例

肩関節屈曲動作時にpainful arc signを認める棘上筋不全断裂の一症例

Type 4 capitellum fractures: Diagnosis and treatment strategies

Background:Fractures of the capitellum are rare injuries of the elbow usually seen in the adolescents. This fracture is often missed in the emergency room if a proper radiograph is not available. Recent reports have described many modalities of treatment favoring headless screw for fixation. The facility for headless screw fixation, however, is not available in most centers. This paper presents the diagnosis and management of type 4 capituller fractures (Mckee) with gadgets available in a district hospital.Materials and Methods:Between 2004 and 2007 three patients with right sided type IV capetullar fracture were treated in a district hospital. There were two boys aged 15 and 17 and one 33 years old lady. In one case, the fracture was missed in the emergency room. A double arc sign in the lateral views of the X-rays of the elbow was seen in all the cases. In each case a preoperative CT scan was done and a diagnosis of Mckee type IV fracture of the capitellum was made. Under tourniquet, using extended lateral approach, open reduction and internal fixation was done using 4mm partially threaded AO cancellous screws (n=2) and 2.7 mm AO screws (n=1), under vision from posterior to anterior direction from the posterior aspect of lateral condyle of humerus avoiding articular penetration.Results:All the fractures united uneventfully. At the end of one year follow-up, two cases had excellent elbow function; implants were removed and there were no signs of AVN or arthritis. The third case had good elbow ROM at 11 months without AVN.Conclusion:Double arc sign on lateral X-rays of the elbow along with pre-operative CT scan evaluation is important to avoid a missed diagnosis and analysis of type IV capitellur fracture. Fixation with non-cannulated ordinary AO screws using extended Kocher's lateral approach has given good results.

Biomechanic results in impingement syndrome of the shoulder

Forces underneath the coraco-acromial vault during elevation of the arm were evaluated with a dynamic shoulder model. The deltoid muscle and the rotator cuff muscles were simulated with a hydrodynamic device, in ten autopsy specimens. Controlled cycles of glenohumeral joint motion were initiated with computerised regulation. An ultrasonic device measured the position of the arm in all spatial orientations. Capacitive sensors recorded forces underneath the coraco-acromial vault. The mean force during one cycle of elevation averaged 13.9 Newton +/- 12.5 Newton underneath the coraco-acromial ligament and 3.44 Newton +/- 4.37 Newton underneath the coracoid process. The peak force averaged 37.8 Newton +/- 33.2 Newton underneath the acromion, 3.03 Newton +/- 2.62 Newton underneath the coraco-acromial ligament and 6.93 Newton +/- 7.38 Newton underneath the coracoid process. The force markedly increased at the final stage of arm elevation and during early reverse-elevation in most specimens, corresponding to the painful arc sign. In some specimens, the force under the coracoid process exceeded the force under the acromion. Osteophytes protruding into the subacromial space may lead to a concentration of force and to high regional pressures.

Diagnostic Accuracy of Clinical Tests for the Different Degrees of Subacromial Impingement Syndrome

The authors evaluated the utility of eight clinical tests commonly used in the diagnosis of rotator cuff disease (RCD). Specifically, they calculated diagnostic values (sensitivity, specificity, predictive values, likelihood ratios, and posttest probabilities) for the Neer impingement sign, Hawkins-Kennedy impingement sign, painful arc sign, supraspinatus muscle strength test, Speed's test, cross-body adduction test, drop-arm sign, and infraspinatus muscle strength test across 3 degrees of severity of RCD: bursitis without a rotator cuff tear, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears.

DIAGNOSTIC ACCURACY OF CLINICAL TESTS FOR THE DIFFERENT DEGREES OF SUBACROMIAL IMPINGEMENT SYNDROME

Background: Several tests for making the diagnosis of rotator cuff disease have been described, but their utility for diagnosing bursitis alone, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears has not been studied. The hypothesis of this study was that the degree of severity of rotator cuff disease affects the diagnostic values of the commonly used clinical tests. Methods: Eight physical examination tests (the Neer impingement sign, Hawkins-Kennedy impingement sign, painful arc sign, supraspinatus muscle strength test, Speed test, cross-body adduction test, drop-arm sign, and infraspinatus muscle strength test) were evaluated to determine their diagnostic values, including likelihood ratios and post-test probabilities, for three degrees of severity in rotator cuff disease: bursitis, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears. A forward stepwise logistic regression analysis was used to determine the best combination of clinical tests for predicting the various grades of impingement syndrome. Results: The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the eight tests varied considerably. The combination of the Hawkins-Kennedy impingement sign, the painful arc sign, and the infraspinatus muscle test yielded the best post-test probability (95%) for any degree of impingement syndrome. The combination of the painful arc sign, drop-arm sign, and infraspinatus muscle test produced the best post-test probability (91%) for full-thickness rotator cuff tears. Conclusions: The severity of the impingement syndrome affects the diagnostic values of the commonly used clinical tests. The variable accuracy of these tests should be taken into consideration when evaluating patients with symptoms of rotator cuff disease. Level of Evidence: Diagnostic Level I. See Instructions to Authors for a complete description of levels of evidence.

Diagnostic Accuracy of Clinical Tests for the Different Degrees of Subacromial Impingement Syndrome

Several tests for making the diagnosis of rotator cuff disease have been described, but their utility for diagnosing bursitis alone, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears has not been studied. The hypothesis of this study was that the degree of severity of rotator cuff disease affects the diagnostic values of the commonly used clinical tests. Eight physical examination tests (the Neer impingement sign, Hawkins-Kennedy impingement sign, painful arc sign, supraspinatus muscle strength test, Speed test, cross-body adduction test, drop-arm sign, and infraspinatus muscle strength test) were evaluated to determine their diagnostic values, including likelihood ratios and post-test probabilities, for three degrees of severity in rotator cuff disease: bursitis, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears. A forward stepwise logistic regression analysis was used to determine the best combination of clinical tests for predicting the various grades of impingement syndrome. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the eight tests varied considerably. The combination of the Hawkins-Kennedy impingement sign, the painful arc sign, and the infraspinatus muscle test yielded the best post-test probability (95%) for any degree of impingement syndrome. The combination of the painful arc sign, drop-arm sign, and infraspinatus muscle test produced the best post-test probability (91%) for full-thickness rotator cuff tears. The severity of the impingement syndrome affects the diagnostic values of the commonly used clinical tests. The variable accuracy of these tests should be taken into consideration when evaluating patients with symptoms of rotator cuff disease.

Anatomical variants in the anterosuperior aspect of the glenoid labrum: a statistical analysis of seventy-three cases.

Anterosuperior labral variations of the glenohumeral joint have been previously described and are thought to represent normal anatomical variants without any known clinical importance. The goals of this study were to characterize anterosuperior labral anatomical variations and to determine their prevalence and clinical importance. A total of 546 patients who had an arthroscopic procedure in the shoulder were prospectively evaluated for variations of the anterosuperior aspect of the labrum. Structural characteristics of the anatomical variants were noted and recorded intraoperatively. The relationships of these anterosuperior labral variations to demographic data, preoperative symptoms, findings on physical examination, and associated intra-articular abnormalities were analyzed statistically and compared with findings in patients with normal anterosuperior labral anatomy. Three distinct variations of the anterosuperior portion of the labrum were found in seventy-three patients (13.4%): a sublabral foramen only (eighteen patients; 3.3%), a sublabral foramen with a cord-like middle glenohumeral ligament (forty-seven; 8.6%), and an absence of labral tissue at the anterosuperior portion of the labrum with a cord-like middle glenohumeral ligament (eight; 1.5%). In multivariate analysis, the presence of one of these three variations revealed a significant positive association with anterosuperior labral fraying (p = 0.000), an abnormal superior glenohumeral ligament (p = 0.012), and increased passive internal rotation with the arm in 90 degrees of abduction (p = 0.046). These lesions were negatively associated with a painful arc sign and the presence of either a partial or full-thickness supraspinatus tendon tear. Statistical analysis revealed a clinical difference between the cord-like middle glenohumeral ligament variants and the sublabral foramen variant. Anterosuperior labral variants may influence glenohumeral biomechanics and may predispose the shoulder to other abnormalities. These variants are associated with increased internal rotation, which may predispose the shoulder to lesions of the superior glenohumeral ligament and anterosuperior portion of the labrum. These variations themselves do not appear to contribute to instability.

Clinical diagnosis of Achilles tendinopathy with tendinosis.

To evaluate sensitivity, specificity, reproducibility, and predictive value of palpation of the painful arc sign and of the Royal London Hospital test in 10 patients with Achilles tendinopathy and in 14 asymptomatic subjects. Test-retest study. University teaching hospital. Ten male athletes on the waiting list for exploration of one of their Achilles tendons for tendinopathy of the main body of the tendon attended a special clinic. Each was invited to bring at least one athlete of the same sex in the same discipline aged within 2 years of themselves with no history and no symptoms of Achilles tendinopathy. A total of 14 controls were thus recruited. Pain and tenderness following performance of palpation, the painful arc sign, and the Royal London Hospital test. There were no statistically significant differences at the 5% level among the effects of investigator or between morning and afternoon measurements for any of the three measurement methods. There was no evidence of a difference of the three assessment methods (p > 0.05). When the three methods were combined, the overall sensitivity was 0.586 (confidence interval [CI], 0.469-0.741), and the overall specificity was 0.833 (CI, 0.758-0.889). In patients with tendinopathy of the Achilles tendon with a tender area of intratendinous swelling that moves with the tendon and whose tenderness significantly decreases or disappears when the tendon is put under tension, a clinical diagnosis of tendinopathy can be formulated, with a high positive predictive chance that the tendon will show ultrasonographic and histologic features of tendinopathy.