## 4 Discussion
\begin{table}
\begin{tabular}{l c c c c c c c} \hline \hline  & \multicolumn{6}{c}{**Risk of Bias**} & \multicolumn{6}{c}{**Applicability Concerns**} \\ \cline{2-9}
**Study** & **Patient** & **Reference** & **Flow and** & **Patient** & **Reference** \\  & **Selection** & **Index Test** & **Standard** & **Timing** & **Selection** & **Index Test** & **Standard** \\ \hline [PERSON] et al. (2021), [17] & \(\oplus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ [PERSON], [PERSON], and [PERSON] (2021) [18] & \(\oplus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ [PERSON] et al. (2020) [19] & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ [PERSON] et al. (2019) [20] & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ [PERSON] et al. (2018) [21] & \(\oplus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ [PERSON], [PERSON], and [PERSON] (2018) [21] & \(\oplus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ [PERSON] et al. (2015) [23] & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ [PERSON] et al. (2015) [24] & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ [PERSON] et al. (2014) [25] & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ [PERSON] et al. (2011) [26] & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ [PERSON] et al. & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ [PERSON], [PERSON], and [PERSON] (2004) [28] & \(\oplus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ [PERSON] et al. (2003) [29] & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ [PERSON] et al. (1997) [30] & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ [PERSON] and [PERSON] (1996) [31] & \(\oplus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) & \(\ominus\) \\ \hline \hline \end{tabular}
\end{table} 
Table 2: Risk of bias assessment of included studies. QUADAS-2 results. There is a conflict between opinions on which imaging modality, i.e., US or MRI, should be used for PTTD diagnoses. MRI has been deemed to be more accurate in some cases; therefore, it is considered to be the gold standard. However, considering the fact that the conservative management of tendinosis and partial tear is similar, the importance of a truly accurate diagnosis of tendinosis and partial tear is low [27]. Furthermore, considering the other benefits of US, such as cost and real-time assessment, US has the potential to replace MRI as the gold standard for PTTD assessment [23]. Although radiography is an accurate way of defining deformity, it is not accurate in defining PTTD; it is unable to look at the structures linked to a flat foot deformity, such as the PTT, deltoid, or the spring ligament [24]. The accuracy of any assessment requires that the execution and interpretation are precise. Some studies have highlighted the use of paratenon fluid in the positive diagnosis of PTTD [34]. However, this has been found in asymptomatic patients; therefore, it could be identified as a normal finding [35]. The location of assessment has also been put into question, as some studies look only at the area below the medial malleolus and not above it. The area above the tendon been shown to be affected; moreover, this is normally the case in more severe presentations of PTTD [18]. Only one included study defines a subjective style assessment, with the patients being asked to provide details about their symptoms and/or medical history [28].