Victorian Institute Of Sport Assessment-Achilles Research Articles

Is the VISA-A Still Seaworthy, or Is It in Need of Maintenance?

Background:The Victorian Institute of Sport Assessment–Achilles (VISA-A) questionnaire is validated and widely used in Achilles tendinopathy. How well it can evaluate treatment outcomes is not well understood.Purpose:To evaluate the responsiveness of the VISA-A in midportion Achilles tendinopathy and compare it with other patient-reported outcome measures.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:Enrolled were 97 participants with clinically diagnosed Achilles tendinopathy (median age, 50 years [interquartile range, 18 years]; symptom duration, 10 months [interquartile range, 28.7 months). The participants underwent a baseline evaluation and completed between 1 and 6 follow-up evaluations at 8, 16, 24, 32, 40, and/or 48 weeks. Participants completed the VISA-A, the Patient Reported Outcomes Measurement Information System short form Version 2.0 (PROMIS) Physical Function and Pain Interference subscales, and the Tampa Scale for Kinesiophobia (TSK). Three thresholds were evaluated with a receiver operating characteristic analysis (minimal clinically important difference [MCID], substantial benefit [SB], and complete recovery [CR]) using an 11-point global rating of change scale as an anchor. Thresholds were evaluated on raw scores as well as changes from baseline.Results:The VISA-A was able to detect all 3 thresholds for changes over time, with raw scores >70.5, >77.5, and >89.5 representing the MCID, SB, and CR, respectively; thresholds for changes from baseline on the VISA-A were increases of 23.5, 19.5, and 37.5 points from baseline, respectively. The PROMIS subscale raw scores had identical thresholds for SB and CR (52.45 for Physical Function and 45.6 for Pain Interference). A score <34.5 on the TSK was the threshold for SB.Conclusion:The VISA-A was the most responsive outcome measure evaluated. Raw scores had increasingly higher thresholds for the MCID, SB, and CR, which were therefore logically consistent.

Effect of Ultrasonography-Guided Corticosteroid Injection vs Placebo Added to Exercise Therapy for Achilles Tendinopathy

Corticosteroid injections and exercise therapy are commonly used to treat chronic midportion Achilles tendinopathy, but the evidence for this combination is limited. To investigate the effect of corticosteroid injection and exercise therapy compared with placebo injection and exercise therapy for patients with Achilles tendinopathy. This was a participant-blinded, physician-blinded, and assessor-blinded randomized clinical trial of patients with Achilles tendinopathy verified by ultrasonography. Assessment of pain and function were conducted at baseline and at 1, 2, 3, 6, 12, and 24 months. Patients were recruited from a university medical clinic and a private rheumatology clinic in Denmark between April 2016 and September 2018. Data analysis was performed from June to September 2021. Corticosteroid injection and placebo injection were performed with ultrasonography guidance. Exercise therapy was based on previous trials and consisted of 3 exercises done every second day. The primary outcome was the Victorian Institute of Sports Assessment-Achilles (VISA-A) score (range, 1-100, with 100 representing no symptoms) at 6 months. Secondary outcomes included pain measured using a 100-mm Visual Analog Scale for morning pain and pain during exercise (with higher scores indicating worse pain), global assessment (Likert scale), and tendon thickness. A total of 100 patients were included, with 52 randomized to placebo (mean age, 46 years [95% CI, 44-48 years]; 32 men [62%]) and 48 randomized to corticosteroid injection (mean age, 47 years [95% CI, 45-49 years]; 28 men [58%]). Patients in the 2 groups had similar height (mean [SD], 177 [8] cm), weight (mean [SD], 79 [12] kg), and VISA-A score (mean [SD], 46 [18]) at baseline. The group receiving exercise therapy combined with corticosteroid injections had a 17.7-point (95% CI, 8.4-27.0 points; P < .001) larger improvement in VISA-A score compared with patients receiving exercise therapy combined with placebo injections at 6 months. No severe adverse events were observed in either group, and there was no deterioration in the long term (2-year follow-up). Corticosteroid injections combined with exercise therapy were associated with better outcomes in the treatment of Achilles tendinopathy compared with placebo injections and exercise therapy. A combination of exercise therapy and corticosteroid injection should be considered in the management of long-standing Achilles tendinopathy. ClinicalTrials.gov Identifier: NCT02580630.

Differences at the Achilles Insertion Between Adults with Insertional and Midportion Achilles Tendinopathy as Observed Using Ultrasound.

The purpose of this study was to determine structural and pathological differences of Achilles tendon insertion between insertional Achilles tendinopathy (IAT) and midportion Achilles tendinopathy (MidAT) in both injured and uninjured sides. Patients (n=34; 58.8% male) with unilateral Achilles tendinopathy (50% with IAT; 50% with MidAT) were recruited. Median age 52 years and Victorian Institute of Sport Assessment - Achilles (VISA-A) score mean 59, and 17 (12 male) had MidAT, median(range) age of 58(48)years, and VISA-A score mean(SD) 59.1(19.7). Ultrasound imaging was used to evaluate structural measurements at the insertion (insertional length, bone-to-insertion length, and tendon insertion angle), tendon length (calcaneus to soleus), tendon thickness at the calcaneal edge, and the presence of pathological changes (boney deformity and/or calcification). A 2×2 mixed Analysis of Variance (group by side) was used to compare IAT and MidAT groups and injured and uninjured sides. Tendon thickness at the calcaneus on the injured side was significantly greater than the uninjured side in the IAT group but not in the MidAT group (P=.001). VISA-A score was 59.9(18.7) in IAT group and 59.1(19.7) for MidAT group (P=.909). There were no significant group-by-side interactions for structural measurements at insertion site. Calcaneal edge tendon thickness was the only significant structural difference observed between involved and uninvolved sides in IAT, although this was not found in in MidAT.

Health-related quality of life in patients with Achilles tendinopathy: Comparison to the general population of the United Kingdom

BackgroundThere is little evidence available regarding the impact of Achilles Tendinopathy (AT) on health-related quality of life (HRQOL). The primary aim of this study was to quantify the clinical and health-related quality-of-life patient-reported outcome measures for a population presenting with either mid-substance or insertional Achilles tendinopathy. MethodsA prospective comparative observational study of consecutive patients with AT presenting for extracorporeal shockwave therapy (ESWT) at a large teaching hospital. The primary outcome was assessment of a validated health-related quality of life PROMs (Euroqol EQ-5D-5L) and comparison to 2 general UK population datasets. The secondary outcomes were Visual Analogue Pain Scale (VAS-Pain) and two validated foot-specific patient reported outcome measures (Foot Function Index (FFI) and Victorian Institute of Sports Assessment-Achilles (VISA-A)). ResultsBetween March 2014 and June 2021, 320 consecutive patients (125 male; 195 female) were diagnosed with AT and referred for a first course of ESWT. EQ-5D-5L PROMs were prospectively collected for 303 of these patients (94.7%). The mean age (± standard deviation(SD)) was 52.1 ± 11.4 years. The mean EQ-5D-5L Index score (mean±SD) for the AT cohort was 0.783 ± 0.131. Patients less than 55 years with AT had a statistically significantly worse quality of life compared with members of the same age group in the general population. The mean VAS-Pain, FFI, VISA-A clinical outcome scores were 6.0 ± 2.3, 49.5 ± 21.2 and 34.1 ± 14.4 respectively. There was a statistically significant moderate correlation between HRQOL and clinical PROMs (VAS-Pain and FFI vs EQ-5D) however there was no correlation with age. ConclusionThis study demonstrates that patients under the age of 55 with AT have a significantly reduced quality of life compared with the general population. Level of evidenceIII

Cross-Cultural Adaptation of Chinese Victorian Institute of Sports Assessment-Achilles (VISA-A) Questionnaire for Achilles Tendinopathy.

Background:Victorian Institute of Sports Assessment (VISA-A) is a patient-reported outcome for assessing symptoms severity associated with Achilles tendinopathy (AT). It is a valid and reliable tool that has been used widely for measuring and monitoring treatment outcomes for AT. This clinical measurement study aims to develop a Chinese version of the VISA-A questionnaire. The study objective is to adapt the VISA-A questionnaire cross-culturally and assess its psychometric property for Chinese-speaking individuals.Methods:VISA-A was translated and adapted cross-culturally according to international guidelines for self-reported questionnaires. During the establishment of Chinese VISA-A, there are 5 stages involved in the creation process, including translation, synthesis, reverse translation, review, and pretesting, which are performed by professionals in various fields, including orthopaedic surgeons, physiotherapists, and professional translators.Results:A total of 60 participants were recruited to complete the Chinese VISA-A and 36-Item Short Form Health Survey (SF-36) questionnaires. The overall test-retest reliability was 0.98 (intraclass correlation coefficient = 0.97-0.99). The correlation between Chinese VISA-A and physical function subscale (r = 0.70) was strong and statistically significant. There were moderate correlations between Chinese VISA-A, limitations to role of physical function subscale (r = 0.30), and bodily pain subscale (r = 0.42), which were also statistically significant. There were statistically significant differences in Chinese VISA-A scores between healthy control and pathologic group (P < .001), at-risk group, and pathologic group (P < .001) respectively.Conclusion:Chinese VISA-A demonstrated good reliability and validity for measuring symptom severity in patients with AT. Chinese VISA-A can be recommended as a self-reported measure for monitoring symptoms severity and treatment progress of patients with Achilles tendinopathy.Level of Evidence: Level II, cohort study.

Do High-Volume Injections Affect the Ultrasonographic Neovascularization in Chronic Achilles Tendinopathy? A Randomized Placebo-Controlled Clinical Trial.

High-volume injections (HVIs) are thought to target neovascularization in chronic midportion Achilles tendinopathy (AT), yet the mechanism has not been clarified. Therefore, we aim to evaluate whether a HVI decreases ultrasonographic Doppler flow in patients with chronic midportion AT. A double-blind, randomized, placebo-controlled clinical trial. Sports medicine department at a district general hospital. Sixty-two patients with clinically diagnosed chronic midportion AT were included and randomized into the intervention group (HVI-group, n = 30) and placebo group (n = 32). A daily calf-muscle exercise program combined with either (1) a HVI (HVI-group: 50 mL) or (2) a placebo-injection (placebo-group: 2 mL) with a mixture of saline and lidocaine. Primary outcome was the surface area quantification (SAQ) score (%) of the Doppler flow during a 24-week follow-up period. Secondary outcome was the association between SAQ scores and symptoms [Victorian Institute of Sports Assessment-Achilles (VISA-A)]. Outcomes were measured before, directly after, and 1 hour after the injection and at 2, 6, 12, and 24 weeks of follow-up. There was no significant between-group difference at 24 weeks [-0.1%; 95% confidence interval (CI), -4.9 to 4.7] or at any of the other time points. Change in SAQ score did not correlate with the change in VISA-A score (P = 0.93). A HVI does not affect Doppler flow in patients with chronic midportion AT. Also, changes in Doppler flow were not associated with the clinical outcome. These findings challenge the theoretical basis of a HVI. NCT02996409.

Tendoscopic peritendon shaving of midportion Achilles tendinopathy: A randomized, placebo-controlled study.

Achilles tendinopathy is among the most frequent tendon injuries in sport. Despite evidence-based management, a significant proportion of patients continue to experience symptoms. This is the first randomized trial to investigate the effect of tendoscopic treatment of midportion Achilles tendinopathy compared with placebo at baseline, 3, 6 and 12months. Patients with midportion Achilles tendinopathy (non-responsive to more than 6months of nonsurgical treatments) were randomly assigned to receive either tendoscopic peritendon shaving or placebo tendoscopic treatment. The primary outcome measure was the total score of the Victorian Institute of Sport Assessment Achilles (VISA-A) questionnaire. Due to three adverse events (sural nerve injuries), in the group receiving tendoscopic treatment, the trial was stopped short of the planned 48 participants. All 23 patients included completed 3months' follow-up (100%), 22 (96%) 6months' and 19 (83%) completed 12months' follow-up. The between-group estimates favored endoscopic treatment and ranged from 19 points (95% confidence interval [CI]: 1-38) at 3months, 14 points (-7 to 34) at 6months and 5 points (95% CI: -19 to 28) at 12months. After 12months, the tendoscopic group improved 47 points (95% CI: 29-65) versus 40 points (95% CI: 22-57) in the placebo-operated group. Despite a smaller sample size due to adverse events, VISA-A indicate faster recovery from tendoscopic treatment compared to placebo. These data suggest that tendoscopic treatment of midportion Achilles tendinopathy should be tested in further research; however, the technique needs to be refined to avoid sural nerve injuries.

Victorian Institute of Sport Assessment-Achilles (VISA-A) Questionnaire-Minimal Clinically Important Difference for Active People With Midportion Achilles Tendinopathy: A Prospective Cohort Study.

To determine the minimal clinically important difference (MCID) for the Victorian Institute of Sport Assessment-Achilles (VISA-A) score in patients with midportion Achilles tendinopathy (AT). Prospective cohort study. We included physically active patients with midportion AT who received exercises and an injection. We measured the VISA-A score (ranging from 0 to 100 points, where 100 points represents a healthy tendon) at baseline and at 12 weeks and 24 weeks after treatment, and the 7-point Global Assessment Scale (ranging from "worse than ever" to "completely recovered") at 12 weeks and 24 weeks after treatment. We dichotomized the Global Assessment Scale to not improved ("worse than ever" to "unchanged") or improved ("moderately improved" to "completely recovered"). The area under the curve and the Youden's index value closest to 1 were determined for both MCIDs (12 and 24 weeks), with corresponding sensitivity and specificity. Sixty-four patients were included, and 61 patients (95%) completed the 24-week follow-up. The MCID was 14 points (95% confidence interval [CI]: 3, 19) over a 12-week period, corresponding to 57% sensitivity and 88% specificity. The MCID was 7 points (95% CI: -10, 28) over a 24-week period, with 85% sensitivity and 62% specificity. A change in VISA-A score of at least 14 points after 12 weeks or at least 7 points after 24 weeks of exercise therapy and an injection reflects a meaningful change for physically active patients with midportion AT. J Orthop Sports Phys Ther 2021;51(10):510-516. doi:10.2519/jospt.2021.10040.

No Difference in Clinical Effects When Comparing Alfredson Eccentric and Silbernagel Combined Concentric-Eccentric Loading in Achilles Tendinopathy: A Randomized Controlled Trial.

Background:Alfredson isolated eccentric loading and Silbernagel concentric–eccentric loading have both shown beneficial effects on clinical symptoms in midportion Achilles tendinopathy (AT), but they have never been compared directly.Purpose:To test for differences in clinical effects at 1-year follow-up between Alfredson and Silbernagel loading in midportion AT.Study Design:Randomized controlled trial; Level of evidence, 2.Methods:A total of 40 recreational athletes were allocated to the Alfredson group (AG) or the Silbernagel group (SG). The primary outcome was the difference in the Victorian Institute of Sports Assessment–Achilles (VISA-A) at 1-year follow-up. Secondary outcomes were the visual analog scale for pain during activities of daily living (VAS-ADL) and sports activities (VAS–sports), the EuroQol 5 Dimensions instrument (EQ-5D), and global perceived effect score. Measurements were performed at baseline and 12-week, 26-week, and 1-year follow-up. Analysis was performed using a linear mixed-regression model with intervention (AG vs SG), time (12 weeks, 26 weeks, and 1 year postoperatively), and intervention-by-time interaction.Results:The VISA-A score improved for both AG and SG, from 60.7 ± 17.1 at baseline to 89.4 ± 13.0 at 1-year follow-up and from 59.8 ± 22.2 to 83.2 ± 22.4, respectively (P < .001 for both). Because the interaction term did not significantly improve the model, we reported a treatment effect without interaction term, indicating a constant difference at each follow-up. The linear mixed model with correction for baseline VISA-A and confounders revealed a nonsignificant treatment effect (2.4 [95% CI, –8.5 to 13.3]; P = .656). In addition, after adjustment for the respective baseline values and confounders, nonsignificant treatment effects were found for the VAS-ADL (–2.0 [95% CI, –11.3 to 7.3]; P = .665) and VAS-sports (1.3 [95% CI, –12.8 to 15.3], P = .858). The EQ-5D subscales improved in both groups. After 1 year, significantly more SG participants considered themselves improved (77.3% [SG] vs 50.0% [AG]; P = .04).Conclusion:No differences in clinical effects were found between Alfredson and Silbernagel loading at up to 1-year follow-up. Both programs significantly improved clinical symptoms, and given their high adherence rates, offering either of them as a home-based program with limited supervision appears to be an effective treatment strategy for midportion AT.Registration:NTR5638 (Netherlands Trial Register number).

Efficacy of high-volume injections with and without corticosteroid compared with sham for Achilles tendinopathy: a protocol for a randomised controlled trial

IntroductionAchilles tendinopathy (AT) is a common and disabling musculoskeletal condition. First-line management involving Achilles tendon loading exercise with, or without, other modalities may not resolve the problem in up to...

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

A criteria-based rehabilitation program for chronic mid-portion Achilles tendinopathy: study protocol for a randomised controlled trial

BackgroundAchilles tendinopathy (AT) is a common overuse injury in running-related sports where patients experience pain and impaired function which can persist. A graded rehabilitation program has been successful in reducing pain and improving function to enable a return to sport. The aim of this study is to compare the effectiveness of a criteria-based rehabilitation program including strength and reactive strength targets, with a previously successful rehabilitation program on changes in pain and function using the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire. Secondary aims will be to assess changes in calf strength, reactive strength, and lower limb running and forward hop biomechanics over the course of a 12-week rehabilitation program, and long-term follow-up investigations.MethodsSixty eligible participants with chronic mid-portion AT who train in running-based sports will be included in this study. They will be randomly assigned to a group that will follow an evidence-based rehabilitation program of daily exercises with progression guided by symptoms or a group performing 3 high-intensity rehabilitation sessions per week with individualised load targets progressing to reactive strength exercises. Testing will take place at baseline, week 6 and 12. Plantar flexor peak torque will be measured using isokinetic dynamometry, reactive strength will be measured using a drop jump and lower limb biomechanical variables will be measured during a single leg forward hurdle hop test and treadmill running using 3D motion analysis. Follow-up interviews will take place at 6, 12 and 24 months after beginning the program which will assess patient participation in sport and possible re-injury.DiscussionThis is the first study to propose an individualised criteria-based graded rehabilitation program in patients in with chronic mid-portion Achilles tendinopathy where progression is guided by strength and reactive strength outcome measures. This study will provide a comprehensive assessment of plantar flexor strength, reactive strength and lower limb biomechanical variables in running and forward hopping with the VISA-A questionnaire as the primary outcome measure and long term post-intervention follow-up assessments performed.Trial registrationClinicalTrials.gov (ID: NCT04384874). Registered retrospectively on April 23rd 2020.

Effect of Platelet-Rich Plasma Injection vs Sham Injection on Tendon Dysfunction in Patients With Chronic Midportion Achilles Tendinopathy

Platelet-rich plasma injections are used as a treatment for chronic midportion Achilles tendinopathy, but evidence for this treatment is limited. In adults with midportion Achilles tendinopathy, to assess the effects of a single platelet-rich plasma injection, compared with sham injection, on the outcome of the Victorian Institute of Sport Assessment-Achilles (VISA-A) score (a single composite measure of Achilles tendinopathy severity). A participant-blinded, multicenter randomized clinical trial that included 240 people from 24 sites assigned to either a platelet-rich plasma injection or a sham injection between April 2016 and February 2020. Final follow-up was July 2020. Participants were older than 18 years with midportion Achilles tendon pain for more than 3 months as confirmed by ultrasound, magnetic resonance imaging, or both. A single intratendinous platelet-rich plasma injection (n = 121) or a single sham injection (insertion of a subcutaneous dry needle not entering the tendon) (n = 119). The primary outcome was the VISA-A score, measured 6 months after treatment allocation. The VISA-A score contains 8 questions that cover 3 domains of pain, function, and activity, analyzed as a composite score (range, 0 [worst symptoms] to 100 [no symptoms]; minimal clinically important difference in score, 12 points). The primary analysis was adjusted for laterality, age, sex, and baseline VISA-A score. Among 240 patients assigned to a platelet-rich plasma or sham injection (mean age, 52 years; 138 [58%] women), 221 (92%) completed the trial. At 6-month follow-up, mean VISA-A score values in the plasma-rich plasma group vs the sham injection group were 54.4 vs 53.4 (adjusted mean difference, -2.7 [95% CI, -8.8 to 3.3]). The most common adverse events compared between patients in the platelet-rich plasma group vs the sham group were injection site discomfort (97 vs 73 patients), swelling (56 vs 52 patients) and bruising (48 vs 49 patients). Among patients with chronic midportion Achilles tendinopathy, treatment with a single injection of intratendinous platelet-rich plasma, compared with insertion of a subcutaneous dry needle, did not reduce Achilles tendon dysfunction at 6 months. These findings do not support the use of this treatment for chronic midportion Achilles tendinopathy. isrctn.org Identifier: ISRCTN13254422.

Functional Gains Using Radial and Combined Shockwave Therapy in the Management of Achilles Tendinopathy

Achilles tendinopathy is a common condition and many patients have functional limitations after initial conservative treatment. Shockwave therapy has been shown to improve function within patients; however, comparative outcomes for different forms of shockwave are poorly described. In this retrospective cohort study, we describe findings from a quality improvement initiative evaluating safety and functional outcomes after treatment with radial shockwave therapy (n=58) or combined radial and focused shockwave therapy (n=29) for patients with Achilles tendinopathy refractory to exercise therapy. All patients were prescribed an eccentric exercise program. We hypothesized both groups would see improvements in function quantified using the Victorian Institute of Sports Assessment-Achilles with similar safety outcomes. Overall, the minimal clinically important difference (defined at 7 for insertional and 12 for noninsertional Achilles tendinopathy) was met in a greater proportion of patients treated with combined shockwave compared to radial shockwave (26 [89.7%] vs 37 [63.8%], p=.022). The change in Victorian Institute of Sports Assessment-Achilles from baseline to final treatment was not different between combined and radial-only groups (23.3 ± 12.6 vs 19.9 ± 18.7, p=.2). Within group differences from baseline to final follow-up measures (mean duration 17.9 ± 14.8 weeks) demonstrated overall functional improvement for both groups (both p < .0001). No serious adverse effects were observed. Our findings suggest combined radial and focused shockwave therapy may provide more predictable functional gains for treatment of Achilles tendinopathy compared to radial shockwave therapy.

A novel technique of minimally invasive calcaneal osteotomy for intractable insertional Achilles tendinopathy associated with Haglund deformity

BackgroundTo date, minimally invasive surgery (MIS) involving calcaneal osteotomy for Haglund deformity associated with intractable insertional Achilles tendinopathy has not been reported. This study presents the radiographic and clinical outcomes of our novel MIS-dorsal closing wedge calcaneal osteotomy (DCWCO) technique compared to open Haglund resection. We hypothesized that earlier clinical improvement after MIS-DCWCO could be achieved by leaving the Achilles tendon insertion site untouched. MethodsWe retrospectively reviewed and compared the clinical and radiographic parameters of patients who underwent MIS-DCWCO (11 cases) or open Haglund resection (14 cases) between January 2012 and June 2019. The minimum duration of follow-up for inclusion was 18 months. We measured the calcaneal pitch, Meary’s, Fowler-Philip, and Böhler’s angles. Clinical outcomes were evaluated using the visual analogue scale (VAS) and Victorian Institute of Sports Assessment-Achilles (VISA-A) scores measured preoperatively and at 3, 6, 9, 12, and ≥18 months, postoperatively. ResultsIn both groups, the Meary’s and calcaneal pitch angles did not change significantly, whereas the Fowler-Philip and Böhler’s angles were significantly changed postoperatively. Significant improvements in VAS and VISA-A scores were observed in both groups (P < 0.001). The extent of correction of the four radiographic and two clinical parameters were not significantly different between the two groups. However, VAS and VISA-A scores at postoperative 6 months were significantly different, whereas these parameters were not significantly different at all other time points. ConclusionBoth techniques provided similar postoperative clinical and radiographic improvement. However, MIS-DCWCO achieved earlier clinical improvement than open Haglund resection. Level of evidenceLevel III, comparative series.

Outcomes of Percutaneous Calcaneoplasty for Insertional Achilles Tendon Problems.

Percutaneous procedures have been used recently to treat insertional Achilles tendon problems. The present study reports our results of this treatment approach. Patients undergoing percutaneous calcaneoplasty for insertional Achilles tendon problems were retrieved. Patients completed the visual analog scale (VAS) for pain and the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire before the operative procedure and at the last follow-up. At the last follow-up, we asked the patients whether they were completely satisfied, moderately satisfied, or unsatisfied after the procedure. Complications were also recorded. A total of 27 patients were enrolled. The average follow-up was 26.5 months (range 6-68). The mean age of patients was 56.2 years (24-82). The mean VAS score before surgery was 8.1 ± 0.9 decreasing by the last follow-up to 2.4 ± 2.3 (P < .0001). The mean VISA-A score improved from 20.7 ± 5.4 to 75.7 ± 25.5 at last follow-up, an improvement of 55% (P < .0001). At the last follow-up, 84.5% (22 of 27) patients were completely satisfied with the procedure, 7.4% (2 of 27) moderately satisfied, and 11.1% (3 of 27) were not satisfied. These last 3 patients presented recurrence of symptoms, requiring revision surgery. For the selected patients, we found percutaneous calcaneoplasty to be an effective treatment for insertional Achilles tendon problems. Level III, retrospective study.

A comparative study of single-vs. double-row technique in surgical treatment of insertional Achilles tendinopathy

Objective: This retrospective study compared the clinical and functional results of single- and double-row surgical techniques for insertional Achilles tendinopathy in the postoperative period. Methods: In this case series, 29 patients who underwent surgery with one of the two techniques were followed up for one year postoperatively. Data were collected from medical records, imaging exams, and visual analog scale (VAS), Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire, 12-item Short Form Health Survey (SF-12), and Foot and Ankle Ability Measure (FAAM) scores. Results: The following mean values (5% significance level) were found for single- and double-row techniques, respectively: postoperative VAS (2.9/2.2), FAAM-ADL (71.9/74.4), FAAM-Sports (28.3/29.8), SF-12 physical component (45.2/47.0), SF-12 mental component (44.9/48.2), and VISA-A (72.1/75.9). The complication rate did not differ significantly between the techniques. Conclusion: No significant differences were found in any of the scores between the two surgical techniques. Level of Evidence III; Therapeutic Studies, Comparative Retrospective Study.

Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (HEALTHY): a randomised trial

Objective(s)To compare the efficacy of in-shoe heel lifts to calf muscle eccentric exercise in reducing pain and improving function in mid-portion Achilles tendinopathy.MethodsThis was a parallel-group randomised superiority trial at...

Are pain coping strategies and neuropathic pain associated with a worse outcome after conservative treatment for Achilles tendinopathy? A prospective cohort study

ObjectivesTo analyse whether (1) passive or active pain coping strategies and (2) presence of neuropathic pain component influences the change of Achilles tendinopathy (AT) symptoms over a course of 24 weeks in conservatively-treated patients. DesignProspective cohort study. MethodsPatients with clinically-diagnosed chronic midportion AT were conservatively treated. At baseline, the Pain Coping Inventory (PCI) was used to determine scores of coping, which consisted of two domains, active and passive (score ranging from 0 to 1; the higher, the more active or passive). Presence of neuropathic pain (PainDETECT questionnaire, −1 to 38 points) was categorized as (a) unlikely (≤12 points), (b) unclear (13–18 points) and (c) likely (≥19 points). The symptom severity was determined with the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire (0–100) at baseline, 6, 12 and 24 weeks. We analysed the correlation between (1) PCI and (2) PainDETECT baseline scores with change in VISA-A score using an adjusted Generalized Estimating Equations model. ResultsOf 80 included patients, 76 (95%) completed the 24-weeks follow-up. The mean VISA-A score (standard deviation) increased from 43 (16) points at baseline to 63 (23) points at 24 weeks. Patients had a mean (standard deviation) active coping score of 0.53 (0.13) and a passive score of 0.43 (0.10). Twelve patients (15%) had a likely neuropathic pain component. Active and passive coping mechanisms and presence of neuropathic pain did not influence the change in AT symptoms (p=0.459, p=0.478 and p=0.420, respectively). ConclusionsContrary to widespread belief, coping strategy and presence of neuropathic pain are not associated with a worse clinical outcome in this homogeneous group of patients with clinically diagnosed AT.

No Additive Clinical or Physiological Effects of Short-term Anti-inflammatory Treatment to Physical Rehabilitation in the Early Phase of Human Achilles Tendinopathy: A Randomized Controlled Trial

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in the treatment of Achilles tendinopathy, but whether they have any additive clinical effect on physical rehabilitation in the early phase of tendinopathy remains unknown. Purpose/Hypothesis: To investigate whether an initial short-term NSAID treatment added to a physical rehabilitation program in the early phase of Achilles tendinopathy would have an additive effect. We hypothesized that the combination of NSAID and rehabilitation would be superior to rehabilitation alone. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 69 patients with early phase Achilles tendinopathy (lasting <3 months) were randomly assigned to either a naproxen group (7 days of treatment; 500 mg twice daily; n = 34) or a placebo group (7 days of placebo treatment; n = 35). Both groups received an identical 12-week physical rehabilitation program. The clinical outcome of the study was evaluated using the Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire and a numerical rating scale (NRS), and the physiological outcome was evaluated using ultrasonography, magnetic resonance imaging (MRI), and ultra-short time to echo T2* mapping MRI (UTE T2* MRI). Follow-up was performed at 1 week, 3 months, and 1 year. Time effects are presented as mean difference ± SEM. Results: No significant differences were found between the 2 treatment groups for any of the outcome measures at any time point (P > .05). For the VISA-A score, a significant time effect was observed between baseline and 3-month follow-up (14.9 ± 2.3; P < .0001), and at 1-year follow-up, additional improvements were observed (6.1 ± 2.3; P < .01). Furthermore, the change in VISA-A score between baseline and 3-month follow-up was greater in patients with very short symptom duration (<1 month) at baseline compared with patients who had longer symptom duration (>2 months) (interaction between groups, 11.7 ± 4.2; P < .01). Despite clinical improvements, total weekly physical activity remained lower compared with preinjury levels at 3 months (–2.7 ± 0.5 h/wk; P < .0001) and 1 year (–3.0 ± 0.5 h/wk; P < .0001). At baseline, ultrasonography showed increased thickness (0.12 ± 0.03 cm; P < .0001) and vascularity (0.3 ± 0.1 cm2; P < .005) on the tendinopathic side compared with the contralateral side, but no changes over time were observed for ultrasonography, MRI, or UTE T2* MRI results. Conclusion: Clinical symptoms in early tendinopathy improved with physical rehabilitation, but this improvement was not augmented with the addition of NSAID treatment. Furthermore, this clinical recovery occurred in the absence of any measurable structural alterations. Finally, clinical improvements after a physical rehabilitation program were greater in patients with very short symptom duration compared with patients who had longer symptom duration. Registration: NCT03401177 (ClinicalTrials.gov identifier) and BFH-2016-019 (Danish Data Protection Agency)