VISA-A Score Research Articles

Rocker shoes reduce Achilles tendon load in running and walking in patients with chronic Achilles tendinopathy

Relative rest and pain relief play an important role in the management of Achilles tendinopathy, and might be achieved by reducing the load on the Achilles tendon. Previous studies have provided evidence that rocker shoes are able to decrease the ankle internal plantar flexion moment in healthy runners during walking and running. Since plantar flexion moment is related to the Achilles tendon loading, rocker shoes might be considered in the conservative management of Achilles tendinopathy. Therefore, the aim of this study was to investigate the biomechanics of running and walking in a group of patients with Achilles tendinopathy wearing standard shoes versus rocker shoes. Cross-over. Thirteen Achilles tendinopathy patients (mean age 48 ± 14.5 years) underwent three-dimensional gait analysis wearing standard running shoes and rocker shoes during running and walking. Surface electromyography of triceps surae and tibialis anterior was recorded simultaneously. Patients had symptoms for an average of 22.5 months (median 11.5 months) and VISA-A scores were 54 ± 16. With the rocker shoes, the peak plantar flexion moment was reduced by 13% in both running (0.28 N m/kg, p<0.001) and walking (0.20 N m/kg, p<0.001). The peak activity of tibialis anterior was increased by 35% (p=0.015) for the rocker shoes in walking. There was no difference between electromyography peak amplitudes of triceps surae between two shoe sessions in both activities. When used by patients with chronic Achilles tendinopathy, rocker shoes cause a significant reduction in plantar flexion moment in the late stance phase of running and walking without substantial adaptations in triceps surae muscular activity.

COMPARING TWO ECCENTRIC EXERCISE PROGRAMMES FOR THE MANAGEMENT OF ACHILLES TENDINOPATHY. A PILOT TRIAL

ObjectivesTo compare eccentric exercises as proposed by Alfredson with eccentric and static exercises as proposed by Stanish in the management of Achilles tendinopathy.MethodsPatients with midportion Achilles tendinopathy for at least...

THE EFFECTIVENESS OF AN INTENSIVE EXERCISE PROGRAMME IN THE FUNCTIONAL RECOVERY OF A SEVERE DEGENERATIVE ACHILLES TENDINOPATHY. IS IT ENOUGH BY ITSELF? A CASE REPORT

IntroductionAchilles tendinopathy (AT) is classically known to be very resistant to treatment. Although other diagnoses such as bursitis and insertional problems have been described, the most common pathology is mid-portion...

Comparing two eccentric exercise programmes for the management of Achilles tendinopathy. A pilot trial

To compare eccentric and static exercises as proposed by Stanish with eccentric exercises as proposed by Alfredson in the management of Achilles tendinopathy. Patients with midportion Achilles tendinopathy for at least 3 months were included in this trial. They were sequentially allocated to receive either Stanish's exercise programme or Alfredson's exercise programme. Outcome measures were pain and function using the VISA-A score. Patients were evaluated at baseline, at the end of treatment (week 12), and 6 months (week 36) after the end of treatment. 41 patients met the inclusion criteria. At the end of treatment, there was a rise in VISA-A score in both groups compared with baseline (p<0.05, paired t-test). There were significant differences in the VISA-A score between the groups at the end of treatment and at the 6-month follow up; Alfredson exercise programme group produced the largest effect (p<0.0005, independent t-test). An exercise programme based on Alfredson protocol was superior to Stanish model to reduce pain and improve function in patients with Achilles tendinopathy at the end of the treatment and at the follow-up. Further research is needed to confirm our results.

High volume image guided injections for the management of chronic tendinopathy of the main body of the Achilles tendon

ObjectivesSeveral substances are routinely injected in and around tendons. The present study evaluated the long term effects of high volume image guided injection (HVIGI) of normal saline, local anaesthetic and aprotinin in athletic patients with resistant tendinopathy of the main body of the Achilles tendon. DesignCase series. MethodsThe study included a series of 94 athletes (69 men and 25 women; average age 37.5 years, range 22–63) with ultrasound confirmed tendinopathy of the main body of the Achilles tendon. All the patients had not improved after at least three months of conservative management. Patients were injected with 10 mL of 0.5% Bupivacaine Hydrochloride, 25 mg aprotinin, and up to 40 mL of injectable normal saline. We prospectively administered the Victorian Institute of Sport Assessment–Achilles tendon (VISA-A) to assess the short- and long-term pain and functional improvement. ResultsAt baseline (n = 94), the VISA-A score was 41.7 ± 23.2 (range 11–60), and had improved to 74.6 ± 21.4 (range 71–100) by 12 months (n = 87) (p = 0.003), with no significant difference between sexes. ConclusionHVIGI with aprotinin significantly reduces pain and improves function in patients with chronic Achilles tendinopathy in the short- and long-term follow up.

Retrospective Analysis of Mini-Open Repair Versus Open Repair for Acute Achilles Tendon Ruptures

Debate exists over optimal treatment for acute Achilles tendon ruptures. Recent literature suggests the mini-open technique may provide the reliability of the open repair with the decreased complication rate of non-operative treatment. This retrospective review compares acute tendon ruptures treated with one of two techniques: open repair (TO) or mini-open repair (MOA). Records were reviewed and 34 patients were found to meet the inclusion criteria for open or mini-open repair of an acute Achilles tendon rupture with follow up of at least 12 months. TO (n=16) and MOA (n=18) had no statistically significant differences in age at time of injury [TO: 41 + 2.5 years (range 20 - 68); MOA: 46 + 2.5 years (range 33 - 73)] or time between injury and surgical repair [TO: 15 + 2 days (range 2 - 30); MOA: 15 + 2 days (range 2 - 30)]. Post-operative VISA-A scores were 82 + 10 (range 42 - 98) and 92 + 5 (range 66 - 100) for TO and MOA, respectively. Significant differences were found in the time between surgical intervention and beginning of rehabilitation [TO: Post op day 37 + 5 (range 21 - 46); MOA: Post op day 19 + 2 (range 7 - 32)] and the time between surgical intervention and full return to activity [TO: Post op month 7 + 1 (range 4 - 11); MOA: Post op month 5 + 0.6 (range 4 - 11)]. These results suggest that the mini-open repair provides acceptable surgical outcomes while optimizing patient function after Achilles tendon repair.

High-volume injection in the management of recalcitrant mid-body Achilles tendinopathy: a prospective case series assessing the influence of neovascularity and outcome

AbstractObjectivesTo determine the effectiveness of ultrasound-guided high-volume injection (HVI) and relevance of neovascularity on outcome in Achilles tendinopathy.MethodsThis prospective clinical study at the Homerton University Hospital included 32 patients with recalcitrant unilateral mid-substance Achilles tendinopathy. Outcome measures used were Victorian Institute of Sport Assessment-Achilles tendon (VISA-A), Visual Analogue Score (VAS), modified Ohberg score and mean maximum tendon thickness.ResultsSignificant improvements in both VAS and VISA-A scores at 1 month (95% confidence interval (CI), 6.6–3.2, P < 0.001 and 37.2–63.7, P < 0.001). This improvement was maintained at 3 months (95% CI, 6.6–2.9, P < 0.001 and 37.2–65.9, P < 0.001). Symptomatic tendons were significantly thicker at baseline than the asymptomatic side (95% CI, 8.3 mm compared to 5.9 mm, P < 0.001). There was a significant decrease in maximum tendon thickness in the symptomatic tendons at baseline and at 3 months (95% CI, 8.3–7....

Safety and outcome of surgical debridement of insertional Achilles tendinopathy using a transverse (Cincinnati) incision

This is a prospective analysis on 30 physically active individuals with a mean age of 48.9 years (35 to 64) with chronic insertional tendinopathy of the tendo Achillis. Using a transverse incision, the tendon was debrided and an osteotomy of the posterosuperior corner of the calcaneus was performed in all patients. At a minimum post-operative follow-up of three years, the Victorian Institute of Sports Assessment scale-Achilles tendon scores were significantly improved compared to the baseline status. In two patients a superficial infection of the wound developed which resolved on antibiotics. There were no other wound complications, no nerve related complications, and no secondary avulsions of the tendo Achillis. In all, 26 patients had returned to their pre-injury level of activity and the remaining four modified their sporting activity. At the last appointment, the mean pain threshold and the mean post-operative tenderness were also significantly improved from the baseline (p < 0.001). In patients with insertional tendo Achillis a transverse incision allows a wide exposure and adequate debridement of the tendo Achillis insertion, less soft-tissue injury from aggressive retraction and a safe osteotomy of the posterosuperior corner of the calcaneum.

Changes in the symptoms and ultrasound signs of achilles tendinopathy during a twelve week course of loaded eccentric training: a pilot study

Background12 weeks of eccentric exercise has been shown to be a useful therapy for Achilles tendinopathy, but little is known of the time-course of recovery, or the nature of any...

Blood Flow of the Achilles Tendon During Military Training

The purpose of this study was to evaluate the vascular response of the Achilles tendon as indicated by power Doppler activity during a military training program of 6 weeks. 49 male military recruits (98 tendons) volunteered for this study. Before and during the military training program, the Achilles tendons were screened with gray-scale ultrasonography and power Doppler US. Reactive tendinopathies of the Achilles tendons were registered by means of a clinical examination, VAS-scores and VISA-A scores. The US examination, the clinical examination, VAS-scores and VISA-A scores showed that 13/98 tendons developed a reactive tendinopathy. 3 of these 13 symptomatic tendons showed intratendinous Doppler activity. In these tendons, pain was always present before the vascular response of the Achilles tendon. Both pain and hypervascularisation remained visible till the end of the basic military training. In 5 asymptomatic tendons with no structural changes of the tendon, a vascular response was seen during one single measurement. It can be hypothesized that there is no relationship between the vascular response of the Achilles tendon and the pain in a reactive tendinopathy. In a reactive tendinopathy, other pain mechanisms must be investigated in future research.

New regimen for eccentric calf muscle training in insertional achilles tendinopathy: a pilot study

Chronic painful insertional achilles tendinopathy is seen both in physically active and non-active population. The conventional eccentric protocol which loaded the achilles in dorsiflexion does not show good result and...

Long-term Outcome Of Patients With Achilles Tendinopathy Treated With Exercise.

Achilles tendinopathy is a common overuse injury among athletes involved in activities that include running and jumping. Systematic reviews indicate that eccentric exercises have the most evidence of effectiveness in treatment of midportion Achilles tendinopathy. The follow-up time is however relatively short ranging from 12 weeks up to a year. PURPOSE: The purpose of this study was to evaluate the long-term outcome of patients with Achilles tendinopathy treated with exercise. METHODS: A follow-up evaluation was performed on 34 (16 women and 18 men) out of 38 patients a mean (SD) of 4.8 (0.2) years after initiation of treatment with exercise. The mean (SD) age of the patients were 51 (8.2) years. All the patients were initially included in a randomized study comparing continued sports activity with rest for the initial 6-weeks while treated with identical exercise protocol. RESULTS: There was no significant (p=0.47) difference between the number of patients with symptoms between the treatment groups. Of the 34 patients 22 (65%) patients with a mean age of 49 reported being fully recovered and having no symptoms (11 women, 11 men). Their VISA-A score was a mean (SD) of 96 (4.3) with no significant differences (p=0.12) compared to the 1 year evaluation. Their physical activity level was a mean (SD) of 4.3 (1.2) with no significant difference compared to prior to injury (p=0.44). 12 (35%) patients with a mean age of 54 reported having symptoms from the Achilles tendon. Seven patients (20.6%) reported having continued symptoms and 5 (14.7%) reported having been fully recovered but had a new occurrence of symptoms. There was a significant (p<0.01) improvement in the VISA-A score at the 5-year follow-up (mean 82, SD 12.6) compared to prior to treatment (mean 58, SD 14.8) for these 12 patients. Their physical activity level was a mean (SD) of 3.9 (0.9) with no significant difference compared to prior to injury (p=0.26). Only two of the patients had received other treatment, one received acupuncture and one further exercise instruction. CONCLUSION: The majorities of patients who receive exercise as treatment for midportion Achilles tendinopathy have a full recovery and no symptoms 5 years after initiation of treatment. Even the patients with continued symptoms remain significantly improved after 5 years compared to prior to treatment.

Gender and eccentric training in Achilles mid-portion tendinopathy

The role of gender in Achilles tendinopathy is yet to be determined. We hypothesized that female patients respond the same as males to 12 weeks of painful eccentric training. A total number of 75 consecutive mid-portion patients with Achilles tendinopathy (25 females, 38 males) were enrolled in a cohort study with 63 being analyzed after 12 weeks according to their gender for tendon and paratendon microcirculatory mapping. Outcome was determined by pain on visual analogue scale, VISA-A score, Foot Ankle Outcome Score (FAOS), tendon and paratendon capillary blood flow, oxygen saturation, and postcapillary venous filling pressures. Eccentric training resulted in a morning resting pain reduction by 44% in males (P = 0.001) and by 27% in females (P = 0.08). VISA-A score improved in males by 27% from 63 +/- 12 to 86 +/- 13 (P = 0.036) and by 20% in females from 60 +/- 14 to 75 +/- 11 (P = 0.043, P < 0.05 for gender difference). Among females, only one out of five FAOS items was increased (sport 72 +/- 21 to 82 +/- 15, P = 0.045), while in males, four out of five items were increased (symptoms, pain, all-day-life, and sport, all P < 0.01). The microcirculatory gender-specific response to eccentric training revealed a greater postcapillary venous filling pressure reduction among symptomatic females and inconclusive capillary blood flow changes. No change in tendon oxygenation was noted in both genders. Symptomatic females suffering Achilles tendinopathy do not benefit as much as symptomatic males from 12 weeks of eccentric training. The pain reduction is significantly lower among symptomatic females in contrast to males, and the improvement in the FAOS and VISA-A scores is significantly lower among females in contrast to males. Additional treatment options warrant scrutiny to symptomatic females suffering Achilles tendinopathy beyond eccentric training.

The short-term effects of high volume image guided injections in resistant non-insertional Achilles tendinopathy

We investigated neovascularisation, tendon thickness and clinical function in chronic resistant Achilles tendinopathy following high volume image guided injections (HVIGI). The subjects involved 11 athletes (mean age 43.5 years ± 11.6, range 22–59) with resistant tendinopathy of the main body of the Achilles tendon for a mean of 51.4 months (±55.56, range 4–144) who failed to improve with an eccentric loading program (mean 11.8 months ± 2.6, range 8–16). The morphological features, neovascularisation and maximal tendon thickness were assessed with power Doppler ultrasound. Clinical function was measured with the Victorian Institute of Sports Assessment-Achilles tendon (VISA-A) questionnaire. All the tendinopathic Achilles tendons were injected with 10 mL of 0.5% bupivacaine hydrochloride, 25 mg of hydrocortisone acetate, and 40 mL of 0.9% NaCl saline solution under real time ultrasound guidance. All outcome measures were recorded at baseline and after a short-term follow-up (mean 2.9 weeks, range 2–4). The results showed a statistically significant difference between baseline and 3-week follow-up in all the outcome measures after HVIGI. The grade of neovascularisation reduced (3–1.1, p = 0.003), the maximal tendon diameter decreased (8.7–7.6 mm, p < 0.001), and the VISA-A scores improved (46.3–84.1, p < 0.001). In conclusion, HVIGI for resistant tendinopathy of the main body of the Achilles tendon is effective to improve symptoms, reduce neovascularisation, and decrease maximal tendon thickness at short-term follow-up.

Cross-cultural adaptation and validation of the VISA-A questionnaire for German-speaking Achilles tendinopathy patients

BackgroundAchilles tendinopathy is the predominant overuse injury in runners. To further investigate this overload injury in transverse and longitudinal studies a valid, responsive and reliable outcome measure is demanded. Most questionnaires have been developed for English-speaking populations. This is also true for the VISA-A score, so far representing the only valid, reliable, and disease specific questionnaire for Achilles tendinopathy. To internationally compare research results, to perform multinational studies or to exclude bias originating from subpopulations speaking different languages within one country an equivalent instrument is demanded in different languages. The aim of this study was therefore to cross-cultural adapt and validate the VISA-A questionnaire for German-speaking Achilles tendinopathy patients.MethodsAccording to the "guidelines for the process of cross-cultural adaptation of self-report measures" the VISA-A score was cross-culturally adapted into German (VISA-A-G) using six steps: Translation, synthesis, back translation, expert committee review, pretesting (n = 77), and appraisal of the adaptation process by an advisory committee determining the adequacy of the cross-cultural adaptation. The resulting VISA-A-G was then subjected to an analysis of reliability, validity, and internal consistency in 30 Achilles tendinopathy patients and 79 asymptomatic people. Concurrent validity was tested against a generic tendon grading system (Percy and Conochie) and against a classification system for the effect of pain on athletic performance (Curwin and Stanish).ResultsThe "advisory committee" determined the VISA-A-G questionnaire as been translated "acceptable". The VISA-A-G questionnaire showed moderate to excellent test-retest reliability (ICC = 0.60 to 0.97). Concurrent validity showed good coherence when correlated with the grading system of Curwin and Stanish (rho = -0.95) and for the Percy and Conochie grade of severity (rho 0.95). Internal consistency (Cronbach's alpha) for the total VISA-A-G scores of the patients was calculated to be 0.737.ConclusionThe VISA-A questionnaire was successfully cross-cultural adapted and validated for use in German speaking populations. The psychometric properties of the VISA-A-G questionnaire are similar to those of the original English version. It therefore can be recommended as a sufficiently robust tool for future measuring clinical severity of Achilles tendinopathy in German speaking patients.

Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial

ObjectiveTo compare the effectiveness and cost-effectiveness of eccentric loading exercises (ELE) with prolotherapy injections used singly and in combination for painful Achilles tendinosis.DesignA single-blinded randomised clinical trial. The primary outcome...

Eccentric Loading versus Eccentric Loading plus Shock-Wave Treatment for Midportion Achilles Tendinopathy

Background Results of a previous randomized controlled trial have shown comparable effectiveness of a standardized eccentric loading training and of repetitive low-energy shock-wave treatment (SWT) in patients suffering from chronic midportion Achilles tendinopathy. No randomized controlled trials have tested whether a combined approach might lead to even better results. Purpose To compare the effectiveness of 2 management strategies—group 1: eccentric loading and group 2: eccentric loading plus repetitive low-energy shock-wave therapy. Study Design Randomized controlled trial; Level of evidence, 1. Methods Sixty-eight patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule. Analysis was on an intention-to-treat basis. Results At 4 months from baseline, the VISA-A score increased in both groups, from 50 to 73 points in group 1 (eccentric loading) and from 51 to 87 points in group 2 (eccentric loading plus shock-wave treatment). Pain rating decreased in both groups, from 7 to 4 points in group 1 and from 7 to 2 points in group 2. Nineteen of 34 patients in group 1 (56%) and 28 of 34 patients in group 2 (82%) reported a Likert scale of 1 or 2 points (“completely recovered” or “much improved”). For all outcome measures, groups 1 and 2 differed significantly in favor of the combined approach at the 4-month follow-up. At 1 year from baseline, there was no difference any longer, with 15 failed patients of group 1 opting for having the combined therapy as cross-over and with 6 failed patients of group 2 having undergone surgery. Conclusion At 4-month follow-up, eccentric loading alone was less effective when compared with a combination of eccentric loading and repetitive low-energy shock-wave treatment.

One-year follow-up of a randomised controlled trial on added splinting to eccentric exercises in chronic midportion Achilles tendinopathy

ObjectiveThe study examined whether the addition of a night splint to eccentric exercises is beneficial for functional outcome in chronic midportion Achilles tendinopathy.DesignOne-year follow-up of a randomised controlled single blinded...

Eccentric calf muscle training in athletic patients with Achilles tendinopathy

Purpose. To evaluate the effects of eccentric strengthening exercises (ESE) in athletic patients with Achilles tendinopathy.Methods. Forty-five athletic patients (29 men, average age 26 years ± 12.8, range 18 – 42; 16 women, average age 28 years ± 13.1, range 20 – 46; average height: 173 ± 16.8, range 158 – 191; average weight 70.8 kg ± 15.3, range 51.4 – 100.5) with a clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A questionnaire at first attendance and at their subsequent visits. The patients underwent a graded progressive eccentric calf strengthening exercises programme for 12 weeks.Results. The mean pre-management VISA-A scores of 36 (SD 23.8; 95% CI: 29 – 46) improved to 52 (SD 27.5; 95% CI: 41.3 – 59.8) at the latest follow up (p = 0.001). Twenty seven of the 45 patients responded to the eccentric exercises. Of the 18 patients who did not improve with eccentric exercises, 5 (mean age: 33 years) improved with two peritendinous aprotinin and local anaesthetic injections. 10 of the 18 patients (9 men, mean age 35 years; 1 woman aged 40 years) who did not improve with eccentric exercises and aprotinin injections proceeded to have surgery. The remaining three patients (3 women, mean age 59.6 years) of the 18 non-responders to eccentric exercises and aprotinin injections declined surgical intervention.Conclusions. ESE in athletic patients provide comparable clinical outcome compared to our previous results in non-athletic patients. ESE are a viable option for the management of AT in athletes, but, in our hands, only around 60% of our athletic patients benefited from an intensive, heavy load eccentric heel drop exercise regimen alone. If ESE fail to improve the symptoms, aprotinin and local anaesthetic injections should be considered. Surgery is indicated in recalcitrant cases after 3 to 6 months of non operative management.

Italian translation of the VISA-A score for tendinopathy of the main body of the Achilles tendon

Purpose. To translate and adapt the English VISA-A questionnaire to Italian, to perform reliability and validity evaluations of the Italian VISA-A version in patients with tendinopathy of the main body of the Achilles tendon.Methods. The VISA-A English version was translated into Italian by a bilingual orthopaedic surgeon. The back translation of the Italian version into English was performed by another bilingual orthopaedic surgeon. The original version was compared with the back translation. The VISA-A-I questionnaire was then administered to 50 male athletes (average age 26.4, range 18 – 49 years) with a diagnosis of tendinopathy of the main body of the AT. For test-retest evaluation, the 50 patients were asked to complete the questionnaire at first examination, and 30 minutes following the end of this examination.Results. The kappa statistics for 50 patients was 0.80 (range 0.7 – 0.86). There were no significant differences between the scores immediately after the consultation and 30 minutes later.Conclusions. Italian and the English versions of the VISA-A questionnaire evaluate the same aspects of clinical severity in patients with tendinopathy of the main body of the Achilles tendon.