Do physical tests have a prognostic value in chronic midportion Achilles tendinopathy?

Objectives: To determine whether baseline physical tests have a prognostic value on patient-reported outcomes in Achilles tendinopathy. Design: Prospective cohort study, secondary analysis of data from a randomized trial. Methods: Patients with chronic midportion Achilles tendinopathy performed a progressive calf muscle exercise program. At baseline and after 2, 6, 12 and 24 weeks, patients completed the Victorian Institute of Sports Assessment—Achilles questionnaire and performed the following physical tests: ankle dorsiflexion range of motion with a bent knee or an extended knee, calf muscle strength, jumping height and pain on palpation (Visual Analogue Scale; 0–100) and after 10 hops (Visual Analogue Scale-10-hops). Associations between baseline test results and improvement (Victorian Institute of Sports Assessment—Achilles scores) were determined using a Mixed Linear Model. Results: 80 patients were included. The mean Victorian Institute of Sports Assessment—Achilles score improved 20 points (95 % confidence interval, 16–25, P &lt; .001) after 24 weeks. There were significant associations between the baseline ankle dorsiflexion range of motion with a bent knee (β 0.2, 95 % confidence interval 0.001 to 0.3, P = .049), the baseline pain provocation tests (Visual Analogue Scale palpation: β − 0.2; 95 % confidence interval: − 0.4 to − 0.1; P &lt; .001, Visual Analogue Scale-10-hops: β − 0.3; 95 % confidence interval: − 0.4 to − 0.2; P &lt; .001) and the change in the Victorian Institute of Sports Assessment—Achilles score. Conclusions: In patients with chronic midportion Achilles tendinopathy, easy-to-perform pain provocation tests have a clinically relevant prognostic value on patient-reported improvement. Patients with less pain during pain provocation tests at baseline have a better improvement in pain, function and activities after 24 weeks than patients with high baseline pain scores.</p

Dutch multidisciplinary guideline on Achilles tendinopathy

Objective To provide a comprehensive, evidence-based overview of the risk factors, prevention, diagnosis, imaging, treatment and prognosis for Achilles tendinopathy. To make clinical recommendations for healthcare practitioners and patients. Design Comprehensive multidisciplinary guideline process funded by the Quality Foundation of the Dutch Federation of Medical Specialists. This process included a development, commentary and authorisation phase. Patients participated in every phase. Data sources Multiple databases and existing guidelines were searched up to May 2019. Information from patients, healthcare providers and other stakeholders were obtained using a digital questionnaire, focus group interview and invitational conference. Study eligibility criteria Studies on both insertional and/or midportion Achilles tendinopathy were eligible. Specific eligibility criteria were described per module. Data extraction and synthesis To appraise the certainty of evidence, reviewers extracted data, assessed risk of bias and used the Grading of Recommendations Assessment, Development and Evaluation method, where applicable. Important considerations were: patient values and preferences, costs, acceptability of other stakeholders and feasibility of implementation. Recommendations were made based on the results of the evidence from the literature and the considerations. Primary outcome measure The primary and secondary outcome measures were defined per module and defined based on the input of patients obtained in collaboration with the Netherlands Patient Federation and healthcare providers from different professions. Results Six specific modules were completed: risk factors and primary prevention, diagnosis, imaging, treatment prognosis and secondary prevention for Achilles tendinopathy. Summary/conclusion Our Dutch multidisciplinary guideline on Achilles tendinopathy provides six modules developed according to the standards of the Dutch Federation of Medical Specialists. Evidence-based recommendations for clinical practice are given for risk factors, prevention, diagnosis, imaging, treatment and prognosis. This guideline can assist healthcare providers and patients in clinical practice

Which treatment is most effective for patients with Achilles tendinopathy?:A living systematic review with network meta-analysis of 29 randomised controlled trials

Objective: To provide a consistently updated overview of the comparative effectiveness of treatments for Achilles tendinopathy. Design: Living systematic review and network meta-analysis. Data sources: Multiple databases including grey literature sources were searched up to February 2019. Study eligibility criteria: Randomised controlled trials examining the effectiveness of any treatment in patients wit

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

Objective: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.Design:A double-blind, randomized, placebo-controlled clinical trial.Setting:Sports medicine department at a district general hospital.Patients: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).Intervention: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.Main Outcome Measures: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.Results: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).Conclusion: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.Trial registration:NCT02996409

Victorian institute of sport assessment-achilles (visa-a) questionnaire—minimal clinically important difference for active people with midportion achilles tendinopathy: A prospective cohort study

OBJECTIVE: 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). DESIGN: Prospective cohort study. METHODS: 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. U RESULTS: 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. U CONCLUSION: 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

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

Objectives To 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. Design Prospective cohort study. Methods Patients 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. Results Of 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). Conclusions Contrary 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