104 Chapter 6 MATERIALS & METHODS Participants We recruited a total of 100 participants, comprising 50 patients diagnosed with AT and 50 asymptomatic individuals. We included 25 patients with insertional AT and 25 patients with midportion AT. To be eligible for inclusion, AT patients had to meet the following criteria: 1) age ≥ 18 years, 2) the clinical diagnosis of AT established by the sports physician and 3) provide informed consent. The patients with AT were consecutively recruited between September 2020 and September 2022 from the outpatient department of Orthopaedic Surgery and Sports Medicine of Erasmus MC University Medical Centre, and the clinical diagnosis was established by a single sports medicine physician with nine years of clinical experience as a medical specialist (RJDV). The diagnosis was made based on the presence of gradual-onset pain in the Achilles tendon region during tendon-loading activities and recognizable and localized pain upon palpation of the Achilles tendon.1,2,6,18 Insertional tendinopathy was diagnosed when the pain was located between the Achilles tendon insertion and the upper border of the calcaneus. Midportion tendinopathy was diagnosed when symptoms were located proximal to the upper border of the calcaneus (free tendon region). Asymptomatic participants were consecutively recruited through informing potential participants via social media platforms (Twitter, Facebook, LinkedIn). To be eligible for inclusion, asymptomatic participants had to meet the following criteria: 1) age ≥ 18 years, 2) no current or past history of Achilles tendon pain or stiffness, 3) no localized tendon pain or nodular thickening upon palpation and 3) provide informed consent. Procedures The study was designed at the Erasmus MC University Medical Centre (Rotterdam, the Netherlands). The local Medical Ethics Committee (Southwest-Holland, the Netherlands) approved the study protocol (MEC-2020-0585, MEC-2021-0033). We adhered to the minimum reporting standards for reporting participant characteristics in tendinopathy research and to the guidelines for reporting reliability and agreement studies.19,20 Supplementary File 2 shows a graphical description of the design of the study. Patients with Achilles tendinopathy Prior to their appointment at the outpatient department, patients completed a standardized digital questionnaire that encompassed demographic information, health status, and sports activities. Physical Activity Level (PAL) was assessed using a 6-point Likert scale.21 Additionally, patients completed the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire, ranging from 0-100.22 A single senior sports physician (RJDV) conducted a comprehensive history taking and physical examination for each patient.
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