158 Chapter 9 DISCUSSION Achilles tendinopathy is a frequently occurring and debilitating condition.1,2 Knowledge in the field of Achilles tendinopathy is increasing rapidly, and recently resulted in the publication of clinical guidelines.3,4 However, many questions remain unanswered. This thesis primarily aimed to evaluate the impact of Achilles tendinopathy, to examine the role of physical and ultrasonographical evaluation and to assess socio-economic status as prognostic factor in Achilles tendinopathy patients. By doing so we hope to contribute to an increased understanding of the condition and a more personalised approach for patients with Achilles tendinopathy. IMPACT To effectively evaluate the severity of Achilles tendinopathy and treatment effectiveness, reliable and valid outcome measures are necessary. Through a 5-step approach, including a systematic review, a 2-round Delphi survey, methodological quality assessment and an in person consensus meeting, we identified a core outcome set for clinical trials of Achilles tendinopathy (COS-AT). The following outcome measures were selected as part of the core outcome set: the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire, the single-leg heel rise test, evaluating pain after activity using a Visual Analogue Scale (VAS, 0-10) and evaluating pain on activity/loading using a VAS (0-10). It is strongly recommended that future clinical trials should include the agreed core outcome set for Achilles tendinopathy (COS-AT) as a minimum. This will facilitate pooling of data and progression of knowledge about Achilles tendinopathy. One important outcome measure selected by the patients and experts was the single-leg heel rise endurance test (HRET) which can be used to assess the strength-endurance of the plantar flexors. Muscle weakness of the plantar flexors is hypothesized to be an essential, modifiable risk factor for Achilles tendinopathy.3,5,6 In contrast to individuals without symptoms, individuals suffering from Achilles tendinopathy exhibit significant reductions in both torque and strength-endurance of the plantar flexors.7 Notably, these reductions are observed bilaterally, implying that it is unsuitable to consider the asymptomatic limb as a representative "healthy limb" or to use as a reference for comparisons with the symptomatic limb in research or clinical assessments.7,8 In a large international crosssectional study we presented normative values for App-based HRET metrics such as the number of repetitions, peak height, total displacement and total work. These normative values were adjusted for personal characteristics as we found that lower physical activity levels, female sex and higher BMI negatively influenced HRET performance. We found no significant difference between the dominant and non-dominant leg for any of the HRET metrics. This further stresses the clinical relevance of normative values for the
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