9 159 General discussion assessment of calf muscle strength and endurance. Clinicians can employ these normative values, openly available as calculator at www.achillestendontool.com/HRET, to assess whether a patient's strength-endurance falls within the established norms. This can aid in individualized patient evaluation and contribute to well-informed rehabilitation guidance. Furthermore, there is an opportunity for researchers to delve deeper into the prognostic significance and the utility of monitoring strength-endurance in relation to Patient-Reported Outcome Measures (PROMs). The combination of the single-leg heel rise endurance test (HRET) and the associated normative values may also hold promising potential for screening individuals at risk of developing Achilles tendinopathy and identifying those with calf muscle strength deficits.8,9 For example, individuals with a history of lower limb tendinopathy5, professional athletes or individuals planning to increase their training load could be screened.5 This early detection can enable healthcare providers to tailor preventive interventions (e.g. performing strengthening exercises of the plantar flexors) to address these deficits and potentially prevent the onset of Achilles tendinopathy. One of the significant benefits of using HRET in this context is its sensitivity to detect deficits in strength-endurance of the plantar flexors, which has been identified as a modifiable risk factor for Achilles tendinopathy.6,7 However, there are some limitations to consider when using the HRET and normative values for preventive purposes. First, it's essential to acknowledge that while muscle weakness is a risk factor, Achilles tendinopathy is a multifactorial condition influenced by various factors such as biomechanical factors and non-modifiable patient characteristics.5 Thus, HRET should be part of a broader assessment that takes these factors into account. Second, the effect of preventive calf muscle strengthening exercises has been scarcely studied, with only one study reporting no effect of this preventive intervention in a selected group (professional football players) and with only 2 sessions of exercises per week during the competitive season.10 Third, it remains a question whether the HRET can be expected to serve as an effective screening tool or prognostic indicator for targeted training in the context of Achilles tendinopathy as the presence of pain in this population may influence the assessment. Patients with Achilles tendinopathy may be limited not only by muscle endurance but also by pain tolerance. This factor introduces a potential limitation, as the HRET assessment may not accurately reflect the true muscle endurance in this patient population. Current guidelines recommend calf muscle strengthening exercises as preventive strategy in a preseason period based on clinical expertise although it is acknowledged that literature on this is lacking.3,11 Further research is needed to evaluate the potential use of preventive interventions for individuals with decreased calf muscle strength at risk of developing symptoms of Achilles tendinopathy. Quality of life is an aspect which has been frequently overlooked when assessing tendinopathy-related outcomes. This recently led to an international group of experts (healthcare providers, researchers and patients) establishing quality of life as core domain
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