9 165 General discussion tendinopathy. Current guidelines advice to start treatment of Achilles tendinopathy with patient education as a cornerstone of the treatment together with load-management and progressive calf muscle strengthening exercises for at least 12 weeks.3,4 This education should consist of 1) explanation about the condition, 2) explanation about the prognosis and 3) pain education and addressing psychological factors.3 The significance of patient education has become increasingly evident in enhancing treatment results in general healthcare52,53, and increasing patient’s knowledge about their condition also plays an important role in improving treatment outcomes in Achilles tendinopathy.54 Could patient education be improved with the use of imaging? Prior studies have demonstrated that collaborative image viewing with patients can enhance their comprehension of their condition, positively influence the nature of the interactions between the clinician and the patient, and can influence their health-related behavioural intentions.55-57 Importantly, the use of ultrasound in patient education in patients with rheumatic and juvenile arthritis has led to improved treatment adherence.58-60 Further research into the value of incorporating imaging into patient education for Achilles tendinopathy patients is necessary to determine if including imaging remains useful in the management of Achilles tendinopathy. PROGNOSTIC FACTORS Prognostic factors play an important role in modern medicine and can help healthcare providers estimate the course of a disease to tailor treatment strategies to individual patients. In the field of oncology for example, the identification of specific tumour characteristics, such as genetic mutations and biomarkers, has paved the way for more personalized and effective treatment options.61 The current conservative treatment for Achilles tendinopathy may not be very effective as one-thirds of patients with new-onset Achilles tendinopathy remain symptomatic at one-year follow-up62 and at ten years of follow-up, up to a quarter of patients continue to experience symptoms.63 However, it is unclear which patients will have a (un)favourable response to treatment as knowledge of prognostic factors is currently limited.3 In a large prospective cohort study, we found that socio-economic status had effect on response to standardized treatment; at 24 weeks follow-up patients with high socioeconomic status reported significantly less symptoms compared to patients with low-socioeconomic status. The mean difference between both groups was 11 points on the Victorian Institute of Sports Assessment-Achilles (VISA-A) scale which is larger than the Minimal Clinically Important Difference (7 points) and therefore regarded as clinically relevant.64,65 It was striking that the difference in VISA-A score mainly occurred between 12 and 24-weeks follow up, with a lack of improvement in patients with low socio-economic status. It could be that reduced access to healthcare and absence of guided rehabilitation for prolonged periods in patients with low socio-economic status
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