2 37 ICON 2023: Core Outcomes for Achilles Tendinopathy structural validity, most studies did not determine this aspect of validity and when it was reported, it was not done using a unidimensional structure. The ongoing inclusion of the VISA-A in the COS-AT (as for any other outcome measure) should be considered against those reviews, and in light of further evaluation of its psychometric properties. However, a notable strength of the VISA-A is that is has been cross-culturally adapted and validated in a broad spectrum of languages.22-28 Another reason why it is currently useful to include the VISA-A questionnaire (as well as VAS related to loading) in the COS-AT is the fact that most previous clinical studies used these outcome measurement instruments.5,7,8 With the aim of improving the ability to synthesize data for meta-analyses in the future, it is likely of benefit that future clinical trials can also be statistically compared against previous ones. Another possible limitation is that we have not included recently developed outcome measurement instruments – as our evidence search census date was March 2021. For example, the TENDINopathy Severity Assessment – Achilles (TENDINS-A) has been recently developed from interviews with patients and clinicians having adequate content validity,29 as well as excellent reliability and structural validity.30 The VISA-A has also been recently developed for sedentary individuals and might be included in the future.31 Our scan of the literature since the census date has not identified any other outcome measurement instruments that would have likely changed the outcome of our COS-AT. When new measurement instruments become available the COS-AT will need to be reviewed and if deemed appropriate it would need a revision with the current COS-AT as foundation. What comes next? Future research should focus on evaluating the clinimetric properties of specific outcome measurement instruments, which have limited evidence but were included in the COS-AT. Furthermore, the COS-AT currently does not cover several core domains in tendinopathy, including patient overall rating, participation, function, psychological factors, quality of life, and pain over a specific time frame.7 Future research should focus on assessing the reliability and validity of outcome measurement instruments within these core domains or to develop new instruments to determine their potential inclusion in the COS-AT. Valid imaging outcomes could be developed for use alongside the COS-AT, but were not included in this process as imaging was not included as core domain. Knowledge dissemination plays a crucial role in ensuring the widespread adoption of the COS-AT within research and clinical practice.32 Efforts should be directed towards effectively communicating the importance of this COS-AT, hereby enhancing its integration into clinical practice guidelines, and facilitating its use in future clinical trials. Continuous engagement with relevant stakeholders, such as professional participants and patients, is important to ensure that the COS-AT will be used widely, ultimately advancing the standardization and quality of care for individuals with Achilles tendinopathy.
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