88 Chapter 5 METHODS Study design This cross-sectional study was designed at the Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC University Medical Center (Rotterdam, the Netherlands). The study received exemption for comprehensive application from the Medical Ethical Committee (MEC-2021-0033) of the Erasmus MC University Medical Center Rotterdam, the Netherlands. All patients provided digital informed consent for this study. We adhered to the STROBE guideline for reporting of cross-sectional studies and to the minimum reporting standards for tendinopathy studies according to the international consensus (ICON) statement.14,15 Patients Adult patients were eligible when they were referred to the Orthopaedic Surgery and Sports medicine outpatient department of the Erasmus MC University Medical Center with symptoms in the region of the Achilles tendon. General practitioners or medical specialists referred these patients using a referral letter, where the region of the pain was stated. The inclusion period was between September 2018 and September 2020. Patients were included if they provided informed consent and if they completed the digital (baseline) questionnaire before their appointment. Patients were excluded if: (1) they did not record the location of their symptoms on the pain map, (2) the pain was not located in the Achilles tendon region or (3) the symptoms changed in the interval between completion of the digital questionnaire and the consultation with the sports physician. Procedures Patients were consecutively enrolled and asked to complete a digital questionnaire before their outpatient appointment. This questionnaire was send to patients using a software package (GEneric Medical Survey Tracker, GemsTracker) for secure distribution of questionnaires during clinical research. The baseline questionnaire consisted of questions on demographics, lifestyle, work, sports activity and injury characteristics. Based on this information, the Ankle Activity Score (0-10 points) was also established.16 The baseline questionnaire also inquired the region where patients experienced most of their symptoms and patients were asked to indicate this on a standardized digital pain map. If patients had bilateral symptoms they were asked to mark the region of the tendon of the side where they experienced most pain. Figure 1 shows the pain map. Patients could choose one of three options (inferior side of the heel, posterior side of the heel in the insertional region of the Achilles tendon or the midportion region of the Achilles tendon). There was also one option stating ‘none of these regions’. Patients were also asked about the severity of pain during activities of daily living and sports activities (when applicable). Severity of pain was assessed using a Visual Analogue Scale (VAS, 0-10). The validated Victorian
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