96 Chapter 5 these locations, but the reported pain locations varied widely.26 This heterogeneity of pain locations made it impossible to assess the level of agreement between pain map location and final diagnosis in patients with knee osteoarthritis.26,27 Children aged 10 – 17 years with an orthopedic condition of the lower leg had a high level of agreement between the identified pain location on a pain map and the physician-determined location of the pain.28 This level of agreement was similar compared to the current study (76% respectively vs. 82%). The diagnostic site was confirmed by an orthopedic surgeon, but because this study only focused on the pain location and diagnostic site and not on the exact diagnosis, a valid comparison between the two studies cannot be made. The strengths of this study are the relatively large sample size and the inclusion of a homogenous group of patients with pain in the Achilles region. Data was collected prospectively and complete for our primary and secondary outcome measures and was obtained in a consistent way by a single sports medicine physician. There are some limitations to this study. These include the academic setting of the study, which may have led to the study population not being representative of the general population of patients with Achilles tendinopathy symptoms. Next to this, patients who do not localise pain to the Achilles region (e.g. to the bottom of the heel) may still have Achilles tendinopathy. In the current study, this was the case in 1 out of 5 patients who reported pain in the inferior heel region. There were also patients who chose the option ‘none of the displayed regions’ and were diagnosed with Achilles tendinopathy, either with or without the presence of another diagnosis (e.g. plantar fasciopathy). There may even be other regions that we did not evaluate, which could be representative for the diagnosis Achilles tendinopathy. Patients were referred by a medical doctor because of pain in the Achilles tendon region, which might have caused selection bias. An additional limitation is the amount of patients with bilateral symptoms, which could have led to inaccuracy in the results if symptoms entailed different regions (midportion/insertional) on both tendons or if a different diagnosis was made on both sides. In the current study this played a minor role as a large majority of these patients (97%) had symptoms in the same region and the same diagnosis was made on both sides. Another limitation is that this study was based on the clinical findings of a single sports physician and was not confirmed by a second examiner. However, several studies demonstrated that the clinical tests used in this study are reliable.6 Future research could focus on further developing the self-administered standardized pain map for patients with pain in the Achilles tendon region and the optimization of agreement between the pain map and physician-determined diagnosis. The figure used in this study could be improved by marking the specific regions on the Achilles tendon. Furthermore, patients could be asked about presence of tendon thickening. This could further improve the reported agreement. Hereafter, the self-administered pain map could be used in epidemiological studies on Achilles tendinopathy and as a screening tool for clinical studies. It could also be used in virtual consultation which may become necessary
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