***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background —There is no disease specific , reliable , and valid clinical measure of Achilles tendinopathy . Objective —To develop and test a question naire based instrument that would serve as an index of severity of Achilles tendinopathy . Methods —Item generation , item reduction , item scaling , and pretesting were used to develop a question naire to assess the severity of Achilles tendinopathy . The final version consisted of eight questions that measured the domains of pain , function in daily living , and sporting activity . Results range from 0 to 100 , where 100 represents the perfect score . Its validity and reliability were then tested in a population of non-surgical patients with Achilles tendinopathy ( n = 45 ) , presurgical patients with Achilles tendinopathy ( n = 14 ) , and two normal control population s ( total n = 87 ) . Results —The VISA-A question naire had good test-retest ( r = 0.93 ) , intrarater ( three tests , r = 0.90 ) , and interrater ( r = 0.90 ) reliability as well as good stability when compared one week apart ( r = 0.81 ) . The mean ( 95 % confidence interval ) VISA-A score in the non-surgical patients was 64 ( 59–69 ) , in presurgical patients 44 ( 28–60 ) , and in control subjects it exceeded 96 ( 94–99 ) . Thus the VISA-A score was higher in non-surgical than presurgical patients ( p = 0.02 ) and higher in control subjects than in both patient population s ( p<0.001 ) . Conclusions —The VISA-A question naire is reliable and displayed construct validity when means were compared in patients with a range of severity of Achilles tendinopathy and control subjects . The continuous numerical result of the VISA-A question naire has the potential to provide utility in both the clinical setting and research . The test is not design ed to be diagnostic . Further studies are needed to determine whether the VISA-A score predicts prognosis Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more Tendinopathy is one of the most frequent overuse injuries associated with sport . It is a failure of a chronic healing response associated with both chronic overloaded and unloaded states . Although several conservative therapeutic options have been proposed , very few of them are supported by r and omized controlled trials . Eccentric exercises provide excellent clinical results both in athletic and sedentary patients , with no reported adverse effects . Combining eccentric loading and low-energy shock wave therapy produces higher success rates compared with eccentric training alone or shock wave therapy alone . High-volume injection of normal saline solution , corticosteroids , or anesthetics can reduce pain and improve long-term function in patients with Achilles or patellar tendinopathy . The use of injectable substances such as platelet-rich plasma , autologous blood , polidocanol , and corticosteroids in and around tendons is not support by strong clinical evidence . Further r and omized controlled trials are necessary to define the best conservative management of tendinopathy Objective : To evaluate the efficacy of ultrasound guided dry needling and autologous blood injection for the treatment of patellar tendinosis . Design : Prospect i ve cohort study . Setting : Hospital/clinic based . Patients : 47 knees in 44 patients ( 40 men , 7 women , mean age 34.5 years , age range 17 to 54 years ) with refractory tendinosis underwent sonographic examination of the patellar tendon following referral with a clinical diagnosis of patellar tendinosis ( mean symptom duration 12.9 months ) . Interventions : Ultrasound guided dry needling and injection of autologous blood into the site of patellar tendinosis was performed on two occasions four weeks apart . Main outcome measures : Pre- and post-procedure Victorian Institute of Sport Assessment scores ( VISA ) were collected to assess patient response to treatment . Follow up ultrasound examination was done in 21 patients ( 22 knees ) . Results : Therapeutic intervention led to a significant improvement in VISA score : mean pre-procedure score = 39.8 ( range 8 to 72 ) v mean post procedure score = 74.3 ( range 29 to 100 ) , p<0.001 ; mean follow up 14.8 months ( range 6 to 22 months ) . Patients were able to return to their sporting interests . Follow up sonographic assessment showed a reduction in overall tendon thickness and in the size of the area of tendinosis ( hypoechoic/anechoic areas within the proximal patellar tendon ) . A reduction was identified in interstitial tears within the tendon substance . Neovascularity did not reduce significantly or even increased . Conclusions : Dry needling and autologous blood injection under ultrasound guidance shows promise as a treatment for patients with patellar tendinosis STUDY DESIGN Cohort study of subjects with insertional Achilles tendinopathy ( IAT ) . OBJECTIVES The purpose of this study was to establish the minimum clinical ly important difference ( MCID ) on the Victorian Institute of Sport Assessment - Achilles Question naire ( VISA-A ) and the Lower Extremity Functional Scale ( LEFS ) for patients with IAT . BACKGROUND The VISA-A and LEFS are two measures commonly utilized for patients with IAT . Previous authors have estimated the MCID for the VISA-A , but a MCID has not been formally established . The MCID for the LEFS has been established for patients with lower extremity conditions in general , but it is not clear if this MCID is applicable to patients with IAT . METHODS Fifteen subjects participating in a r and omized controlled trial study ing the effectiveness of intervention for IAT over a 12-week period were included in this study . Subjects completed the VISA-A and LEFS forms at baseline and 12 weeks after the initiation of treatment . All subjects also completed a 15-point global rating of change ( GROC ) question naire at 12 weeks after the initiation of treatment . Subjects were classified as improved or stable based on their GROC scores . RESULTS The area under the curve ( AUC ) for the VISA-A was 0.97 and a MCID of 6.5 points was identified . The AUC for the LEFS was 0.97 and a MCID of 12 points was identified . CONCLUSION The VISA-A and LEFS are both useful outcome measures to assess response in patients with IAT . LEVEL OF EVIDENCE 3 Background : Achilles tendinopathy ( AT ) is a common and difficult to treat musculoskeletal disorder . Purpose : To examine whether 1 injection of platelet-rich plasma ( PRP ) would improve outcomes more effectively than placebo ( saline ) after 3 months in patients with AT . Study Design : R and omized controlled trial ; Level of evidence , 1 . Methods : A total of 24 patients with chronic AT ( median disease duration , 33 months ) were r and omized ( 1:1 ) to receive either a blinded injection of PRP ( n = 12 ) or saline ( n = 12 ) . The primary endpoint was improvement in Victorian Institute of Sports Assessment –Achilles ( VISA-A ) score at 3 months . Secondary outcomes were pain at rest , pain while walking , pain when tendon was squeezed , ultrasonographic changes in tendon thickness , and color Doppler activity . Patients were informed that they could drop out after 3 months if they were dissatisfied with the treatment . Results : After 3 months , all 24 patients were reassessed ( no dropouts ) . No difference between the PRP and the saline group could be observed with regard to the primary outcome ( VISA-A score : mean difference [ MD ] , –1.3 ; 95 % CI , −17.8 to 15.2 ; P = .868 ) . Secondary outcomes were pain at rest ( MD , 1.6 ; 95 % CI , −0.5 to 3.7 ; P = .137 ) , pain while walking ( MD , 0.8 ; 95 % CI , −1.8 to 3.3 ; P = .544 ) , pain when tendon was squeezed ( MD , 0.3 ; 95 % CI , −0.2 to 0.9 ; P = .208 ) , color Doppler activity ( MD , 0.3 ; 95 % CI , −0.2 to 0.8 ; P = .260 ) , and tendon thickness ( MD , 0.8 mm ; 95 % CI , 0.1 to 1.6 mm ; P = .030 ) . After the 3-month follow-up , a large dropout was observed : 75 % of patients in the PRP group and 33 % in the saline group . Conclusion : PRP injection did not result in an improved VISA-A score over a 3-month period in patients with chronic AT compared with placebo . The only secondary outcome demonstrating a statistically significant difference between the groups was change in tendon thickness ; this difference indicates that a PRP injection could increase tendon thickness compared with saline injection . The conclusions are limited to the 3 months after treatment owing to the large dropout rate Background Achilles tendinopathy is a common disease among both athletes and in the general population in which the use of platelet-rich plasma has recently been increasing . Good evidence for the use of this autologous product in tendinopathy is limited , and data on longer-term results are lacking . Purpose To study the effects of a platelet-rich plasma injection in patients with chronic midportion Achilles tendinopathy at 1-year follow-up . Study Design R and omized controlled trial ; Level of evidence , 1 . Methods Fifty-four patients , aged 18 to 70 years , with chronic tendinopathy 2 to 7 cm proximal to the Achilles tendon insertion were r and omized to receive either a blinded injection containing platelet-rich plasma or saline ( placebo group ) in addition to an eccentric training program . The main outcome was the vali date d Victorian Institute of Sports Assessment –Achilles score . Patient satisfaction was recorded and ultrasound examination performed at baseline and follow-up . Results The mean Victorian Institute of Sports Assessment –Achilles score improved in both the platelet-rich plasma group and the placebo group after 1 year . There was no significant difference in increase between both groups ( adjusted between-group difference , 5.5 ; 95 % confidence interval , –4.9 to 15.8 , P = .292 ) . In both groups , 59 % of the patients were satisfied with the received treatment . Ultrasonographic tendon structure improved significantly in both groups but was not significantly different between groups ( adjusted between-group difference , 1.2 % ; 95 % confidence interval , –4.1 to 6.6 , P = .647 ) . Conclusion This r and omized controlled trial showed no clinical and ultrasonographic superiority of platelet-rich plasma injection over a placebo injection in chronic Achilles tendinopathy at 1 year combined with an eccentric training program OBJECTIVE Achilles tendinopathy is prevalent in athletes , but can also affect sedentary patients . We studied the effects of eccentric exercises in sedentary non-athletic patients with Achilles tendinopathy . METHODS Thirty-four sedentary patients ( 18 males , average age 44 years , range 23 - 67 ; 16 females , average age 51 years , range 20 - 76 ; average BMI : 28.6+/-4.7 , range 22.1 - 35.4 ) with a clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A question naire at first attendance ( 39+/-S.D. 22.8 ) and at their subsequent visits . The patients underwent a grade d progressive eccentric calf strengthening exercises programme for 12 weeks . RESULTS Fifteen patients ( 44 % ) did not improve with  eccentric exercise regimen . Three patients improved after perintendinous injections aprotinin and local anaesthetic . Surgery was performed in seven patients as 6 months of conservative management failed to produce improvements . The overall average VISA-A scores at latest follow up was 50 ( S.D. 26.5 ) . CONCLUSIONS Eccentric exercises , though effective in nearly 60 % of our patients , may not benefit sedentary patients to the same extent reported in athletes We prospect ively studied the effect of heavy-load eccentric calf muscle training in 15 recreational athletes ( 12 men and 3 women ; mean age , 44.3 7.0 years ) who had the diagnosis of chronic Achilles tendinosis ( degenerative changes ) with a long duration of symptoms despite conventional nonsurgical treatment .  Calf muscle strength and the amount of pain during activity ( recorded on a visual analog scale ) were measured before onset of training and after 12 weeks of eccentric training . At week 0 , all patients had Achilles tendon pain not allowing running activity , and there was significantly lower eccentric and concentric calf muscle strength on the injured compared with the noninjured side . After the 12-week training period , all 15 patients were back at their preinjury levels with full running activity . There was a significant decrease in pain during activity , and the calf muscle strength on the injured side had increased significantly and did not differ significantly from that of the noninjured side . A comparison group of 15 recreational athletes with the same diagnosis and a long duration of symptoms had been treated conventionally , i.e. , rest , nonsteroidal antiinflammatory drugs , changes of shoes or orthoses , physical therapy , and in all cases also with ordinary training programs . In no case was the conventional treatment successful , and all patients were 
    Output:
    
Conclusions PRP injection with eccentric training did not improve VISA-A scores , reduce tendon thickness , or reduce color Doppler activity in patients with chronic Achilles tendinopathy compared with saline injection .