***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 Background The common regime of eccentric exercise in use for Achilles tendinopathy is somewhat arduous and compliance issues can arise . This is the first study to investigate the effectiveness of a regime of fewer exercise sessions combined with photobiomodulation for the treatment of Achilles tendinopathy . Methods A double blind r and omized controlled trial and intention-to-treat analysis were performed . Eighty participants , 18–65 years with Achilles tendinopathy and symptoms for longer than 3 months , were included in the trial . Participants r and omized into one of four groups ; 1 ( Placebo + Ex Regime 1 ) or 2 ( Laser + Ex Regime 1 ) or 3 ( Placebo + Ex Regime 2 ) or 4 ( Laser + Ex Regime 2 ) . The primary outcome measure was the Victorian Institute of Sports Assessment -Achilles ( VISA-A ) question naire . Outcomes were collected at baseline , week 4 and week 12 . Results Sixteen participants were lost to follow-up at 12 weeks , 4 of which due to adverse reactions . As per intention to treat , missing data were imputed , 80 participants were included in the final analysis . For VISA-A at 12 weeks , group 4 achieved significant gains over the other 3 groups : group 1 ( 18.5 [ 9.1 , 27.9 ] ) , group 2 ( 10.4 [ 1.5 , 19.2 ] ) , group 3 ( 11.3 [ 3.0 , 19.6 ] ) . There was a moderate effect size in favour of exercise twice per week ( 7.2 [ −1.8 , 16.2 ] , ES .7 ) . Conclusions Twice-daily exercise sessions are not necessary as equivalent results can be obtained with two exercise sessions per week . The addition of photobiomodulation as adjunct to exercise can bring added benefit Objective The study examined whether the addition of a night splint to eccentric exercises is beneficial for functional outcome in chronic midportion Achilles tendinopathy . Design One-year follow-up of a r and omised controlled single blinded clinical trial . Setting Sports medicine department in a general hospital . Patients 58 patients ( 70 tendons ) were included . Interventions All patients completed a 12-week heavy load eccentric training programme . One group received a night splint in addition to eccentric exercises . Main outcome measurements Outcome scores were : Victorian Institute of Sport Assessment —Achilles ( VISAA ) score , subjective patient satisfaction and neovascularisation score measured with power Doppler ultrasonography ( PDU ) . Results For both groups the VISA-A score increased significantly ( from 50 to 76 ( p<0.01 ) in the eccentric group and from 49 to 78 ( p<0.01 ) in the night splint group ) . No significant differences in the VISA-A score were found between the groups from baseline to one year ( p = 0.32 ) . The presence of neovessels at baseline did not predict a change in the VISA-A score after one year in the whole group ( p = 0.71 ) . Conclusion Eccentric exercises with or without a night splint improved functional outcome at one year follow-up . At follow-up there was no significant difference in clinical outcome when a night splint was used in addition to an eccentric exercise programme . Between 3 months and one year follow-up , a continuing increase in the VISA-A score was found . Assessment of the neovascularisation score with PDU at baseline has no prognostic value on long-term clinical outcome AIM Prognosis and treatment of Achilles tendon pain ( achillodynia ) has been insufficiently studied . The purpose of the present study was to examine the long-term effect of eccentric exercises compared with stretching exercises on patients with achillodynia . METHODS Patients with achillodynia for at least 3 months were r and omly allocated to one of two exercise regimens  . Exercise was performed daily for a 3-month period . Symptom severity was evaluated by tendon tenderness , ultrasonography , a question naire on pain and other symptoms , and a global assessment of improvement . Follow-up was performed at time points 3 , 6 , 9 , 12 weeks and 1 year . RESULTS Of 53 patients with achillodynia 45 patients were r and omized to either eccentric exercises or stretching exercises . Symptoms gradually improved during the 1-year follow-up period and were significantly better assessed by pain and symptoms after 3 weeks and all later visits . However , no significant differences could be observed between the two groups . Women and patients with symptoms from the distal part of the tendon had significantly less improvement . CONCLUSIONS Marked improvement in symptoms and findings could be gradually observed in both groups during the 1-year follow-up period . To that extent this is due to effect of both regimens or the spontaneous improvement is unsettled Aim To evaluate the effectiveness of customised foot orthoses in chronic mid-portion Achilles tendinopathy . Methods This was a participant-blinded , parallel-group r and omised controlled trial at a single centre ( La Trobe University , Melbourne , Australia ) . One hundred and forty participants aged 18–55 years with mid-portion Achilles tendinopathy were r and omised to receive eccentric calf muscle exercises with either customised foot orthoses ( intervention group ) or sham foot orthoses ( control group ) . Allocation to intervention was concealed . The Victorian Institute of Sports Assessment -Achilles ( VISA-A ) question naire was completed at baseline , then at 1 , 3 , 6 and 12 months , with 3 months being the primary end point . Differences between groups were analysed using intention to treat with analysis of covariance . Results After r and omisation into the customised foot orthoses group ( n=67 ) or sham foot orthoses group ( n=73 ) , there was 70.7 % follow-up of participants at 3 months . There were no significant differences between groups at any time point . At 3 months , the mean ( SD ) VISA-A score was 82.1 ( 16.3 ) and 79.2 ( 20.0 ) points for the customised and sham foot orthosis groups , respectively ( adjusted mean difference ( 95 % CI)=2.6 ( −2.9 to 8.0 ) , p=0.353 ) . There were no clinical ly meaningful differences between groups in any of the secondary outcome measures . Conclusions Customised foot orthoses , prescribed according to the protocol in this study , are no more effective than sham foot orthoses for reducing symptoms and improving function in people with mid-portion Achilles tendinopathy undergoing an eccentric calf muscle exercise programme . Trial Registration Number Australian New Zeal and Clinical Trials Registry : number ACTRN12609000829213 Achilles tendinopathy is common and treatment with eccentric exercises seems promising . We design ed a prospect i ve r and omized clinical trial to test the hypothesis that eccentric calf muscle exercises reduce pain and improve function in patients with Achilles tendinopathy . Forty-four patients were recruited from primary care ( mean age : 45 years ; 23 women ; 65 % active in sports ) and r and omized to three treatment groups for 12 weeks :  eccentric exercises , a night splint or a combination of both treatments . Pain and function were evaluated at 6 , 12 , 26 and 52 weeks by the Foot and Ankle Outcome Score . At 6 weeks , the eccentric group reported a significant pain reduction ( 27 % compared with baseline , P = 0.007 ) which lasted for 1 year ( 42 % , P = 0.001 ) . The two groups treated with a night splint also reported significant but less pain reduction than the eccentric group . Differences between all the three groups were not significant . At 12 weeks , the eccentric group reported significantly less pain than the splint-only group ( P = 0.04 ) . More patients in the eccentric group than in the splint group returned to sport after 12 weeks . We conclude that eccentric exercises seem to reduce pain and improve function in patients with Achilles tendinopathy . Our results are in line with previous studies and strengthen the recommendation that patients should undergo an eccentric exercise program prior to considering other treatments such as surgery Background Achilles tendinopathy is a common condition that can cause marked pain and disability . Numerous non-surgical treatments have been proposed for the treatment of this condition , but many of these treatments have a poor or non-existent evidence base . The exception to this is eccentric calf muscle exercises , which have become a st and ard non-surgical intervention for Achilles tendinopathy . Foot orthoses have also been advocated as a treatment for Achilles tendinopathy , but the long-term efficacy of foot orthoses for this condition is unknown . This manuscript describes the design of a r and omised trial to evaluate the efficacy of customised foot orthoses to reduce pain and improve function in people with Achilles tendinopathy . Methods One hundred and forty community-dwelling men and women aged 18 to 55 years with Achilles tendinopathy ( who satisfy inclusion and exclusion criteria ) will be recruited . Participants will be r and omised , using a computer-generated r and om number sequence , to either a control group ( sham foot orthoses made from compressible ethylene vinyl acetate foam ) or an experimental group ( customised foot orthoses made from semi-rigid polypropylene ) . Both groups will be prescribed a calf muscle eccentric exercise program , however , the primary difference between the groups will be that the experimental group receive customised foot orthoses , while the control group receive sham foot orthoses . The participants will be instructed to perform eccentric exercises 2 times per day , 7 days per week , for 12 weeks . The primary outcome measure will be the total score of the Victorian Institute of Sport Assessment - Achilles ( VISA-A ) question naire . The secondary outcome measures will be participant perception of treatment effect , comfort of the foot orthoses , use of co- interventions , frequency and severity of adverse events , level of physical activity and health-related quality of life ( assessed using the Short-Form-36 question naire - Version two ) . Data will be collected at baseline , then at 1 , 3 , 6 and 12 months . Data will be analysed using the intention to treat principle . Discussion This study is the first r and omised trial to evaluate the long-term efficacy of customised foot orthoses for the treatment of Achilles tendinopathy . The study has been pragmatically design ed to ensure that the study findings are generalisable to clinical practice .Trial registration Australian New Zeal and Clinical Trials Registry Number : ACTRN12609000829213 In a previous uncontrolled pilot study we demonstrated very good clinical results with eccentric calf muscle training on patients with painful chronic Achilles tendinosis located at the 2–6 cm level in the tendon . In the present prospect i ve multicenter study ( Sundsvall and Umeå ) patients with painful chronic Achilles tendinosis at the 2–6 cm level in the tendon were r and omized to treatment with either an eccentric or a concentric training regimen for the calf muscles . The study included 44 patients , with 22 patients ( 12 men , 10 women ; mean age 48 years ) in each treatment group .  The amount of pain during activity ( jogging or walking ) was recorded by the patients on a visual analogue scale , and patient satisfaction was assessed before and after treatment . The patients were instructed to perform their eccentric or concentric training regimen on a daily basis for 12 weeks . In both types of treatment regimen the patients were told to do their exercises despite experiencing pain or discomfort in the tendon during exercise . The results showed that after the eccentric training regimen 82 % of the patients ( 18/22 ) were satisfied and had resumed their previous activity level 
    Output:
    
Moderate level evidence favoured eccentric exercise over control for improving pain and function in mid-portion tendinopathy .
Moderate level evidence favoured eccentric exercise over concentric exercise for reducing pain .
There was moderate level evidence of no significant difference in pain or function between eccentric exercise and heavy slow resistance exercise .
There was low level evidence that eccentric exercise was not superior to stretching for pain or QoL. There was moderate level evidence that a combined exercise protocol was not superior to a lower dosage protocol for improving functional performance .
Eccentric exercise was not superior to splinting for pain ( moderate evidence ) or function ( low level evidence ) .
Summary We conditionally recommend exercise for improving pain and function in mid-portion Achilles tendinopathy .
The balance of evidence did not support recommendation of one type of exercise programme over another .
We conditionally recommend against the addition of a splint to an eccentric exercise protocol and we do not recommend the use of orthoses to improve pain and function in Achilles tendinopathy