***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 : Conservative treatment of patellar tendinopathy has been minimally investigated . Effective vali date d treatment protocol s are required . Objectives : To investigate the immediate ( 12 weeks ) and long term ( 12 months ) efficacy of two eccentric exercise programmes for the treatment of patellar tendinopathy . Methods : This was a prospect i ve r and omised controlled trial of 17 elite volleyball players with clinical ly diagnosed and imaging confirmed patellar tendinopathy . Participants were r and omly assigned to one of two treatment groups : a decline group and a step group . The decline group were required to perform single leg squats on a 25 ° decline board , exercising into tendon pain and progressing their exercises with load . The step group performed single leg squats on a 10 cm step , exercising without tendon pain and progressing their exercises with speed then load . All participants completed a 12 week intervention programme during their preseason . Outcome measures used were the Victorian Institute of Sport Assessment ( VISA ) score for knee function and 100 mm visual analogue scale ( VAS ) for tendon pain with activity . Measures were taken throughout the intervention period and at 12 months . Results : Both groups had improved significantly from baseline at 12 weeks and 12 months . Analysis of the likelihood of a 20 point improvement in VISA score at 12 months revealed a greater likelihood of clinical improvements in the decline group than the step group . VAS scores at 12 months did not differ between the groups . Conclusions : Both exercise protocol s improved pain and sporting function in volleyball players over 12 months . This study indicates that the decline squat protocol offers greater clinical gains during a rehabilitation programme for patellar tendinopathy in athletes who continue to train and play with pain 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 Extracorporeal shockwave therapy has been shown to be effective in the treatment of chronic tendon pathology in the elbow , shoulder , and plantar fascia . This prospect i ve study examines the efficacy of extracorporeal shockwave therapy in the treatment of chronic Achilles tendon disorders . METHODS Twenty-three patients ( 23 feet ) were treated with extracorporeal shockwave therapy for Achilles tendinosis , insertional tendonitis , or both . Indications for treatment were a minimum of 6 months of conservative care , and a visual analog pain score > 5 . The mean follow-up was 20 months ( range , 4 - 35 months ) . RESULTS Ninety-one percent ( 14 patients ) were satisfied or very satisfied ( 23 patients ) with treatment . Eighty-seven percent ( 20 patients ) stated that extracorporeal shockwave therapy improved their condition , 13 % ( 3 patients ) said it did not affect the condition , and none stated that it made them worse . Eighty-seven percent ( 20 patients ) stated they would have the procedure again if given the choice . Four months after extracorporeal shockwave therapy , the mean visual analog score for morning pain decreased from 7.0 to 2.3 , and activity pain decreased from 8.1 to 3.1 . CONCLUSION High-power extracorporeal shockwave therapy is safe , noninvasive , and effective , and it has a role in the treatment of chronic Achilles tendinopathy Introduction Extracorporeal shockwave therapy ( ESWT ) produces good results in the treatment of insertional Achilles tendinopathy . The efficacy of combined administration of dietary supplements with ESWT has not yet been studied . Methods In this prospect i ve , r and omized clinical trial , Shock Waves therapy and Arginine for Achilles Tendinopathy ( SWAAT ) , subjects affected by insertional Achilles tendinopathy were enrolled . Between January and October 2011 , all participants underwent three sessions of ESWT .  In addition , the patients in the experimental group received a daily dietary supplement containing arginine , Vinitrox ( Bio Serae Laboratories SAS , Bram , France ) , collagen , methyl-sulfonyl-methane , vitamin C , and bromelain , while the control group patients received placebo . Results There was no statistically significant difference in the visual analog scale ( VAS ) score between the two groups at 2 months ( 3.9 vs. 5.1 ; P = 0.07 ) , whereas at 6 months the value was significantly lower in the experimental group ( 2.0 vs. 2.9 ; P = 0.04 ) . The difference in the Ankle-Hindfoot Scale score at 2 and 6 months of follow-up ( FU ) was significantly in favor of the experimental group ( 2 months : 85.4 vs. 72.1 ; P = 0.0035 ; 6 months : 92.4 vs. 76.5 ; P = 0.0002 ) . The Roles and Maudsley score also showed a statistically significant difference between the two groups in favor of the experimental arm as regards patient satisfaction ( at 2 months : 1.7 vs. 2.8 ; P < 0.0001 ; at 6 months : 1.5 vs. 2.3 ; P < 0.001 ) . There was a statistically significant reduction in tissue oximetry values compared to baseline in both treatment groups at 2 and 6 months of FU . Comparing the groups , only at the last FU , at 6 months , was a significantly lower oximetry value observed in the experimental group versus controls ( 60.2 vs. 66.0 ; P = 0.007 ) . Conclusion On the basis of the results obtained in this study , the authors conclude that in the treatment of insertional Achilles tendinopathy , ESWT induces a hemodynamic re-equilibrium with an in tendon trophism . The addition of specific dietary supplements could improve the therapeutic response Background : Patellar tendinopathy is a common overuse injury among jumping athletes . No evidence -based treatment guidelines exist . Extracorporeal shockwave therapy ( ESWT ) appears to be a promising treatment but its effectiveness has not been studied in athletes with patellar tendinopathy who have symptoms for 3 to 12 months and are still playing . Purpose : The TOPGAME study was created to determine the effectiveness of ESWT on pain , symptoms , and function in athletes with early symptomatic patellar tendinopathy who are still in training and competition . Study Design : R and omized controlled trial ; Level of evidence , 1 . Methods : Athletes playing volleyball , basketball , or h and ball with patellar tendinopathy for 3 to 12 months were r and omized into the ESWT or placebo group during the first half of the season . The ESWT group received 3 ESWT treatments while the placebo group received sham ESWT . In-season follow-up measurements were 1 , 12 , and 22 weeks after treatment . The primary outcome was severity of patellar tendinopathy determined with the Victorian Institute of Sport Assessment –Patella ( VISA-P ) question naire . Secondary outcome measures were pain during activities of daily living and sports and after functional knee-loading tests rated on a visual analog scale and subjective improvement . Multilevel analyses were performed to determine differences between groups over time . Results : Of the 127 symptomatic athletes invited to participate , 62 were eligible , gave consent , and were r and omized into the ESWT ( n = 31 ) or placebo group ( n = 31 ) . Mean VISA-P scores before and 1 , 12 , and 22 weeks after treatment were 59.4 ( ±11.7 ) , 66.8 ( ±16.2 ) , 66.7 ( ±17.5 ) , and 70.5 ( ±18.9 ) for the ESWT group and 62.4 ( ±13.4 ) , 66.3 ( ±19.0 ) , 68.9 ( ±20.3 ) , and 72.7 ( ±18.0 ) for the placebo group . For the VISA-P , there was a significant effect for time ( P < .01 ) but no treatment × time interaction effect ( P = .82 ) . The same pattern was seen in visual analog scale pain scores . One week after final treatment , significantly more athletes in the ESWT group reported subjective improvement ( 65 % vs 32 % ; χ2 = 6.46 , P = .01 ) . This was the only difference noted between the 2 groups . Conclusion : Extracorporeal shockwave therapy as a solitary treatment during the competitive season has no benefit over placebo treatment in the management of actively competing jumping athletes with patellar tendinopathy who have symptoms for less than 12 months Background Dealing with heterogeneity in meta-analyses is often tricky , and there is only limited advice for authors on what to do . We investigated how authors addressed different degrees of heterogeneity , in particular whether they used a fixed effect model , which assumes that all the included studies are estimating the same true effect , or a r and om effects model where this is not assumed . Methods We sample d r and omly 60 Cochrane review s from 2008 , which presented a result in its first meta- analysis with substantial heterogeneity ( I2 greater than 50 % , i.e. more than 50 % of the variation is due to heterogeneity rather than chance ) . We extracted information on choice of statistical model , how the authors had h and led the heterogeneity , and assessed the method ological quality of the review s in relation to this . Results The distribution of heterogeneity was rather uniform in the whole I2 interval , 50 - 100 % . A fixed effect model was used in 33 review s ( 55 % ) , but there was no correlation between I2 and choice of model ( P = 0.79 ) . We considered that 20 review s ( 33 % ) , 16 of which had used a fixed effect model , had major problems . The most common problems were : use of a fixed effect model and lack of rationale for choice of that model , lack of comment on even severe heterogeneity and of reservations and explanations of its likely causes . The problematic review s had significantly fewer included trials than other review s ( 4.3 vs. 8.0 , P = 0.024 ) . The problems became less pronounced with time , as those review s that were most recently up date d more often used a r and om effects model . Conclusion One-third of Cochrane review s with substantial heterogeneity had major problems in relation to their h and ling of heterogeneity . More attention is needed to this issue , as the problems we identified can be essential for the conclusions of the review Background Results of a previous r and omized controlled trial have shown comparable effectiveness of a st and ardized eccentric loading training and of repetitive low-energy shock-wave treatment ( SWT ) in patients suffering from chronic midportion Achilles tendinopathy . No r and omized controlled trials have tested whether a combined approach might lead to even better results . Purpose To compare the effectiveness of 2 management strategies — group 1 : eccentric loading and group 2 : eccentric loading plus repetitive low-energy shock-wave therapy . Study Design R and omized controlled trial ; Level of evidence , 1 . Methods Sixty-eight patients with a chronic recalcitrant ( > 6 months ) noninsertional Achilles tendinopathy were enrolled in a r and omized controlled study . All patients had received unsuccessful management for > 3 months , including at least ( 1 ) peritendinous local injections , ( 2 ) nonsteroidal anti-inflammatory drugs , and ( 3 ) physiotherapy . A computerized r and om-number generator was used to draw up an allocation schedule . Analysis was on an intention-to-treat basis . Results At 4 months from baseline , the VISA-A score increased in both groups , from 50 to 73 points in group 1 ( eccentric loading ) and from 51 to 87 points in group 2 ( eccentric loading plus shock-wave treatment ) . Pain rating decreased in both groups , from 7 to 4 points in group 1 and from 7 to 2 
    Output:
    
Results Moderate-level evidence suggests ( 1 ) no difference between focused ESWT and placebo ESWT at short and mid-term in PT and ( 2 ) radial ESWT is superior to conservative treatment at short , mid and long term in PHT .
Low-level evidence suggests that ESWT ( 1 ) is comparable to eccentric training , but superior to wait- and -see policy at 4 months in mid-portion AT ; ( 2 ) is superior to eccentric training at 4 months in insertional AT ; ( 3 ) less effective than corticosteroid injection at short term , but ESWT produced superior results at mid and long term in GTPS ; ( 4 ) produced comparable results to control treatment at long term in GTPS ; and ( 5 ) is superior to control conservative treatment at long term in PT .
Conclusion Low level of evidence suggests that ESWT may be effective for some lower limb conditions in all phases of the rehabilitation