***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 
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    ***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 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 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 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 points in group 2 . Nineteen of 34 patients in group 1 ( 56 % ) and 28 of 34 patients in group 2 ( 82 % ) reported a Likert scale of 1 or 2 points ( “ completely recovered ” or “ much improved ” ) . For all outcome measures , groups 1 and 2 differed significantly in favor of the combined approach at the 4-month follow-up . At 1 year from baseline , there was no difference any longer , with 15 failed patients of group 1 opting for having the combined therapy as cross-over and with 6 failed patients of group 2 having undergone surgery . Conclusion At 4-month follow-up , eccentric loading alone was less effective when compared with a combination of eccentric loading and repetitive low-energy shock-wave treatment 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 ( before injury ) , compared to 36 % of the patients ( 8/22 ) who were treated with the concentric training regimen . The results after treatment with eccentric training was significantly better ( P<0.002 ) than after concentric training . The good clinical results previously demonstrated in the pilot study with eccentric calf muscle training on patients with chronic Achilles tendinosis , were thus reproduced in this multicenter , showing superior results to treatment with concentric training BACKGROUND It remains unclear whether application of local anesthesia ( LA ) interferes with clinical efficacy of extracorporeal shock wave therapy ( ESWT ) for chronic plantar fasciitis . AIMS To evaluate the effect of local anesthesia on the clinical outcome after repetitive low-energy ESWT for chronic plantar fasciitis . METHODS Eighty-six patients with chronic plantar fasciitis were r and omly assigned to receive either low-energy ESWT without LA , given weekly for three weeks ( Group I , n=45 ; 3 x 2000 pulses , total energy flux density per shock 0.09 mJ/mm2 ) or identical ESWT with LA ( Group II , n=41 ) . Primary outcome measure was : Reduction of pain from baseline to month 3 post-treatment in a pain numeric rating scale [ 0 - 10 points ] during first steps in the morning , evaluated by an independent blinded observer . Calculations were based on intention-to-treat . RESULTS No difference was found between the groups at baseline . At 3 months , the average pain score was 2.2+/-2.0 points for patients of Group I , and 4.1+/-1.5 points for patients of Group II . The mean between-group difference was 1.9 points ( 95 % CI : [ 1.1 - 2.7 points ] ; P<.001 ) . Significantly more patients of Group I achieved 50 % reduction of pain compared to Group II ( 67 % vs 29 % , P<.001 ) . CONCLUSION ESWT as applied should be done without LA in patients suffering from chronic heel pain .  LA applied prior treatment reduced the efficiency of low-energy ESWT Background Eccentric exercises ( EEs ) are recommended for the treatment of Achilles tendinopathy , but the clinical effect from EE has a slow onset . Hypothesis The addition of low-level laser therapy ( LLLT ) to EE may cause more rapid clinical improvement . Study Design R and omized controlled trial ; Level of evidence , 1 . Methods A total of 52 recreational athletes with chronic Achilles tendinopathy symptoms were r and omized to groups receiving either EE + LLLT or EE + placebo LLLT over 8 weeks in a blinded manner . Low-level laser therapy ( Λ = 820 nm ) was administered in 12 sessions by irradiating 6 points along the Achilles tendon with a power density of 60 mW/cm2 and a total dose of 5.4 J per session . Results The results of the intention-to-treat analysis for the primary outcome , pain intensity during physical activity on the 100-mm visual analog scale , were significantly lower in the LLLT group than in the placebo LLLT group , with 53.6 mm versus 71.5 mm ( P = .0003 ) at 4 weeks , 37.3 mm versus 62.8 mm ( P = .0002 ) at 8 weeks , and 33.0 mm versus 53.0 mm ( P = .007 ) at 12 weeks after r and omization . Secondary outcomes of morning stiffness , active dorsiflexion , palpation tenderness , and crepitation showed the same pattern in favor of the LLLT group . Conclusion Low-level laser therapy , with the parameters used in this study , accelerates clinical recovery from chronic Achilles tendinopathy when added to an EE regimen . For the LLLT group , the results at 4 weeks were similar to the placebo LLLT group results after 12 weeks OBJECTIVE To test the feasibility of a r and 
    Output:
    
Effect sizes from individual RCTs support the use of eccentric exercise .