Skip to main content
PMC home page
British Journal of Sports Medicine logoLink to British Journal of Sports Medicine
. 2001 Oct;35(5):335–341. doi: 10.1136/bjsm.35.5.335

The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy

J Robinson 1, J Cook 1, C Purdam 1, P Visentini 1, J Ross 1, N Maffulli 1, J Taunton 1, K Khan 1
PMCID: PMC1724384  PMID: 11579069

Abstract

Background—There is no disease specific, reliable, and valid clinical measure of Achilles tendinopathy.

Objective—To develop and test a questionnaire 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 questionnaire 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 populations (total n = 87).

Results—The VISA-A questionnaire 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 populations (p<0.001).

Conclusions—The VISA-A questionnaire 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 questionnaire has the potential to provide utility in both the clinical setting and research. The test is not designed to be diagnostic. Further studies are needed to determine whether the VISA-A score predicts prognosis.

Key Words: Achilles; tendinopathy; tendinitis; outcome; questionnaire

Full Text

The Full Text of this article is available as a PDF (131.8 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Alfredson H., Lorentzon R. Chronic Achilles tendinosis: recommendations for treatment and prevention. Sports Med. 2000 Feb;29(2):135–146. doi: 10.2165/00007256-200029020-00005. [DOI] [PubMed] [Google Scholar]
  2. Alfredson H., Pietilä T., Jonsson P., Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998 May-Jun;26(3):360–366. doi: 10.1177/03635465980260030301. [DOI] [PubMed] [Google Scholar]
  3. Alfredson H., Pietilä T., Lorentzon R. Chronic Achilles tendinitis and calf muscle strength. Am J Sports Med. 1996 Nov-Dec;24(6):829–833. doi: 10.1177/036354659602400620. [DOI] [PubMed] [Google Scholar]
  4. Almekinders L. C. Tendinitis and other chronic tendinopathies. J Am Acad Orthop Surg. 1998 May-Jun;6(3):157–164. doi: 10.5435/00124635-199805000-00003. [DOI] [PubMed] [Google Scholar]
  5. Bellamy N. Pain assessment in osteoarthritis: experience with the WOMAC osteoarthritis index. Semin Arthritis Rheum. 1989 May;18(4 Suppl 2):14–17. doi: 10.1016/0049-0172(89)90010-3. [DOI] [PubMed] [Google Scholar]
  6. Booth F. W., Gordon S. E., Carlson C. J., Hamilton M. T. Waging war on modern chronic diseases: primary prevention through exercise biology. J Appl Physiol (1985) 2000 Feb;88(2):774–787. doi: 10.1152/jappl.2000.88.2.774. [DOI] [PubMed] [Google Scholar]
  7. Boyden E. M., Kitaoka H. B., Cahalan T. D., An K. N. Late versus early repair of Achilles tendon rupture. Clinical and biomechanical evaluation. Clin Orthop Relat Res. 1995 Aug;(317):150–158. [PubMed] [Google Scholar]
  8. Coleman B. D., Khan K. M., Kiss Z. S., Bartlett J., Young D. A., Wark J. D. Open and arthroscopic patellar tenotomy for chronic patellar tendinopathy. A retrospective outcome study. Victorian Institute of Sport Tendon Study Group. Am J Sports Med. 2000 Mar-Apr;28(2):183–190. doi: 10.1177/03635465000280020801. [DOI] [PubMed] [Google Scholar]
  9. Cook J. L., Khan K. M., Kiss Z. S., Purdam C. R., Griffiths L. Prospective imaging study of asymptomatic patellar tendinopathy in elite junior basketball players. J Ultrasound Med. 2000 Jul;19(7):473–479. doi: 10.7863/jum.2000.19.7.473. [DOI] [PubMed] [Google Scholar]
  10. Cook J. L., Kiss Z. S., Khan K. M. Patellar tendinitis: the significance of magnetic resonance imaging findings. Am J Sports Med. 1999 Nov-Dec;27(6):831–831. doi: 10.1177/03635465990270062601. [DOI] [PubMed] [Google Scholar]
  11. Downie W. W., Leatham P. A., Rhind V. M., Wright V., Branco J. A., Anderson J. A. Studies with pain rating scales. Ann Rheum Dis. 1978 Aug;37(4):378–381. doi: 10.1136/ard.37.4.378. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Flandry F., Hunt J. P., Terry G. C., Hughston J. C. Analysis of subjective knee complaints using visual analog scales. Am J Sports Med. 1991 Mar-Apr;19(2):112–118. doi: 10.1177/036354659101900204. [DOI] [PubMed] [Google Scholar]
  13. Harms-Ringdahl K., Carlsson A. M., Ekholm J., Raustorp A., Svensson T., Toresson H. G. Pain assessment with different intensity scales in response to loading of joint structures. Pain. 1986 Dec;27(3):401–411. doi: 10.1016/0304-3959(86)90163-6. [DOI] [PubMed] [Google Scholar]
  14. Harrison E., Magee D., Quinney H. Development of a clinical tool and patient questionnaire for evaluation of patellofemoral pain syndrome patients. Clin J Sport Med. 1996 Jul;6(3):163–170. doi: 10.1097/00042752-199607000-00005. [DOI] [PubMed] [Google Scholar]
  15. Huskisson E. C., Jones J., Scott P. J. Application of visual-analogue scales to the measurement of functional capacity. Rheumatol Rehabil. 1976 Aug;15(3):185–187. doi: 10.1093/rheumatology/15.3.185. [DOI] [PubMed] [Google Scholar]
  16. Huskisson E. C. Measurement of pain. Lancet. 1974 Nov 9;2(7889):1127–1131. doi: 10.1016/s0140-6736(74)90884-8. [DOI] [PubMed] [Google Scholar]
  17. Höher J., Münster A., Klein J., Eypasch E., Tiling T. Validation and application of a subjective knee questionnaire. Knee Surg Sports Traumatol Arthrosc. 1995;3(1):26–33. doi: 10.1007/BF01553522. [DOI] [PubMed] [Google Scholar]
  18. Józsa L., Kvist M., Bálint B. J., Reffy A., Järvinen M., Lehto M., Barzo M. The role of recreational sport activity in Achilles tendon rupture. A clinical, pathoanatomical, and sociological study of 292 cases. Am J Sports Med. 1989 May-Jun;17(3):338–343. doi: 10.1177/036354658901700305. [DOI] [PubMed] [Google Scholar]
  19. Kaikkonen A., Kannus P., Järvinen M. A performance test protocol and scoring scale for the evaluation of ankle injuries. Am J Sports Med. 1994 Jul-Aug;22(4):462–469. doi: 10.1177/036354659402200405. [DOI] [PubMed] [Google Scholar]
  20. Khan K. M., Maffulli N. Tendinopathy: an Achilles' heel for athletes and clinicians. Clin J Sport Med. 1998 Jul;8(3):151–154. [PubMed] [Google Scholar]
  21. Khan K. M., Visentini P. J., Kiss Z. S., Desmond P. M., Coleman B. D., Cook J. L., Tress B. M., Wark J. D., Forster B. B. Correlation of ultrasound and magnetic resonance imaging with clinical outcome after patellar tenotomy: prospective and retrospective studies. Victorian Institute of Sport Tendon Study Group. Clin J Sport Med. 1999 Jul;9(3):129–137. doi: 10.1097/00042752-199907000-00003. [DOI] [PubMed] [Google Scholar]
  22. Kirkley A., Griffin S., McLintock H., Ng L. The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability. The Western Ontario Shoulder Instability Index (WOSI). Am J Sports Med. 1998 Nov-Dec;26(6):764–772. doi: 10.1177/03635465980260060501. [DOI] [PubMed] [Google Scholar]
  23. Kitaoka H. B., Patzer G. L. Analysis of clinical grading scales for the foot and ankle. Foot Ankle Int. 1997 Jul;18(7):443–446. doi: 10.1177/107110079701800713. [DOI] [PubMed] [Google Scholar]
  24. Kvist M. Achilles tendon injuries in athletes. Sports Med. 1994 Sep;18(3):173–201. doi: 10.2165/00007256-199418030-00004. [DOI] [PubMed] [Google Scholar]
  25. Leppilahti J., Forsman K., Puranen J., Orava S. Outcome and prognostic factors of achilles rupture repair using a new scoring method. Clin Orthop Relat Res. 1998 Jan;(346):152–161. [PubMed] [Google Scholar]
  26. Lian O., Holen K. J., Engebretsen L., Bahr R. Relationship between symptoms of jumper's knee and the ultrasound characteristics of the patellar tendon among high level male volleyball players. Scand J Med Sci Sports. 1996 Oct;6(5):291–296. doi: 10.1111/j.1600-0838.1996.tb00473.x. [DOI] [PubMed] [Google Scholar]
  27. Lysholm J., Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982 May-Jun;10(3):150–154. doi: 10.1177/036354658201000306. [DOI] [PubMed] [Google Scholar]
  28. Maffulli N., Testa V., Capasso G., Bifulco G., Binfield P. M. Results of percutaneous longitudinal tenotomy for Achilles tendinopathy in middle- and long-distance runners. Am J Sports Med. 1997 Nov-Dec;25(6):835–840. doi: 10.1177/036354659702500618. [DOI] [PubMed] [Google Scholar]
  29. Mafi N., Lorentzon R., Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc. 2001;9(1):42–47. doi: 10.1007/s001670000148. [DOI] [PubMed] [Google Scholar]
  30. Paavola M., Kannus P., Paakkala T., Pasanen M., Järvinen M. Long-term prognosis of patients with achilles tendinopathy. An observational 8-year follow-up study. Am J Sports Med. 2000 Sep-Oct;28(5):634–642. doi: 10.1177/03635465000280050301. [DOI] [PubMed] [Google Scholar]
  31. Percy E. C., Conochie L. B. The surgical treatment of ruptured tendo achillis. Am J Sports Med. 1978 May-Jun;6(3):132–136. doi: 10.1177/036354657800600307. [DOI] [PubMed] [Google Scholar]
  32. Price D. D., McGrath P. A., Rafii A., Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain. 1983 Sep;17(1):45–56. doi: 10.1016/0304-3959(83)90126-4. [DOI] [PubMed] [Google Scholar]
  33. Scott P. J., Huskisson E. C. Measurement of functional capacity with visual analogue scales. Rheumatol Rehabil. 1977 Nov;16(4):257–259. doi: 10.1093/rheumatology/16.4.257. [DOI] [PubMed] [Google Scholar]
  34. Shalaby M., Almekinders L. C. Patellar tendinitis: the significance of magnetic resonance imaging findings. Am J Sports Med. 1999 May-Jun;27(3):345–349. doi: 10.1177/03635465990270031301. [DOI] [PubMed] [Google Scholar]
  35. Thordarson D. B., Krieger L. E. Operative vs. nonoperative treatment of intra-articular fractures of the calcaneus: a prospective randomized trial. Foot Ankle Int. 1996 Jan;17(1):2–9. doi: 10.1177/107110079601700102. [DOI] [PubMed] [Google Scholar]
  36. Visentini P. J., Khan K. M., Cook J. L., Kiss Z. S., Harcourt P. R., Wark J. D. The VISA score: an index of severity of symptoms in patients with jumper's knee (patellar tendinosis). Victorian Institute of Sport Tendon Study Group. J Sci Med Sport. 1998 Jan;1(1):22–28. doi: 10.1016/s1440-2440(98)80005-4. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

[[View Questionnaire]]
brjsmed_35_5_335__index.html (567B, html)
brjsmed_35_5_335__1.pdf (86.9KB, pdf)

Articles from British Journal of Sports Medicine are provided here courtesy of BMJ Publishing Group

RESOURCES