VISA-A: Achilles Tendon

Name

First NameLast Name

Email

example@example.com

Today's Date

Date

If you are completing this form regarding a different date, enter it here (Month, Day, Year)

Date

Please indicate which achilles tendon this survey is about:

VAS: Overall, how bad is your pain (0=no pain, 100 =maximum imaginable pain)

1. For how many minutes do you have stiffness in the Achilles area on first getting up?

Rows	100 minutes stiffness	90 minutes	80 minutes	70min	60 min	50 min	40 min	30 min	20 min	10 min	No stiffness at all
Minutes

Once you are warmed up for the day, please rate the amount of achilles pain you have for the following activities:

Rows	0 (no pain at all)	1	2	3	4	5	6	7	8	9	10 (strong, severe pain)
2. Stretching the Achilles tendon fully over the edge of a step (with your knee straight).
3. After walking on flat ground for 30 min, how much pain do you have over the next 2 hours? (If unable to walk on flat ground for 30min, score 10 for this question).
4. Pain walking downstairs with normal gait cycle.
5. Pain during or immediately after doing 10 single leg heel raises on flat surface

How many single leg hops can you do without pain?

Rows	10 or more	9	8	7	6	5	4	3	2	1	0 unable to hop
Single leg hops

7. Are you currently involved in any sport or other physical activity?

Please complete only one of the folowing: 8A, 8B, or 8C

For sports which require Achilles tendon loading, select only one of the following:

8A: If you have NO PAIN during sports, how long can you train or practise?

Rows	0 min	1-10 mins	11-20 mins	21-30 mins	>30 mins
8A: If you have NO PAIN during sports, how long can you train or practise?

8B: If you have PAIN but it does NOT STOP YOU from doing sports, how long can you train or practise?

Rows	0 min	1-10 mins	11-20 mins	21-30 mins	>30 mins
8B: If you have PAIN but it does NOT STOP YOU from doing sports, how long can you train or practise?

8C: If PAIN STOPS YOU from completing sports, how long can you train or practice before stopped by PAIN?

Rows	0 min	1-10 mins	11-20 mins	21-30 mins	>30 mins
8C: If PAIN STOPS YOU from completing sports, how long can you train or practice before stopped by PAIN?

VISA-A Score

Office use only:

8A: 0, 7, 14, 21, 30
8B: 0, 4, 10, 14, 20
8C: 0, 2, 5, 7, 10