P: (07) 839 1800 F: (07) 839 1810

E: [email protected] W: www.riverradiology.co.nz
A: Victoria Clinic, A: Hood St Clinic,
750 Victoria St, Hamilton 3204 30 Hood St, Hamilton 3204

Please return by fax or email to:

[email protected]

The VISA-A Questionnaire: An index of the severity of Achilles tendinopathy

Personal Information

Name Date of Birth

In this questionnaire, the term pain refers specifically to pain the in Achilles Tendon region.

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

0 1 2 3 4 5 6 7 8 9 10
100 Minutes (Please circle the corresponding number) 0 Minutes Points Subtotal

2. Once you are warmed up for the day, do you have pain when stretching the Achilles tendon
fully over the edge of a step? (keeping knee straight)

0 1 2 3 4 5 6 7 8 9 10
Severe Pain (Please circle the corresponding number) No Pain Points Subtotal

3. After walking on flat ground for 30 minutes, do you have pain within the next 2 hours?
(If unable to walk on flat ground for 30 minutes because of pain, score 0 for this question).

0 1 2 3 4 5 6 7 8 9 10

Severe Pain (Please circle the corresponding number) No Pain Points Subtotal

4. Do you have pain walking downstairs with a normal gait cycle?

0 1 2 3 4 5 6 7 8 9 10
Severe Pain (Please circle the corresponding number) No Pain Points Subtotal

5. Do you have pain during or immediately after doing 10 (single leg) heel raises from a flat surface?

0 1 2 3 4 5 6 7 8 9 10
Severe Pain (Please circle the corresponding number) No Pain Points Subtotal
 P: (07) 839 1800 F: (07) 839 1810

E: [email protected] W: www.riverradiology.co.nz
A: Victoria Clinic, A: Hood St Clinic,
750 Victoria St, Hamilton 3204 30 Hood St, Hamilton 3204

Please return by fax or email to:

[email protected]

6. How many single leg hops can you do without pain?

0 1 2 3 4 5 6 7 8 9 10
(Please circle the corresponding number) Points Subtotal

7. Are you currently undertaking sport or other physical activity?

0 Not at all
1 Modified training ± modified competition
2 Full training ± competition but not at same level as when symptoms began
3 Competing at the same or higher level as when symptoms began

(Please tick the corresponding box) Points Subtotal

8. Please complete EITHER A, B or C in this question.

• If you have no pain while undertaking Achilles tendon loading sports please complete Q8a only.
• If you have pain while undertaking Achilles tendon loading sports but it does not stop you from completing the
activity, please complete Q8b only.
• If you have pain that stops you from completing Achilles tendon loading sports, please complete Q8c only.

A. If you have no pain while undertaking Achilles tendon loading sports, for how long can you train/practise?

Nil 1-10 mins 11-20 mins 21-30 mins >30 mins

0 7 14 21 30

(Please tick the corresponding box) Points Subtotal

B. If you have some pain while undertaking Achilles tendon loading sport, but it does not stop you from
completing your training/practice for how long can you train/practise?

Nil 1-10 mins 11-20 mins 21-30 mins >30 mins

0 7 14 21 30

(Please tick the corresponding box) Points Subtotal

C. If you have pain that stops you from completing your training/practice in Achilles tendon loading sport, for how
long can you train/practise?

Nil 1-10 mins 11-20 mins 21-30 mins >30 mins

0 7 14 21 30

(Please tick the corresponding box) Points Subtotal

Total Score: /100

Total: %