Table 4

Barriers to implementing optimal assessment for assessment and monitoring of patients with mid-portion Achilles tendinopathy

Key themeDefinition of key themeExemplar quote
Financial constraintsClinicians are conscious of the financial burden their services place on patients and opt for the outcome measure that would give them the ideal information to inform management strategies.‘Costs can sometimes be an issue. So that’s why they might not engage with physio because again, it’s more cost. And that’s why I always say to them, look, I could do some imaging. I could spend some money on imaging or an MRI or something like that, but I don't want to spend that on you or an injection.’ (Participant 3)
‘Patient cost is definitely part of it.’ (Participant 8)
‘Can they afford to see me every two weeks for follow up?’ (Participant 2)
Time constraintsClinicians reported that having sufficient time within consultations prevents them from assessing everything they would typically like to within consultations.‘Time that they’re allowed to spend at the club. And the time allocated to pre-training screening is actually, pretty limited.’ (Participant 5)
‘I just didn’t have time to do all of them [outcome measures] every single time.’ (Participant 4)
‘Time again [as a barrier] for the more elaborate things like, you know, that one RM lift-off test or whether it’s, endurance tests.’ (Participant 8)
Access to equipmentClinicians reported that access to equipment could be an issue. They may want to do certain assessments but either do not have the equipment or the equipment is being used for another purpose during their patients’ consult.‘I do like to get them on the treadmill or get them out into that space as we have one, but sometimes there’s gym classes and things, we can't access it.’ (Participant 2)
‘For me at work in private practice, I don’t have capacity to look at that. So, if it was part of a program for a patient, they were doing it in Smith machine. For example, at the gym, I’d get them to report back to me.’ (Participant 9)
Patient symptom severityClinicians were conscious of performing too many assessments, which may provide valuable information, at the cost of flaring up the symptoms of a patient with an irritable condition.‘The patient’s symptoms are the perfect barrier to do a strength assessment.’ (Participant 4)
‘I think part of this comes down to how irritable or not it [Achilles tendon] is.’ (Participant 11)
‘Does it [Physical examination] overload the patient?’ (Participant 8)
Access to sports medicine doctorsClinicians reported that in some situations access to sports medicine doctors would be valuable but it is often challenging logistically.‘I think that’s always the barrier. I mean, when we talk about these kind of these amazing sports clubs… they can actually go and do the blood tests, they're on site.’ (Participant 1)
Decreased monitoring once improvement was clearIt was reported that it can be easy to decrease the amount of monitoring when you are getting clear improvements with a patient.‘Athletes… they can tend to slip through the cracks once they start going well, you might not monitor their loads as closely.’ (Participant 5)
Engagement with the management planIt was reported that when someone has failed rehabilitation, or is not progressing at the rate, they may want that having the patient re-engage with healthcare providers can be a challenge.‘So for me, it’s then convincing them to go back to their physio to progress this. Or if they’re not comfortable with that, then finding them someone else who can, who’s good at giving a tendon reloading program. I think that’s one of the biggest barriers I find.’ (Participant 3)
Good communication between healthcare providersCommunication was reported to be an issue and sometimes a clinician within the multidisciplinary team might be performing monitoring; however, with poor communication channels between healthcare providers not everyone is aware of this.‘To have that dialogue with the patient and then try and have that dialogue with the physiotherapist, by sending them a letter outlining what I think is going on and hopefully that they give me correspondence back that it keeps me in the loop.’ (Participant 13)
Knowledge of what to assess and monitorClinicians’ knowledge was reported to be a barrier as inexperienced clinicians are not sure of everything they should be assessing.‘I don’t really know what I don’t know yet. And, I’m still learning my way through lots of things.’ (Participant 2)
Motivation to prepare self-reported outcome measuresThe burden of having to prepare self-reported measures in advance, such as the VISA, was reported. This can lead clinicians to not providing these assessments to patients.‘In brutal honesty, motivation and organization. So if I’m busy, and I don’t get printing off each day, I might not do a VISA, and you can call that laziness.’ (Participant 12)
Patient understandingClinicians feel like patients do not always understand self-reported outcome measures and they can lack confidence in the findings of these tools.‘Sometimes when you get to the functional questions at the end, it just gets the patient gets a bit confused. I think. And I’m not, I’m not sure that it’s, look, it’s obviously been… tested and validated, so it’s a good one, but yeah.’ (Participant 3)
Patient compliance to monitoringWhile patients may have the ideal intentions to monitor things like running distance or daily symptoms, sometimes they will forget and therefore this cannot be provided to the clinician.‘Some things in practice that I say people like, they just forget to do it.’ (Participant 10)
  • RM, Repitition Maximum; VISA, Victorian Institute of Sport Assessment.