Diagnosis

Diagnosis of Achilles tendinopathy is often achieved through patient's history and clinical examination (1)

• should inquire about pain - onset, duration and aggravating factors
  • detailed history should be taken regarding pain to various activities, intensity of training, and exercise technique. Also information about previous treatments should be recorded as well
  • typically pain presents after exercise, 2-6 cm proximal to the site of tendon insertion
• as the disease progresses the patient may have pain during exercise
  • pain may interfere with daily activities in severe cases
  • the degree of morning stiffness correlates to the severity of the disease
  • runners are likely to have pain at the beginning and end of each training session. In between there may be a stage of diminished discomfort (1)
    
    
• during clinical examination
  • both legs should be exposed from above the knees and examination of the leg should be done while the patient is in standing position and in prone position
  • examination of foot and heel should be done to find out any malalignment, deformity, noticeable asymmetry tendon size, localised thickening, Haglund heel or for any previous scars (1)
  • Achilles tendon should be inspected for any swelling, tenderness, heat, increased erythema, nodularity and crepitation
    • during the acute phase - the tendon is diffusely swollen, palpation reveals tenderness (usually greatest in its middle third), crepitation. dorsiflexion of the ankle joint does not cause movement of the area of swelling and tenderness
    • in more chronic phase - crepitation and swelling may diminish, exercise induced pain remains the cardinal symptom, a tender, nodular swelling in patients with chronic disease signify tendiniosis and particularly in these patients dorsiflexion and plantar flexion of the ankle may cause the focal tender nodules to move (2)
  • Achilles tendon rupture should be excluded during clinical examination (3)
• if the tendon is intact, its function should be assessed by provoking tendon pain during tendon-loading activities
  • in majority a simple single-leg heel raises will be adequate to cause pain
  • hopping on the spot or hopping forward may be required in more active individuals to reproduce pain
  • in some athletes repetition of these loading tests may be necessary in order to make a full evaluation of the tendon (3)
    
    
• imaging
  • plain soft tissue radiography - useful in identifying associated or incidental bony abnormalities (4)
  • ultrasound and MRI are the imaging modalities of choice in achilles tendinopathy, colour and power Doppler imaging have recently been included (3)
  • interpretation of imaging results should be done with caution as findings may not correlate with the symptoms of the patient (4)

Reference:

• 1. Kader D et al. Achilles tendinopathy: some aspects of basic science and clinical management. Br J Sports Med. 2002;36(4):239-49
• 2. Paavola M et al. Current Concepts Review: Achilles Tendinopathy. The Journal of Bone and Joint Surgery (American)2002; 84:2062-2076
• 3. Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options. Br J Sports Med. 2007;41(4):211-6
• 4. Maffulli N, Kader D. Tendinopathy of tendo achillis. J Bone Joint Surg Br. 2002;84(1):1-8