Are You Assessing Achilles Tendinopathy Thoroughly Enough?

Achilles tendinopathy can seem relatively straightforward to diagnose, and we’ve probably all been guilty of jumping to treatment a little too quickly.

But a more thorough assessment can set your patient up for a more effective treatment pathway.

Experts assess suspected Achilles tendinopathy not only to establish the diagnosis, but also to identify meaningful movements to monitor, establish outcomes that matter to the patient and identify factors that may influence rehabilitation.

Dr Ruth Chimenti gives us an insight into how an expert approaches this. In this blog, we’ll cover a few things to include in your assessment, so you have better information to guide your treatment.

If you want to learn everything there is to know about Achilles tendinopathy assessment and management from an expert, watch Ruth’s full Masterclass here.

First, make sure it’s actually Achilles tendinopathy

This seems obvious, but there can be other things going on, and missing these nuances can cost you and your patient.

Achilles tendinopathy is typically characterised by pain localised to the Achilles tendon, pain provoked by tendon-loading activities and pain on palpation. Localised tendon thickening may also be present, although its absence doesn’t rule out the diagnosis. Patients will also commonly report stiffness.

However, several conditions can produce symptoms around the Achilles region.

For midportion symptoms, differential diagnoses include plantaris tendinopathy, paratendonitis, sural nerve neuropathy and symptoms arising from nearby structures such as tibialis posterior, flexor hallucis longus or flexor digitorum longus.

The behaviour and location of symptoms can provide useful clues. For example, paratendonitis may be aggravated by repeated ankle movement even without weight-bearing, such as during swimming. Sural nerve symptoms are more likely to be lateral and have neuropathic qualities such as sharp, shooting or tingling pain.

For insertional symptoms, consider retrocalcaneal or superficial calcaneal bursitis, ankle or subtalar joint pain, Haglund’s deformity, calcaneal bone spurs and, in younger patients, Sever’s disease.

Imaging isn’t routinely required to diagnose Achilles tendinopathy. It may be useful when the diagnosis remains uncertain, progress is delayed or invasive treatment is being considered. Ultrasound is often clinically accessible and relatively low cost and risk.

But imaging findings need context. Around one-quarter of people without pain can show imaging features of Achilles tendinopathy. Imaging can therefore help with differential diagnosis and education, but shouldn’t become more important than the person in front of you.

Movement Evoked Pain (MEP) assessment

Interestingly, one study found that when people were asked to recall the location of their Achilles pain and this was compared with where they experienced pain during movement, 40% reported a different location.

That makes MEP testing a useful addition to your assessment. Choose a movement or series of movements and record pain before the task, the worst pain experienced during it and symptoms 24 hours later. Also ask exactly where the pain occurs and what it feels like.

The task can be standardised. For example, five single-leg heel raises. Alternatively, they can be specific to the patient; the Patient-Specific Functional Scale can help identify an activity that reliably reproduces their symptoms and matters to them.

This gives you a clinically relevant baseline that you can reproduce as rehabilitation progresses. Watch Ruth explain MEP assessment in this video from her Masterclass:

Use outcome measures

Pain intensity alone doesn’t capture the overall impact of Achilles tendinopathy.

The TENDINS-A provides an Achilles-specific way to assess disability and function. Incorporating a standardised patient-reported outcome measure gives you another reference point for monitoring progress, rather than relying solely on pain ratings or your impression of how the patient is doing.

Watch Ruth explain the TENDINS-A in this clip from her Masterclass:

Assessment beyond pain

An international tendinopathy consensus group identified psychosocial factors as an important domain to assess. Relevant factors include fear of movement, pain beliefs, pain-related self-efficacy and fear avoidance.

For example, does the patient believe pain means they are damaging their tendon? Are they worried that loading could cause a rupture? Have they stopped running, jumping or even walking normally because they are afraid of making things worse? How confident are they that they can manage a temporary increase in symptoms?

These beliefs can directly influence how someone approaches rehabilitation.

Fear of movement is particularly worth assessing at baseline and monitoring over time. Watch Ruth explain why in this video from her Masterclass:

You don’t need to turn every Achilles assessment into an exhaustive psychosocial evaluation. But asking a few targeted questions can identify barriers that won’t appear during a heel raise test.

Wrapping up

A thorough Achilles tendinopathy assessment shouldn’t just leave you more confident in the diagnosis, it should give you information you can use to guide rehabilitation.

Applying these principles can give you a more complete picture of what is limiting your patient, while establishing meaningful outcomes you can track as rehabilitation progresses.

Want an in-depth understanding of current Achilles tendinopathy assessment and management? Watch Ruth’s full Masterclass here.