Lower Limb Tendinopathy Assessment

Original Editor - Mandy Roscher Top Contributors - Mandy Roscher, Kim Jackson, Jess Bell, Tarina van der Stockt and Robin Tacchetti

Introduction

Tendinopathy is associated with localised, load-related tendon pain. It causes decreased function and structural changes, and it is linked with chronic pain and reduced participation in activities. Major risk factors for lower limb tendinopathy include abnormal kinematics and overuse. A thorough assessment is required to diagnose lower limb tendinopathy and identify the contributing and aggravating factors. Clinical reasoning around various differential diagnosis is also important to make sure the diagnosis is accurate.

Pathology can occur in any tendon, but in the lower limb, it commonly affects the Achilles, patella, hamstring, and gluteal tendons. Both the athletic and sedentary populations can be affected by lower limb tendinopathy.

Key Questions to Ask in the Interview / Subjective Assessment

Pain Behaviour

Where is your pain?

A key feature of tendinopathy is localised pain that increases with dose-dependent loading. One exception to this rule is gluteal tendinopathy, which can cause pain to refer down the leg, typically not past the knee.

What aggravates your pain? / What makes your pain worse?

Pain in tendinopathy tends to be aggravated by high tensile load, compressive loads, or a combination of the two. The pain remains localised, but typically increases as the load increases.

24 Hour Pattern

Do you have night pain?

Tendons do not generally cause night pain. Again, gluteus medius tendinopathy is an exception to this rule, as night pain can occur due to compressive loads (e.g., when lying on the affected leg or, alternatively, when lying on the unaffected leg, but the affected leg drops down into adduction).

Do you have any stiffness in the morning?

Tendinopathies often cause morning pain and stiffness, but this normally eases relatively quickly with movement. Other conditions, including various arthritic or inflammatory conditions, also cause morning pain and stiffness, but this pain typically takes longer to ease (i.e., more than 30 minutes) or it doesn't ease. It is important to screen for metabolic, systemic or inflammatory conditions during your assessment. The SCREENDEM tool is useful for screening for inflammatory and rheumatological conditions. Please watch the following optional video if you would like to learn more about this tool.

24-Hour Response

Does your pain subside or increase during activity?

Tendons generally have a warm-up phenomenon. Pain that subsides during activity is generally a strong indicator of tendinopathy. If pain increases during activity, then look at other differential diagnoses or structures around the tendon, such as the tendon sheath and paratenon.

How do you feel the day after?

Tendons are generally painful the day after energy storage activities. We can determine a tendon’s irritability based on its 24-hour response to activity. If pain remains for more than 24 hours after an activity, the tendon is classified as irritable. If the pain is the same or settles within 24 hours, then it can be classified as stable. Irritability is an important consideration when determining the stage of tendinopathy and at what level to commence rehabilitation.

Present History

What have you changed? / What load have you added?

New tendon pain is typically caused by a change in loading. A tendon's capacity just exceeds the loads placed upon it—small changes in load can make a difference. Careful questioning around recent changes in load will help identify factors that may be contributing to the tendinopathy. Changes in load include alterations in training intensity, a change in footwear, recent participation in a sports tournament, and an increase in speed or plyometrics.

Past History

It’s also important to consider a patient’s past history. Is this the first event? Are there any pre-existing injuries? Is this a long-term problem? Comprehensive questioning on previous injuries, rest periods, etc. helps establish a clearer clinical picture.

Red Flags and Risk Factors

As with all conditions, screening for red flags and general health issues and serious pathology is extremely important.

The following risk factors have been linked with tendinopathy:

• hormone replacement therapy
• contraceptive medication
• metabolic risk factors
• diabetes
• obesity
• high adiposity in lower limb tendinopathies
• use of fluoroquinolones
• lack of range of movement
• inflexibility
• strength imbalance
• poor vascularity
• blood type O
• altered lower limb biomechanics
• low-temperature training

Goals and Expectations

Establishing a person’s goals and expectations is essential when planning a comprehensive management programme. A sedentary 60-year-old will have very different goals to an elite athlete.

Patient-Reported Outcomes

The Victoria Institute of Sport Assessment has developed self-administered questionnaires for tendinopathy. These are the VISA-P (patella), VISA-A (Achilles), VISA-H (hamstrings) and VISA-G (gluteal). Because the VISA Questionnaires do not detect small changes, Malliaras et al. recommend repeating them only every four weeks or more to record progress. It has recently been suggested that the Tendinopathy Severity Assessment-Achilles (TENDINS-A) should be used to measure Achilles tendinopathy severity instead of the VISA-A.

Physical Examination / Objective Examination

The physical examination tests the hypothesis you have developed through clinical reasoning during the interview.

Pain-provocation testing

Dose-dependent loading helps to confirm a diagnosis of tendinopathy. Pain that remains localised to the tendon and increases with progressive loading is a strong indicator of tendinopathy.

During progressive loading tests, the two essential questions to ask are:

• Is this painful?
• Where is the pain?

Each tendon has specific movements that place it under compressive and tensile loads; progressive loading protocols vary depending on which tendon is being assessed. The key is to load the tendon sufficiently to confirm the diagnosis while avoiding overloading and aggravating the tendon.

Muscle Strength, Joint Range and Functional Assessment

During the physical examination, it’s important to assess the entire kinetic chain to determine contributing factors. Again, these factors are unique to each person—there is no “recipe” for assessment. However, assessing the range and motion and strength of involved joints and muscles will help guide management.

Palpation

Pain on tendon palpation has low diagnostic specificity for tendinopathy. While pathological tendons are typically tender on palpation, many other conditions can cause similar tenderness. Moreover, a tender tendon may not be the source of the patient's presenting symptoms. However, the absence of pain on palpation can help rule out tendinopathy.

Imaging

Ultrasound and MRI are both used for tendon imaging. While MRI is more detailed and specific, it is significantly more expensive than ultrasound. However, imaging should be used with caution when confirming tendinopathy as the source of symptoms. Abnormalities and pathology found on imaging correlate poorly with pain and function—asymptomatic individuals often show tendon pathology on scans, while painful tendons may appear normal on imaging. However, imaging can be valuable in complex clinical presentations to exclude other differential diagnoses.

Key Findings in Specific Tendinopathies

Patella

In patellar tendinopathies, pain is localised to the inferior pole of the patella. Pain increases with knee extension activities that involve energy storage and release, such as jumping or quick changes in direction. Patellar tendinopathy commonly affects athletes aged 15-30 years who participate in sports with jumping and direction changes, such as basketball, volleyball, athletics (jumping events), tennis, and football.

During a progressive load assessment, pain should remain localised and increase with increasing load. Loading activities should progress from shallow squats to deep squats, then small hops, followed by big hops.

Midportion Achilles

In midportion Achilles tendinopathy, pain is localised 2-6cm proximal to the Achilles tendon insertion. Pain is aggravated by energy storage and release activities, such as jumping and running. Repetitive movements, like swimming and cycling, do not typically aggravate symptoms. Morning stiffness is a hallmark sign of a midportion Achilles tendinopathy.

During the progressive load assessment, begin with double-leg calf raises, progress to single-leg calf raises, then double-leg jumps, single-leg small hops, single-leg larger hops, repeated single-leg hops, and finally forward hopping.

Gluteal Tendinopathy

Gluteal tendinopathy is characterised by pain at the greater trochanter. It is more common in sedentary women aged over 49 years. Pain often refers down the lateral thigh, and single-leg tasks can be painful. Symptoms are aggravated by compressive loads, such as:

• hanging on a hip in standing (i.e., relative hip adduction)
• sitting with the legs crossed
• single-leg tasks with excessive lateral pelvic tilt (hip adduction)
• crossing the midline during running
• sleeping on the painful side (direct compression)
• sleeping on the unaffected side when the top leg drops into adduction

Proximal Hamstring Tendinopathy

Proximal hamstring tendinopathy can cause long-standing pain and disability. Pain is localised to the ischial tuberosity and is provoked by activities that involve deep hip flexion (compressive load), including:

• squatting
• lunging
• sitting, especially on harder surfaces

There will be pain with energy storage activities, but not typically with slow walking, standing or lying.

During the progressive load assessment, begin with single-leg bent-knee bridges (low load), progress to long-lever bridges (moderate load), then arabesque movements (high load), and finally single-leg deadlifts (high load).

Single Leg Long Lever Bridge

Arabesque