Achilles Tendinopathy Toolkit: Section A - Clinical Evaluation

Original Editor - User Name Top Contributors - Kim Jackson, Olajumoke Ogunleye, Cindy John-Chu and Rishika Babburu  

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Introduction

The purpose of this document is to summarize the clinical evaluation of somebody who has been diagnosed with Achilles Tendinopathy.

The first steps involved in assessing a person presenting with Achilles tendinopathy is to carry out a subjective and objective examination, including a detailed history, to confirm the diagnosis. The toolkit leads you through the process of identifying potential risk factors association with Mid-Portion Achilles Tendinopathy, important questions and observations that form part of the subjective and objective assessment, as well as discussing Functional Tests and Differential Diagnosis.

Risk Factors

There are potential risk factors associated with mid-portion achilles tendinopathy. These can be further classified as non-modifiable and modifiable risk factors:

• Non-Modifiable Risk Factors
  • mid-age 30-60 years [ref 3,5]
  • male>female [ref 6]
  • Metabolic Disorders:
    • Renal disease [ref 3] - Urate deposits (tophi) in the Achilles tendon related to hyperuricemia (gout) [ref 7]
    • Diabetes [ref 3]
  • Family history:
    • Familial Hypercholesterolemia (HeFH) [ref 3] - New onset of Achilles tendon pain is often the first sign of hypercholesterolemia and should be investigated for serum cholesterol levels. [ref 7]. Tendon Xanthomas are fatty deposits from high cholesterol levels and commonly found at the Achilles tendon.
    • Genetic variants [ref 2,3] -Certain genetic polymorphisms predispose tendon to altered collagen structure.
  • Systemic Inflammatory Disorder:
    • Seronegative Spondyloarthropathy (SpA) - 98% of SpAhave at least one enthesis disorder, commonly at the Achilles tendon.[ref 9]. Consider use of SpAscreening tools such as SCREEND’EM [ref 9]

• Modifiable Risk Factors
  • Lifestyle:
    • Smoking [ref 2,8]
    • Obesity [ref 3,7]
    • Alcohol (moderate consumption) [ref 2]
    • Sedentary behaviour, inactivity [ref 3]
  • Medications:
    • Fluoroquinolones [ref 2] - Specifically, Ofloxacin was identified compared to similar anti-biotics from the same drug group. [ref 1]
    • Systemic corticosteroid (long term Prednisone) [ref 10]
    • Hormone Replacement Therapy (HRT) [ref 5]
  • Previous lower extremity tendinopathy [ref 1]
  • Footwear [ref 2,4,5]
  • Biomechanics:
    • Limited dorsiflexion [ref 2,4,5]
    • Decreased plantar flexor strength [ref 2,4,5]
    • Limited hip mobility [ref 2]
    • Altered gait pattern [ref 2]
    • Foot posture and mechanics [ref 5] - Static exam: hindfoot INV/EV (subtalar mobility)[ref 5]
    • Dynamic exam: excess foot pronation [ref 2]
  • Training Errors:
    • Training load - abrupt change in load, intensity, or volume [ref 4]
    • Training environment - higher risk with cold weather and winter training season [ref 1]

Assessment

Things to look out for when assessing for achilles tendinopathy include taking a thorough history from the patient including a detailed discussion about symptoms, the onset of injury and location of pain, as well as objective signs and biopsychological factors.

Subjective Assessment

The subjective assessment allows the patient to share details of the history of the injury, their current status, function, activity level, symptoms as well as any biopsychosocial factors that may have an impact on their treatment and recovery.

• Subjective Symptoms [ref 16]
  • Location -described in mid-portion of Achilles tendon.
  • Morning pain and stiffness –described on initial weight bearing upon rising from bed or following periods of inactivity.
• History
  • Gradual onset of symptoms.
  • Pain with loading activity –sport or daily living.
• Biopsychosocial Factors
  • Psychological factors, such as fear of movement (kinesiophobia),[ref 11] as well as fears and beliefs about injury, may contribute to pain sensitivity.[ ref 12]
  • Nervous System Sensitivity is characterized by allodynia and hypersensitivity, and has been considered to be a factor in persistent Achilles tendon pain.[ref 13,14,15]
• Objective Signs/Observations
  • Biomechanical Impairments:[ref 5]
    • Plantarflexorweakness
    • Dorsiflexion stiffness
    • Abnormal foot mechanics and lower limb abnormalities
  • Palpation tests - Localized tenderness in a zone 2-6 cm above calcaneal insertion in mid-portion of the Achilles tendon. Swelling or thickening may or may not be present. Some studies suggest that only palpation testing was found to be reliable and accurate for diagnosing Achilles tendinosis. [ref 16,17,18] A combination of palpation tests is recommended in describing mid-portion Achilles tendinopathy. [ref 17,18] A selection of the palpation tests are listed below:
    • Palpation“pinch test” [ref 17,18]. In prone lying, ankle relaxed with foot hanging freely. Most painful site located by pinch pressure applied from proximal to distal along the length of the Achilles tendon. Mid-portion Achilles tendinopathy is identified in a zone 2-6 cm above the calcaneal insertion.
    • Arc Sign [ref 17,18]

• Click to go back to the Main Achilles Tendinopathy Toolkit page
• Click to continue to Section B - Outcome Measures
• Click to continue to Section C - Summary of Evidence and Recommendations for Interventions
• Click to continue to Section D - Exercise Programs
• Click to continue to Section E - Low Level Laser Therapy Dosage Calculation
• Click to continue to Section F - Medical and Surgical Interventions