Achilles Tendinopathy

Diagnosis

In general, history and physical exam features are better at ruling in, rather than ruling out achilles tendinopathy. Self reported morning stiffness is the only feature with a moderate negative likelihood ratio.

Test	Sensitivity	Specificity	LR+	LR-
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Diffuse

• Ankle (Tibiotalar) Osteoarthritis
• Subtalar Osteoarthritis
• Inflammatory arthropathies - Rheumatoid Arthritis, septic arthritis, osteomyelitis, gout, Osteonecrosis.
• Sarcoid periarthritis
• Benign or malignant neoplasms, myelodysplastic and leukaemic disorders
• Plant-thorn synovitis
• CRPS

Ankle pain persistent following injury

• Fractures - anterior process calcaneus, lateral process talus, posterior process talus (or, rare, os trigonum fracture), osteochondral lesion, tibial plafond chondral lesion, base of fifth metatarsal
• Bony impingements - anterior, posterior, anterolateral
• Atypical sprains - chronic ligamentous instability, medial ligament sprain, syndesmosis sprain (AITFL sprain), subtalar joint sprain
• Tendon injuries - chronic peroneal tendon weakness, peroneal tendon subluxation/rupture, tibialis posterior tendon subluxation/rupture
• Other - inadequate rehabilitation, chronic synovitis, sinus tarsi syndrome

Lateral Ankle Pain

• Peroneal Tendinopathy or recurrent dislocation of peroneal tendons
• Sinus Tarsi Syndrome
• Impingement syndrome (anterolateral, posterior)
• Stress fractures (talus, distal fibula)
• Referred Pain (lumbar, peroneal nerve, superior tibiofibular joint)
• Cuboid Syndrome
• Os Peroneum
• Osteochondritis dissecans (anterior lateral talus)

Medial Ankle Pain

• Tibialis Posterior Tendinopathy
• Flexor Hallucis Longus Tendinopathy
• Medial Calcaneal Nerve Entrapment
• Stress fracture (calcaneal, talar, medial malleolar, navicular)
• Tarsal Tunnel Syndrome
• Posterior Ankle Impingement
• Referred Pain from the lumbar spine
• Complications of acute ankle injuries
• Os tibiale externum (accessory navicular)
• Osteochondritis dissecans (posterior medial talus)

Posterior Ankle Pain

• Midportion Achilles Tendinopathy
• Insertional Achilles Tendinopathy
• Retrocalcaneal bursitis
• Paratenon inflammation
• Posterior impingement syndrome
• Plantaris Tendinopathy
• Sever Disease (Calcaneal Apophysitis)
• Accessory or low soleus muscle
• Referred Pain (neural structures, lumbar spine), and sural neuropathy
• Achilles tendon rupture
• Achilles enthesopathy due to inflammatory arthropathies
• Osteochondritis dissecans (posterior medial talus)