Achilles Tendinopathy

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Clinical Features

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 Sens. Spec. LR+ LR- K
Palpation (tenderness) 64% 81% 3.15 0.48  
Arc Sign 42% 88% 3.24 0.68  
Royal London Hospital Test
54% 86% 3.84 0.54  
Morning stiffness 89% 58% 2.12 0.19  
Palpation thickening 59% 90% 5.9 0.46  
Crepitus 3% 100% inf 0.97  
Stretch on passive dorsiflexion
with knee joint in flexion
13% 87% 1.00 1.00  
Single legged heel raise 22% 93% 3.14 0.95  
Hop test 43% 87% 3.31 0.66  
Thompson test (for rupture)          
  • Palpation: Palpate midportion and insertion
  • Royal London Hospital Test: Pain on palpation disappears on maximal dorsiflexion compared to plantarflexion in achilles tendinopathy
  • Arc test: palpate for thickened part/nodule, then have patient move ankle. In achilles tendinopathy the nodule should move, if it does not move then consider paratendonitis. Paratendonitis may show swelling.
  • Modified straight leg raise for assessing sural nerve neuropathy: bring ankle into dorsiflexion and inverison, then flex the hip.
  • Posterior impingement: passively hyperplantarflex the ankle looking for pain provocation.
  • Plantaris tendinopathy: medial pain as the plantaris compresses against the medial achilles tendon
  • Accessory/low soleus: can lead to compartment syndrome like symptoms e.g. symptoms settle quickly after the patient stops running


Diagnosing achilles tendinopathy follows the same overarching assessment principles as other lower limb tendinopathies.

  1. Epidemiological Data
    • Prevalent in all age groups especially runners
  2. Highly localised pain at tendon enthesis
    • Only exception to the general lower limb tendinopathy rule, because can also get midportion achilles tendinopathy
  3. Pain onset 24 hours after high and fast load activities
  4. Proportional pain load relationship
    • Every stage perform a couple of repetitions and gauge pain.
    • Start with walking or running to assess the pain, double calf raises on the ground, double calf raises on a step, single leg calf raises, single leg knee bent calf raises, add load if required, add speed to calf raises with knee bent, hopping double leg, hopping single leg, hopping forward, backwards, sideways, jumps for maximal height with single leg.
  5. Hallmark signs
    • Morning stiffness, this is the most sensitive sign.
    • Often have pain after arising from sitting.
  6. Muscle Wasting.

Differential Diagnosis

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 rehabiliation, chronic synovitis, sinus tarsi syndrome, complex regional pain syndrome type 1

Lateral Ankle Pain

Medial Ankle Pain

Posterior Ankle Pain

  • Midportion Achilles Tendinopathy (this includes tendinosis, paratendonitis, and partial tears)
  • Posterior impingement syndrome
  • Insertional Achilles Tendinopathy (including retrocalcaneal bursitis and haglund's disease)
  • Plantaris Tendinopathy
  • Sever's disease (adolescents)
  • Achilles bursitis
  • Accessory or low soleus muscle
  • Referred pain (neural structures, lumbar spine), and sural neuropathy
  • Achilles tendon rupture
  • Achilles tendinopathy due to inflammatory arthropathies


Physical Therapy

Graded loading programme