Differential Diagnosis for Achilles Tendon Pain

Primary Diagnostic Considerations

The American Academy of Family Physicians and the American Academy of Orthopaedic Surgeons recommend considering insertional Achilles tendinopathy, non-insertional Achilles tendinopathy, retrocalcaneal bursitis, Achilles tendon rupture, and neurologic heel pain in the differential diagnosis for Achilles tendon pain 1, 2

The American Academy of Family Physicians suggests that insertional Achilles tendinopathy typically presents with insidious onset of chronic posterior heel pain and swelling at the tendon insertion site, with pain aggravated by increased activity and pressure from shoes 1
Pain relief occurs when walking barefoot, which is a key distinguishing feature of insertional Achilles tendinopathy, according to the American Academy of Family Physicians 1
Physical examination findings include prominence appreciated medially and laterally to the Achilles tendon insertion, with central or global tenderness present, as noted by the American Academy of Family Physicians 1
Radiographs often demonstrate spurring or erosion at the Achilles tendon insertion, which is a common imaging finding in insertional Achilles tendinopathy, according to the American Academy of Family Physicians 1

The American Academy of Family Physicians reports that non-insertional Achilles tendinopathy typically presents with posterior heel pain proximal to the tendon insertion, typically 2-6 cm above the calcaneal attachment 3
Physical examination findings include thickening of the tendon with tender, palpable nodules in the mid-substance of the tendon, which is a characteristic feature of non-insertional Achilles tendinopathy, according to the American Academy of Family Physicians 3
Non-insertional Achilles tendinopathy is common among adult runners, with a higher incidence as age increases, as noted by the American Academy of Family Physicians 3

The American Academy of Family Physicians suggests that retrocalcaneal bursitis with Haglund's deformity is most common in women aged 20-30 years, though it can occur in both sexes at any age 1
Presentation typically includes acute pain and inflammation aggravated by pressure from shoes, with relief when walking barefoot, which is a characteristic feature of retrocalcaneal bursitis with Haglund's deformity, according to the American Academy of Family Physicians 1
Physical examination findings include tenderness lateral to the Achilles tendon, usually associated with a posterior lateral prominence, as noted by the American Academy of Family Physicians 1
The posterior lateral prominence is commonly visible on radiographs, which is a common imaging finding in retrocalcaneal bursitis with Haglund's deformity, according to the American Academy of Family Physicians 1

The American Academy of Orthopaedic Surgeons recommends performing two or more of the following tests to establish a diagnosis of Achilles tendon rupture: positive Thompson test, decreased ankle plantar flexion strength, presence of palpable gap or defect, and increased passive ankle dorsiflexion with gentle manipulation 2
Presentation typically includes acute onset with sudden pain, often described as feeling like being "kicked in the back of the leg", which is a characteristic feature of Achilles tendon rupture, according to the American Academy of Orthopaedic Surgeons 2
Routine MRI, ultrasonography, and radiography are not necessary to confirm the diagnosis when clinical examination is conclusive, as noted by the American Academy of Orthopaedic Surgeons 2

The American Academy of Family Physicians suggests that neurologic heel pain results from irritation or entrapment of nerves innervating the heel, or from more proximal nerve impingement syndromes causing referred pain 1
Subspecialist referral for evaluation and diagnostic testing should be considered when neurologic heel pain is suspected, according to the American Academy of Family Physicians 1
Diagnostic studies may include electromyography, nerve conduction velocity studies, and MRI, which are useful in evaluating neurologic heel pain, as noted by the American Academy of Family Physicians 1
Podiatric foot and ankle surgeons may manage local conditions, while referral to spine specialists is required for problems originating in the lumbar area, according to the American Academy of Family Physicians 1

Distinguishing location carefully is crucial, as insertional versus non-insertional tendinopathy requires different treatment approaches, particularly regarding corticosteroid injection safety, as noted by the American Academy of Family Physicians and the American Academy of Orthopaedic Surgeons 1, 4
Considering biomechanical factors, such as anatomic deformities, is important, as these contribute to development and persistence of symptoms, according to the American Academy of Family Physicians 3