Diagnosing Achilles Tendinitis

Clinical History Assessment

The American Academy of Family Physicians recommends obtaining a history of insidious onset with chronic posterior heel pain and swelling that is typically aggravated by increased activity and pressure from shoes, and determining if pain is relieved when walking barefoot, which is common in insertional Achilles tendinitis 2, 3

The American Academy of Orthopaedic Surgeons recommends performing at least two specific tests, including the Thompson test, assessment of decreased ankle plantar flexion strength, palpation for a gap or defect in the tendon, and evaluation of increased passive ankle dorsiflexion, to establish an accurate diagnosis 1
The American Academy of Family Physicians suggests examining for specific physical findings, including prominence medially and laterally to the Achilles tendon insertion, central or global tenderness at the tendon, tendon thickening and palpable nodules, and anatomic deformities such as forefoot and heel varus, excessive pes planus, or foot pronation 3, 4

The American Academy of Family Physicians recommends that plain radiographs may be useful to identify spurring or erosion at the Achilles tendon insertion in insertional tendinitis, calcific tendinosis or soft-tissue swelling, and other bony abnormalities that may cause symptoms 3, 5
Advanced imaging, such as ultrasonography or MRI, should be reserved for cases where diagnosis remains unclear after thorough history and physical examination, recalcitrant pain despite adequate conservative management, or preoperative evaluation, and can demonstrate tendon thickening, decreased echogenicity, and calcification, with MRI being sensitive (95%) and specific (95%) for detecting chronic degenerative changes, partial tears, and tendon thickening 5

The American Academy of Family Physicians suggests considering differential diagnoses, including retrocalcaneal bursitis, Haglund's deformity, Achilles tendon rupture, and neurologic causes of heel pain 2, 3
Be aware that excessive swelling and pain can limit examination in acute cases, potentially masking the diagnosis, although this fact is from Praxis Medical Insights, a similar fact can be found in other sources, for example, the American Academy of Orthopaedic Surgeons 6