eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Achilles Tendon Injuries and Tendonitis: Differential Diagnoses & Workup

Author: Anthony J Saglimbeni, MD, Staff Physician, Family Practice Residency, President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School
Coauthor(s): Christian J Fulmer, DO, Private Practice in Sports and Family Medicine; Team Physician, Valley Christian High School
Contributor Information and Disclosures

Updated: Oct 14, 2009

Differential Diagnoses

Other Problems to Be Considered

Achilles tendonitis
Partial Achilles tendon rupture
Retrocalcaneal bursitis
Ankle osteoarthritis
Ruptured Baker cyst
Deep venous thrombosis
Haglund deformity (pump bump)
Gastrocnemius-soleus muscle strain or rupture

Workup

Laboratory Studies

  • Laboratory studies usually are not necessary in evaluating and diagnosing an Achilles tendon rupture or injury. Evaluation may help rule out some of the other possibilities in the differential diagnosis. These may include CBC count with differential, coagulopathy panel, erythrocyte sedimentation rate, and arthritis panel. Results are all normal in these injuries.

Imaging Studies

  • Imaging studies are not necessary to diagnose common Achilles problems; however, they can be helpful in evaluating possibilities in the differential diagnosis and should be ordered as clinically indicated.
  • Plain radiography
    • Radiographs of the tibia and fibula often are indicated when the history shows trauma that could have resulted in fracture of these long bones. In Achilles tendonitis, some calcification in the distal Achilles may be evident. With Achilles rupture, the bones appear normal and soft tissue swelling may be evident.
    • Radiographs of the knee and ankle may help discover findings of degenerative or inflammatory arthropathies.
  • Ultrasonography of leg and thigh: Ultrasonography of the leg and thigh can help evaluate the possibility of deep vein thrombosis (DVT) and also can be used to rule out a Baker cyst. In experienced hands, ultrasonography also can identify a ruptured Achilles tendon or the signs of tendinopathy.
  • Magnetic resonance imaging (MRI): MRI can facilitate definitive diagnosis of a disrupted tendon. This is especially useful when considering the possibility of partial disruption of the Achilles tendon. Partial disruption often is undetectable clinically and may be misdiagnosed as simple Achilles tendonitis; however, partial Achilles disruption often responds to surgical intervention. Imaging the knee can confirm a Baker cyst, as well as the probable underlying pathology causing the Baker cyst.

More on Achilles Tendon Injuries and Tendonitis

Overview: Achilles Tendon Injuries and Tendonitis
Differential Diagnoses & Workup: Achilles Tendon Injuries and Tendonitis
Treatment & Medication: Achilles Tendon Injuries and Tendonitis
Follow-up: Achilles Tendon Injuries and Tendonitis
References
Further Reading
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References

  1. Grigg NL, Stevenson NJ, Wearing SC, et al. Incidental walking activity is sufficient to induce time-dependent conditioning of the Achilles tendon. Gait Posture. Oct 5 2009;[Medline].

  2. Henriksen M, Aaboe J, Bliddal H, et al. Biomechanical characteristics of the eccentric Achilles tendon exercise. J Biomech. Sep 21 2009;[Medline].

  3. Gardin A, Movin T, Svensson L, et al. The long-term clinical and MRI results following eccentric calf muscle training in chronic Achilles tendinosis. Skeletal Radiol. Sep 23 2009;[Medline].

  4. Wegrzyn J, Luciani JF, Philippot R, et al. Chronic Achilles tendon rupture reconstruction using a modified flexor hallucis longus transfer. Int Orthop. Aug 21 2009;[Medline].

  5. Silbernagel KG, Nilsson-Helander K, Thomee R, et al. A new measurement of heel-rise endurance with the ability to detect functional deficits in patients with Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc. Aug 19 2009;[Medline].

  6. Hawkins D, Lum C, Gaydos D, et al. Dynamic creep and pre-conditioning of the Achilles tendon in-vivo. J Biomech. Sep 15 2009;[Medline].

  7. Adler RS, Finzel KC. The Complementary Roles of MR Imaging and Ultrasound of Tendons. Radiol Clin North Am. Jul 2005;43(4):771-807. [Medline].

  8. Alvarez-Nemegyei J, Canoso JJ. Heel pain: diagnosis and treatment, step by step. Cleve Clin J Med. May 2006;73(5):465-71.

  9. Brown DE. Ankle and leg injuries. In: Mellion MB, Walsh M, Shelton GL, eds. The Team Physician's Handbook, 3rd ed. Philadelphia, Pa: Hanley & Belfus; 2002:. 518-9.

  10. Canale T. Rupture of muscles and tendons. In: Campbell's Operative Orthopaedics. Vol 10. St. Louis, Mo: Mosby; 2003:. 2458-2468.

  11. Furia JP. High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles tendinopathy. Am J Sports Med. May 2006;34(5):733-40.

  12. Humble RN, Nugent LL. Achilles'' tendonitis. An overview and reconditioning model. Clin Podiatr Med Surg. Apr 2001;18(2):233-54. [Medline].

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  14. Kingma JJ, de Knikker R, Wittink HW. Eccentric overload training in patients with a chronic Achilles tendinopathy: a systematic review. Br J Sports Med. Oct 11 2006.

  15. Maffulli N, Testa V, Capasso G. Surgery for chronic Achilles tendinopathy yields worse results in nonathletic patients. Clin J Sport Med. Mar 2006;16(2):123-8.

  16. Pedowitz RA, Saglimbeni AJ. The leg. In: Safran MR, McKeag DB, Van Camp SP, eds. Manual of Sports Medicine. Vol 1. Philadelphia, Pa: Lippincott-Raven; 1998:. 460-6.

  17. Taunton J, Smith C, Magee DJ. Leg, foot and ankle injuries. In: Athletic Injuries and Rehabilitation. Vol 1. Philadelphia, Pa: WB Saunders; 1996:. 736-9.

  18. Tomczak RL. Surgery of the Achilles'' tendon. Clin Podiatr Med Surg. Apr 2001;18(2):255-71, vi. [Medline].

  19. Ufberg J, Harrigan RA, Cruz T, Perron AD. Orthopedic pitfalls in the ED: Achilles tendon rupture. Am J Emerg Med. Nov 2004;22(7):596-600.

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Further Reading

Clinical guidelines:
Ankle & foot (acute & chronic). Work Loss Data Institute - Public For Profit Organization. 2003 (revised 2008 Apr 15). 152 pages. NGC:006552

Clinical trials:
Acute Achilles Repair With or Without OrthADAPT Augmentation

Chronic Insertional Achilles Tendonitis Treated With or Without Flexor Hallucis Longus Tendon Transfer

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Keywords

Achilles tendon, Achilles tendonitis, Achilles tendon rupture, Achilles tendinitis, Achilles tendon surgery, Achilles tendon pain, Achilles tendon injury, Achilles tendon treatment, Achilles tendon tear

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Contributor Information and Disclosures

Author

Anthony J Saglimbeni, MD, Staff Physician, Family Practice Residency, President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School
Disclosure: Nothing to disclose.

Coauthor(s)

Christian J Fulmer, DO, Private Practice in Sports and Family Medicine; Team Physician, Valley Christian High School
Christian J Fulmer, DO is a member of the following medical societies: American Academy of Family Physicians, American Academy of Osteopathy, American Medical Society for Sports Medicine, and American Osteopathic Association
Disclosure: Nothing to disclose.

Medical Editor

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM, President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine
Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, Physiatric Association of Spine, Sports and Occupational Rehabilitation, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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