eMedicine Specialties > Sports Medicine > Foot and Ankle

Achilles Tendonitis: Differential Diagnoses & Workup

Author: Laura M Gottschlich, DO, Assistant Professor of Family and Community Medicine, Medical College of Wisconsin; Consulting Staff, St. Joseph Family Medicine Residency Program
Coauthor(s): Kevin J Eerkes, MD, Clinical Assistant Professor, Department of Medicine, New York University School of Medicine; Medical Team Physician, New York University Athletics; David Y Lin, MD, Fellow, Department of Orthopedic Surgery, Section of Pediatrics, University of Tennessee Campbell Clinic; Evan Schwartz, MD, Director of Orthopedic Surgery, New York Medical College; Assistant Professor, St John's Queens Hospital, Department of Surgery, Albert Einstein School of Medicine
Contributor Information and Disclosures

Updated: Dec 15, 2009

Differential Diagnoses

Achilles Tendon Rupture
Calcaneofibular Ligament Injury
Ankle Fracture
Compartment Syndromes
Ankle Impingement Syndrome
Retrocalcaneal Bursitis
Ankle Sprain
Talofibular Ligament Injury
Athletic Foot Injuries

Other Problems to Be Considered

Achilles bursitis (ie, pump bump)
Calf injuries and syndromes
Deep venous thrombosis
Haglund deformity
Inflammatory arthropathies (eg, Reiter syndrome, psoriatic arthritis)
Tendinous xanthomas (eg, hyperbetalipoproteinemia, hyperlipoproteinemias)

Workup

Laboratory Studies

    • Laboratory studies are usually not necessary
    • In patients with who do not fit the typical profile of those with Achilles tendinitis or who have systemic or bilateral symptoms, appropriate laboratory workup and medical referral may be carried out to evaluate for possible autoimmune disorder.

Imaging Studies

    • X-rays are usually not useful in the diagnosis of Achilles tendinitis.
    • There may be tendon calcifications in tendinosis or spurs at the calcaneal insertion site, but neither are diagnostic for Achilles tendinitis.
    • Magnetic resonance imaging (MRI) can provide useful information in refractory cases and in patients being considered for surgery.16 In paratenonitis, fluid may be seen in and around the tendon. In chronic paratenonitis, the paratenon may be thicken and fibrotic.
    • In tendinosis, increased MRI signal is evident in the tendon and degenerative changes, and occasionally partial tears may be seen. Keep in mind that these MRI findings may also be present in asymptomatic individuals.
    • Ultrasound is a relatively inexpensive, fast, and repeatable modality. Use of ultrasound permits dynamic assessment of the tendon and determines the degree of thickening but requires technical expertise.16,17 Ultrasound does not distinguish a partial tear from tendinosis as MRI can. In a small study, De Zordo et al compared a newly introduced ultrasound technique, real-time sonoelastography, with clinical examination and conventional ultrasound in differentiating Achilles tendon tendinopathy changes between symptomatic patients and healthy volunteers.18 Relative to 93% of healthy volunteers, who had hard tendons, 57% of the symptomatic patients demonstrated distinct softening of the Achilles tendon on sonoelastography, with more frequent involvement in the distal and middle thirds than the proximal third of the tendon. Seven percent of the volunteers and 11% of the patients had mild tendon softening.18 Using clinical examination as the reference standard, De Zordo et al found that sonoelastography had a mean 94% sensitivity, 99% specificity, and 97% accuracy, with a 0.89 correlation to ultrasound.18 The investigators concluded that this imaging modality was comparable to clinical examination and ultrasound findings only with distinct softening of the Achilles tendon, but very early changes in tissue elasticity in Achilles tendinopathy may cause mild softening, which should be assessed in follow-up studies.18

More on Achilles Tendonitis

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

  1. Keene JS. Tendon injuries of the foot and ankle. In: DeLee JC, Drez D, eds. Orthopaedic Sports Medicine. Philadelphia, Pa: WB Saunders; 1994:1788-94.

  2. Saltzman C, Bonar S. Tendon problems of the foot and ankle. In: Lutter LD, Mizel MS, Pfeffer GB, eds. Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1994:236-73.

  3. Wheaton MT, Molnar TJ. Overuse injuries of the lower extremities. In: Griffin, LY, ed. Orthopaedic Knowledge Update: Sports Medicine. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1994:225-7.

  4. Puddu G, Ippolito E, Postacchini F. A classification of Achilles tendon disease. Am J Sports Med. Jul-Aug 1976;4(4):145-50. [Medline].

  5. Schepsis AA, Jones H, Haas AL. Achilles tendon disorders in athletes. Am J Sports Med. Mar-Apr 2002;30(2):287-305. [Medline].

  6. Saltzman CL, Tearse DS. Achilles tendon injuries. J Am Acad Orthop Surg. Sep-Oct 1998;6(5):316-25. [Medline].

  7. Kvist M. Achilles tendon injuries in athletes. Ann Chir Gynaecol. 1991;80(2):188-201. [Medline].

  8. Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med. Mar-Apr 1987;15(2):168-71. [Medline].

  9. Clement DB, Taunton JE, Smart GW. Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med. May-Jun 1984;12(3):179-84. [Medline].

  10. James SL, Bates BT, Osternig LR. Injuries to runners. Am J Sports Med. Mar-Apr 1978;6(2):40-50. [Medline].

  11. Clancy WG Jr, Neidhart D, Brand RL. Achilles tendonitis in runners: a report of five cases. Am J Sports Med. Mar-Apr 1976;4(2):46-57. [Medline].

  12. Van Ginckel A, Thijs Y, Hesar NG, Mahieu N, De Clercq D, Roosen P, et al. Intrinsic gait-related risk factors for Achilles tendinopathy in novice runners: a prospective study. Gait Posture. Apr 2009;29(3):387-91. [Medline].

  13. Carr AJ, Norris SH. The blood supply of the calcaneal tendon. J Bone Joint Surg Br. Jan 1989;71(1):100-1. [Medline]. [Full Text].

  14. Astrom M, Rausing A. Chronic Achilles tendinopathy. A survey of surgical and histopathologic findings. Clin Orthop Relat Res. Jul 1995;316:151-64. [Medline].

  15. Glazebrook MA, Wright JR Jr, Langman M, Stanish WD, Lee JM. Histological analysis of achilles tendons in an overuse rat model. J Orthop Res. Jun 2008;26(6):840-6. [Medline].

  16. Neuhold A, Stiskal M, Kainberger F, Schwaighofer B. Degenerative Achilles tendon disease: assessment by magnetic resonance and ultrasonography. Eur J Radiol. May-Jun 1992;14(3):213-20. [Medline].

  17. Daftary A, Adler RS. Sonographic evaluation and ultrasound-guided therapy of the Achilles tendon. Ultrasound Q. Sep 2009;25(3):103-10. [Medline].

  18. De Zordo T, Chhem R, Smekal V, et al. Real-time sonoelastography: findings in patients with symptomatic Achilles tendons and comparison to healthy volunteers. Ultraschall Med. Nov 27 2009;epub ahead of print. [Medline].

  19. Rees JD, Lichtwark GA, Wolman RL, Wilson AM. The mechanism for efficacy of eccentric loading in Achilles tendon injury; an in vivo study in humans. Rheumatology (Oxford). Jul 22 2008;epub ahead of print. [Medline].

  20. Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. May-Jun 1998;26(3):360-6. [Medline].

  21. Reese RC Jr, Burruss TP, Patten J. Athletic training techniques and protective equipment. In: Nicholas JA, Hershman EB, eds. The Lower Extremity & Spine in Sports Medicine. 2nd ed. St Louis, Mo: Mosby; 1995:267-75.

  22. Sorosky B, Press J, Plastaras C, Rittenberg J. The practical management of Achilles tendinopathy. Clin J Sport Med. Jan 2004;14(1):40-4. [Medline].

  23. Kvist H, Kvist M. The operative treatment of chronic calcaneal paratenonitis. J Bone Joint Surg Br. Aug 1980;62(3):353-7. [Medline]. [Full Text].

  24. Emerson C, Morrissey D, Perry M, Jalan R. Ultrasonographically detected changes in Achilles tendons and self reported symptoms in elite gymnasts compared with controls - an observational study. Man Ther. Jul 28 2009;epub ahead of print. [Medline].

  25. Knobloch K, Schreibmueller L, Kraemer R, et al. Gender and eccentric training in Achilles mid-portion tendinopathy. Knee Surg Sports Traumatol Arthrosc. Dec 9 2009;epub ahead of print. [Medline].

  26. Lake JE, Ishikawa SN. Conservative treatment of achilles tendinopathy: emerging techniques. Foot Ankle Clin. Dec 2009;14(4):663-74. [Medline].

  27. Malliaras P, Richards PJ, Garau G, Maffulli N. Achilles tendon Doppler flow may be associated with mechanical loading among active athletes. Am J Sports Med. Nov 2008;36(11):2210-5. [Medline].

  28. Pearce CJ, Ismail M, Calder JD. Is apoptosis the cause of noninsertional achilles tendinopathy?. Am J Sports Med. Dec 2009;37(12):2440-4. [Medline].

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Further Reading

Related eMedicine Topics

Clinical Trials
 Clinical Guidelines

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Keywords

Achilles tendonitis, Achilles tendinitis, Achilles heel, Achilles injury, Achilles paratenonitis, Achilles peritenonitis, Achilles paratendinitis, Achilles peritendinitis, Achilles tendinosis, Achilles rupture, Achilles tendo calcaneitis

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Contributor Information and Disclosures

Author

Laura M Gottschlich, DO, Assistant Professor of Family and Community Medicine, Medical College of Wisconsin; Consulting Staff, St. Joseph Family Medicine Residency Program
Laura M Gottschlich, DO is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Association, American Medical Society for Sports Medicine, and American Osteopathic Association
Disclosure: Nothing to disclose.

Coauthor(s)

Kevin J Eerkes, MD, Clinical Assistant Professor, Department of Medicine, New York University School of Medicine; Medical Team Physician, New York University Athletics
Disclosure: Nothing to disclose.

David Y Lin, MD, Fellow, Department of Orthopedic Surgery, Section of Pediatrics, University of Tennessee Campbell Clinic
David Y Lin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Evan Schwartz, MD, Director of Orthopedic Surgery, New York Medical College; Assistant Professor, St John's Queens Hospital, Department of Surgery, Albert Einstein School of Medicine
Evan Schwartz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

Medical Editor

David T Bernhardt, MD, Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics, University of Wisconsin
David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
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