Diagnosing Achilles Pain

To arrive at a clinical diagnosis of Achilles tendonitis, tendinosis, or other tendon condition, a doctor must eliminate other problems that cause similar symptoms, such as:

• Posterior ankle impingement
• Os trigonum syndrome
• Tenosynovitis
• Dislocation of the peroneal tendons or other plantar flexor tendons.

See What Is the Difference Between Tendonitis, Tendinosis, and Tendinopathy?

A physician will diagnose the cause of the pain based on a combination of a physical exam, a detailed patient history, and if needed, diagnostic tests.

Physical exam
A doctor will examine the foot and lower leg and look for signs of Achilles tendinopathy. He or she will probably conduct a series of clinical assessments, such as the Thompson test (or “calf-squeeze”) to test the integrity of the Achilles tendon. The doctor may also ask the patient to do a series of exercises such as leg lifts, hops, or jumps to gauge the level of activity-related pain, as well as exactly where it occurs.

Patient history
In addition to a clinical exam the doctor will also take a detailed patient history. A doctor will ask the patient:

• To describe the pain. For example, patients may describe pain as sharp versus dull, intermittent versus constant, and mild or severe.
• What makes the patient better or worse, such as whether the pain increases with activity.
• About his or her recent sports involvement, including any changes to the training schedule, surface, or type of sport being played.
• To report past injuries and/or inflammations of the Achilles tendon, including when and how they occurred, if they recurred, and what treatments were used.
• To describe any changes in the Achilles tendon area, such as increasing pain at the bony prominence at the back of the heel, swelling, tenderness, redness, or loss of strength or range of motion.

Diagnostic imaging
Medical imaging is usually not required to arrive at an Achilles tendinopathy diagnosis. However, in some cases a doctor may order imaging to get a detailed view of the tendon or to rule out other conditions.

• Magnetic resource imaging (MRI) provides a detailed view of the Achilles tendon and the surrounding structures and can reveal tendon thickening or micro-tears in the tendon consistent with tendinopathy or partial Achilles tendon ruptures.¹Weber C., Wedegärtner U., Maas L.C., Buchert R., Adam G., and Maas R.: [MR imaging of the Achilles tendon: evaluation of criteria for the differentiation of asymptomatic and symptomatic tendons]. Rofo 2011; 183: pp. 631-640^,2Uquillas CA, Guss MS, Ryan DJ, Jazrawi LM, Strauss EJ. Everything Achilles: Knowledge Update and Current Concepts in Management: AAOS Exhibit Selection. J Bone Joint Surg Am. 2015 Jul 15;97(14):1187-95. doi: 10.2106/JBJS.O.00002. Review. PubMed PMID: 26178893.
• Ultrasound allows the doctor to view the tendon while it is still and during movement. Ultrasound testing may be enhanced with color Doppler effects, which help the doctor assess whether the Achilles tendon is vascular, or has blood flow, because blood does not flow to the Achilles tendon in its normal, uninjured state.³Alfredson H. Ultrasound and Doppler-guided mini-surgery to treat midportion Achilles tendinosis: results of a large material and a randomised study comparing two scraping techniques. Br J Sports Med. Jan 2011; 45:407–410. doi:10.1136/bjsm.2010.081216. Accessed November 7, 2014.

X-rays are not typically used to diagnose Achilles tendon damage or tears but are helpful in identifying associated contributors to pain, such as a bony prominence (bump) on the back of the heel, called Haglund’s deformity; osteophytes (bone spurs); stress fractures; and os trigonum syndrome.

See The 2 Common Types of Heel Spurs