Guideline sources The following summarized guidelines for the evaluation and management of achilles tendinopathy are prepared by our editorial team based on guidelines from the Dutch Multidisciplinary Guideline (DMG 2021), the American College of Rheumatology (ACR 2018), and the American Physical Therapy Association (APTA 2018). 1 2 3 Guidelines 1. Screening and diagnosis Diagnosis: Diagnose midportion Achilles tendinopathy based on the presence of all the following findings: symptoms localized 2-7 cm proximal to the Achilles tendon insertion painful Achilles tendon midportion on (sports) loading https://web.pathway.md/diseases/reczZeUKisuY7l3bF 1/7 6/23/23, 1:27 AM Achilles tendinopathy Pathway local thickening of the Achilles tendon midportion (may be absent in cases with short symptom duration) pain on local palpation of the Achilles tendon midportion. E Show 2 more Differential diagnosis: Suspect alternative diagnoses in patients with posterior ankle pain: Situation Guidance Plantaris tendinopathy or rupture Musculotendinous disorders Plantar fasciopathy or fascia rupture Tendinopathy of the flexor tendons of the toes or ankle Rupture of the crural fascia Accessory soleus muscle Exercise-related compartment syndrome of the deep flexor compartment Soft tissue tumor Stress fracture of the calcaneus Bone disorders Bone tumor of the calcaneus Infectious pathology of the calcaneus (such as Brodies abscess) Posterior ankle impingement Joint disorders Chondral pathology of the subtalar joint Neuropathy of the sural nerve Neurological disorders Tarsal tunnel syndrome. E Take into account underlying causes and associated pathologies in patients with a clinical diagnosis of Achilles tendinopathy: Situation Guidance Achilles tendon rupture (partial or complete) Mechanical causes Calcifying Achilles tendinopathy Plantaris tendon mediated Achilles tendinopathy (medially localized Achilles tendinopathy due to invagination of the plantaris tendon) Retrocalcaneal bursitis with or without Haglund's morphology https://web.pathway.md/diseases/reczZeUKisuY7l3bF 2/7 6/23/23, 1:27 AM Achilles tendinopathy Pathway Paratendinopathy of the Achilles tendon Subcutaneous Achilles bursitis Sever's disease (children and adolescents) Axial spondyloartritis Inflammatory causes Reactive arthritis Psoriatic arthritis Diabetes mellitus, hypercholesterolemia, gout Metabolic causes Familial hypercholesterolemia (tendon xanthomas) Fluoroquinolone antibiotics. E Medications 2. Diagnostic investigations History and physical examination: consider using a subjective report of pain located 2-6 cm proximal to the Achilles tendon insertion that began gradually and pain with palpation of the midportion of the tendon, in addition to the arc sign and Royal London Hospital test, for the diagnosis of midportion Achilles tendinopathy. C Show 3 more Diagnostic imaging: As per DMG 2021 guidelines, consider obtaining additional imaging (X-ray of the calcaneus, ultrasound of the Achilles tendon, or MRI of the ankle) in the following situations: symptoms do not fit with all 4 diagnostic criteria symptoms match all 4 diagnostic criteria but there is an unexpected course or change of symptoms during follow-up surgery is being considered. E Show 7 more As per ACR 2018 guidelines: Obtain an X-ray of the ankle as the initial imaging in patients with chronic ankle pain. E Obtain either ankle MRI without IV contrast or ankle ultrasound when tendon abnormality is suspected and ankle radiographs are normal in patients with chronic ankle pain. E 3. Medical management Nonsteroidal anti-inflammatory drugs: be cautious when using NSAIDs in patients with Achilles tendinopathy. E https://web.pathway.md/diseases/reczZeUKisuY7l3bF 3/7 6/23/23, 1:27 AM Achilles tendinopathy Pathway 4. Nonpharmacologic interventions Exercise: As per DMG 2021 guidelines, advise progressive calf muscle strengthening exercises for at least 12 weeks in patients with Achilles tendinopathy. Ensure the form of exercise therapy is suitable for the individual patient. Take into consideration the role of motivation, time constraints, pain monitoring, and availability of facilities and resources. Consider advising performing exercises initially on a flat surface in patients with insertional Achilles tendinopathy. E As per APTA 2018 guidelines, advise mechanical loading either in the form of eccentric exercise or a heavy-load, slow-speed (concentric/eccentric) exercise program to decrease pain and improve function in patients with midportion Achilles tendinopathy without presumed frailty of the tendon structure. A Show 3 more Footwear and ankle support: As per DMG 2021 guidelines, consider offering night splint and inlays in case of insufficient effectiveness of patient education and loading advice in combination with continued exercise therapy. E As per APTA 2018 guidelines, insufficient evidence to support the use of heel lifts or orthoses in patients with midportion Achilles tendinopathy. I Show 3 more Manual therapy: As per DMG 2021 guidelines, consider offering application of ultrasound and friction massages in case of insufficient effectiveness of patient education and loading advice in combination with continued exercise therapy. E As per APTA 2018 guidelines, consider offering joint mobilization to improve mobility and function and soft tissue mobilization to increase ROM in patients with midportion Achilles tendinopathy. C Acupuncture: As per DMG 2021 guidelines, consider offering acupuncture or intratendinous needling in case of insufficient effectiveness of patient education and loading advice in combination with continued exercise therapy. E As per APTA 2018 guidelines, consider offering combined therapy of dry needling with injection under ultrasound guidance and eccentric exercise to decrease pain in patients with symptoms > 3 months and increased tendon thickness. C Collagen supplements: consider offering collagen supplements in case of insufficient effectiveness of patient education and loading advice in combination with continued exercise therapy. E 5. Therapeutic procedures https://web.pathway.md/diseases/reczZeUKisuY7l3bF 4/7 6/23/23, 1:27 AM Achilles tendinopathy Pathway Injection therapy: consider offering injection therapies (polidocanol, lidocaine, autologous blood, platelet-rich plasma, stromal vascular fraction, hyaluronic acid, prolotherapy, or high-volume injection) in case of insufficient effectiveness of patient education and loading advice in combination with continued exercise therapy. Be cautious when using corticosteroid injections. E Updated evidence: Corticosteroid injection for AT In adult patients with ultrasound-verified Achilles tendinopathy for 3 months, US-guided corticosteroid injection was superior to US-guided placebo injection with respect to improvement in Victorian Institute of Sports Assessment-Achilles score at 6 months. Finn Johannsen et al. JAMA Netw Open. 2022 Jul 1. Iontophoresis: offer iontophoresis with dexamethasone to decrease pain and improve function in patients with acute midportion Achilles tendinopathy. B Laser and light therapy: As per DMG 2021 guidelines, consider offering laser and light therapies in case of insufficient effectiveness of patient education and loading advice in combination with continued exercise therapy. E As per APTA 2018 guidelines, insufficient evidence to recommend low-level laser therapy in patients with midportion Achilles tendinopathy. I Extracorporeal shockwave therapy: consider offering extracorporeal shockwave therapy in case of insufficient effectiveness of patient education and loading advice in combination with continued exercise therapy. E 6. Surgical interventions Indications for surgery: consider performing surgery only in patients not recovering after at least 6 months of active treatment. Discuss the expected effectiveness of surgical intervention compared with active non-surgical treatments and the potential surgical complications. E 7. Patient education General counseling: As per DMG 2021 guidelines, discuss the initial active treatment options together with the patient. Assess specific patient characteristics (such as activity level and the presence of comorbidities) to personalize treatment. E Show 7 more As per APTA 2018 guidelines: https://web.pathway.md/diseases/reczZeUKisuY7l3bF 5/7 6/23/23, 1:27 AM Achilles tendinopathy Pathway Avoid advising complete rest in patients with non-acute midportion Achilles tendinopathy, rather advise continuing their recreational activity within their pain tolerance while participating in rehabilitation. D Consider counseling patients with midportion Achilles tendinopathy regarding the following key elements: theories supporting the use of physical therapy and the role of mechanical loading modifiable risk factors, including BMI and footwear typical time course for recovery from symptoms. C 8. Preventative measures Avoidance of fluoroquinolone: consider advising the avoidance of fluoroquinolone antibiotics if alternative antibiotics are available and the clinical picture allows in the context of the importance of preventing Achilles tendinopathy. E Secondary prevention: advise that sufficient time should be spent on active treatment before starting with provocative (sports) loading. E Show 3 more 9. Follow-up and surveillance Indications for specialist referral: consider referring patients to a sports medicine physician or an orthopedic surgeon if there is continued uncertainty about the diagnosis or there is an unexpected course or change of symptoms during follow-up. E Show 2 more Assessment of treatment response: Consider using the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire to evaluate the course of Achilles tendinopathy. E Do not obtain imaging to monitor treatment response and/or predict the course of symptoms of Achilles tendinopathy. D References 1. Robert-Jan de Vos, Arco C van der Vlist, Johannes Zwerver et al. Dutch multidisciplinary guideline on Achilles tendinopathy. Br J Sports Med. 2021 Oct;55 20 1125 1134. Open 2. Expert Panel on Musculoskeletal Imaging:, Eric Y Chang, Anthony S Tadros et al. ACR Appropriateness Criteria Chronic Ankle Pain. J Am Coll Radiol. 2018 May;15 5S S26 S38. Open 3. Robroy L Martin, Ruth Chimenti, Tyler Cuddeford et al. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther. 2018 May;48 5 A1 A38. Open https://web.pathway.md/diseases/reczZeUKisuY7l3bF 6/7 6/23/23, 1:27 AM Achilles tendinopathy Pathway 4. Finn Johannsen, Jens Lykkegaard Olesen, Tommy Frisgaard hlenschl ger et al. Effect of Ultrasonography-Guided Corticosteroid Injection vs Placebo Added to Exercise Therapy for Achilles Tendinopathy: A Randomized Clinical Trial. JAMA Netw Open. 2022 Jul 1;5 7):e2219661. Open https://web.pathway.md/diseases/reczZeUKisuY7l3bF 7/7