The main finding is tenderness and/or a swelling in the tendon. Hutchison (2013) found that localised tenderness in the mid-portion of the tendon was the most predictive examination finding for a diagnosis of tendonopathy.
Distinguish between peritendonitis and a swelling in the tendon itself by moving the ankle up and down (the arc test). A swelling in the tendon due to pure tendonopathy will move with the tendon on movement of the ankle, while a swelling of the paratenon will not move. In the Royal London Hospital test, a swelling that is most painful when the ankle is in maximum dosiflexion indicated tendonopathy.
Maffulli et al (2003) compared local palpation, the Royal London Hospital test and the painful arc test for the diagnosis of non-insertional Achilles tendonopathy. Ten patients awaiting tendon debridement were the subjects, and fourteen asymptomatic athletes were controls. Each patient was examined twice by each of 3 experienced surgeons. In each case findings were classified as tendonopathy present or absent. All patients and controls also has USS, and the patients had histological examination of tendon biopsies. Sensitivity of palpation was 0.583, of the arc sign 0.525 and the RLH test 0.542. Specificities were 0.845, 0.833 and 0.912 respectively – none of these was significantly better than the others. Kappa values varied from 0.553 to 0.857. These tests are a good, but not absolute, predictor of the presence of tendonopathy.
Distinguish between insertional and non-insertional tendonopathy and look for a Haglund's deformity.
In patients with insertional tendonopathy, check for retrocalcaneal bursitis. The Achilles tendon, calcaneum and retrocalcaneal bursa are marked in the first section of the video. A pinch applied just in front of the distal tendon may reproduce bursa pain. Dorsiflexing the ankle reduces the retrocalcaneal space and may intensify or produce the pain. It can be difficult to distinguish posterior ankle impingement pain from Achilles pain. However, Achilles or retrocalcaneal bursa pain is usually worst on dorsiflexion, while posterior ankle impingement pain is triggered by plantar flexion.
Check the tendon is functionally intact with the calf squeeze and Matles tests. Don't rely on demonstrating the patient's ability to go on tiptoe or plantar flex the ankle against resistance - some people can do these normally with the long flexors.