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Malliaras P, Gravare Silbernagel K, de Vos RJ, Bourke J, Sancho I, Hanlon SL, Agergaard AS, Bahr R, Bittencourt NFN, Bordalo M, Brorsson A, Tzortziou Brown V, Cardoso T, Child S, Chimenti RL, Cowley E, D'Hooghe P, Derman W, Finnoff JT, Fu SN, Halstead J, Hamilton B, Nilsson-Helander KM, Hölmich P, Houghton J, James AM, Kulig K, Lau A, Ling S, Maffulli N, Masci L, Mayes S, Mc Auliffe S, McCrum C, Morrissey D, Munteanu SE, Murphy MC, Newsham-West R, O'Neill S, Padhiar N, Papadopoulou T, Rees JD, Rio EK, Ruffino D, Scott A, Speirs S, Sun Y, Thorborg K, Trease L, Verhaar JAN, Wezenbeek E, White S, Zellers JA, Zhang S, Korakakis V, Vicenzino B. Diagnostic domains, differential diagnosis and conditions requiring further medical attention that are considered important in the assessment for Achilles tendinopathy: a Delphi consensus study. Br J Sports Med 2025:bjsports-2024-109185. [PMID: 40240126 DOI: 10.1136/bjsports-2024-109185] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2025] [Indexed: 04/18/2025]
Abstract
The absence of agreed methods to diagnose Achilles tendinopathy impedes research and clinical practice. This gap results in heterogeneous and/or poorly described study samples, making it challenging to apply findings in clinical practice. The aim of this Delphi study was to define consensus on (1) diagnostic domains; (2) differential diagnoses; and (3) conditions requiring further medical attention, when assessing for Achilles tendinopathy.We conducted a sequential three-stage process which included: (1) identifying diagnostic domains, differential diagnoses and conditions requiring further medical attention based on existing scoping reviews and clinical practice guidelines; (2) developing Delphi survey questions; and (3) administering a five-round Delphi online survey. Consensus was defined as ≥70% agreement.52 participants completed the surveys. Four diagnostic domains were deemed essential and reached consensus (pain location (93%); pain during activity (97%); tests that provoke pain (87%); palpation to assess pain (83%)). 15 differential diagnoses reached consensus: 2 for both midportion and insertional (partial tear (80%); posterior ankle impingement (78%)), 6 for midportion (plantaris tendinopathy (84%); tibialis posterior or flexor hallucis longus tendinopathy/tenosynovitis (72%); flexor digitorum longus tendinopathy (77%); accessory soleus muscle (74%); paratendinopathy (86%); sural nerve neuropathy (81%)) and 7 for insertional (superficial (88%) and retrocalcaneal bursitis (86%); Haglund's/calcaneal exostosis (80%), intratendinous calcifications (73%); Sever's disease (78%); calcaneal stress reaction/fracture (80%); subtalar/ankle pain (71%)). Six conditions requiring further medical attention reached consensus: (Achilles tendon rupture (83%); systemic inflammatory joint disease (86%); metabolic syndrome (75%); familial hypercholesterolaemia (77%); endocrine and hormonal disorders (80%); drug reactions (77%)).This consensus identified essential diagnostic domains, differential diagnoses and conditions requiring further medical attention that should be considered when assessing for Achilles tendinopathy.
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Affiliation(s)
- Peter Malliaras
- Physiotherapy Department, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
| | | | - Robert-Jan de Vos
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Jaryd Bourke
- Physiotherapy Department, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
| | - Igor Sancho
- Deusto Physical TherapIker Group, Physical Therapy Department, University of Deusto Faculty of Health Sciences, Donostia - San Sebastian, Spain
| | - Shawn L Hanlon
- Department of Kinesiology, California State University Fullerton, Fullerton, California, USA
| | - Anne-Sofie Agergaard
- Department of Orthopedic Surgery, and Department of Physical and Occupational Therapy, Copenhagen University Hospital-Bispebjerg and Frederiksberg Institute of Sports Medicine Copenhagen, Copenhagen, Denmark
| | - Roald Bahr
- Norwegian School of Sport Sciences, Oslo Sports Trauma Research Center, Oslo, Oslo, Norway
| | | | - Marcelo Bordalo
- Aspetar Orthopedic and Sports Medicine Hospital, Doha, Qatar
| | - Annelie Brorsson
- Department of Orthopaedics, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden
| | | | | | - Sally Child
- Olympic Park Sports Medicine Centre, Melbourne, Victoria, Australia
| | - Ruth L Chimenti
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, Iowa, USA
| | - Emma Cowley
- University of Southampton School of Health Sciences, Southampton, UK
| | - Pieter D'Hooghe
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Ad Dawhah, Qatar
| | - Wayne Derman
- Institute of Sport and Exercise Medicine (ISEM), Department of Exercise, Sport and Lifestyle Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Tygerberg, South Africa
| | - Jonathan T Finnoff
- United States Olympic and Paralympic Committee, Colorado Springs, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Siu Ngor Fu
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Jill Halstead
- Leeds Community Healthcare NHS Trust, Leeds, UK
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, West Yorkshire, UK
| | - Bruce Hamilton
- High Performance Sport New Zealand, Auckland University of Technology, Auckland, New Zealand
| | - Katarina Maria Nilsson-Helander
- Department of Orthopaedics, Sahlgrenska University Hospital Mölndal, Institute of Clinical Science at Sahlgrenska Academy, Goteborg, Sweden
| | - Per Hölmich
- Sports Orthopaedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark, Hvidovre Hospital Department of Orthopaedic Surgery, Hvidovre, Denmark
| | | | - Alicia M James
- Podiatry, Peninsula Health, Frankston, Victoria, Australia
| | - Kornelia Kulig
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California, USA
| | - Amanda Lau
- Institute of Sport Exercise and Health, London, UK
| | - Samuel Ling
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, University of Rome La Sapienza Faculty of Medicine and Psychology, Roma, Italy
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, London, UK
| | | | - Sue Mayes
- La Trobe University La Trobe Sport and Exercise Medicine Research Centre, Melbourne, Victoria, Australia
| | - Sean Mc Auliffe
- Department of Physiotherapy, University of Limerick, Limerick, Ireland
| | - Carol McCrum
- Rheumatology Department, Canberra Health Services, Canberra, Australian Capital Territory, Australia
| | - Dylan Morrissey
- Sport and Exercise Medicine, Queen Mary University of London, London, UK
- Physiotherapy Department, Barts Health NHS Trust, London, UK
| | - Shannon E Munteanu
- Discipline of Podiatry, La Trobe University School of Allied Health, Human Services, and Sport, Melbourne, Victoria, Australia
| | - Myles Calder Murphy
- Nutrition and Health Innovation Research Institute, Edith Cowan University, Joondalup, Western Australia, Australia
- School of Health Sciences, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Richard Newsham-West
- La Trobe University La Trobe Sport and Exercise Medicine Research Centre, Melbourne, Victoria, Australia
| | - Seth O'Neill
- School of Healthcare, College of Life Sciences, University of Leicester, Leicester, UK
| | - Nat Padhiar
- Barts and The London School of Medicine and Dentistry, London, UK
| | | | | | - Ebonie Kendra Rio
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia
| | | | - Alex Scott
- Physical therapy, The University of British Columbia - Vancouver Campus, Vancouver, British Columbia, Canada
| | | | - Yang Sun
- Huashan Hospital Fudan University Department of Sports Medicine, Shanghai, China
| | - Kristian Thorborg
- Sports Orthopaedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark, Hvidovre Hospital, Hvidovre, Denmark
| | - Larissa Trease
- La Trobe University La Trobe Sport and Exercise Medicine Research Centre, Melbourne, Victoria, Australia
| | - Jan A N Verhaar
- Department of Orthopedics and Sports Medicine, Erasmus MC, Rotterdam, Netherlands
| | - Evi Wezenbeek
- Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerpen, Belgium
| | - Sue White
- Victorian Institute of Sport, Albert Park, Victoria, Australia
| | - Jennifer A Zellers
- Program in Physical Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - S Zhang
- Sports Medicine, Fudan University, Shanghai, Shanghai, China
| | - Vasileios Korakakis
- Department of Health Sciences, University of Nicosia, Nicosia, Nicosia, Cyprus
| | - Bill Vicenzino
- Physiotherapy, The University of Queensland, Brisbane, Queensland, Australia
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Kaalund S, Kjaer SG, Rathleff MS, Fredberg U. Tendoscopic peritendon shaving of midportion Achilles tendinopathy: A randomized, placebo-controlled study. Scand J Med Sci Sports 2021; 32:351-358. [PMID: 34694643 DOI: 10.1111/sms.14078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 09/03/2021] [Accepted: 10/11/2021] [Indexed: 11/27/2022]
Abstract
Achilles tendinopathy is among the most frequent tendon injuries in sport. Despite evidence-based management, a significant proportion of patients continue to experience symptoms. This is the first randomized trial to investigate the effect of tendoscopic treatment of midportion Achilles tendinopathy compared with placebo at baseline, 3, 6 and 12 months. Patients with midportion Achilles tendinopathy (non-responsive to more than 6 months of nonsurgical treatments) were randomly assigned to receive either tendoscopic peritendon shaving or placebo tendoscopic treatment. The primary outcome measure was the total score of the Victorian Institute of Sport Assessment Achilles (VISA-A) questionnaire. Due to three adverse events (sural nerve injuries), in the group receiving tendoscopic treatment, the trial was stopped short of the planned 48 participants. All 23 patients included completed 3 months' follow-up (100%), 22 (96%) 6 months' and 19 (83%) completed 12 months' follow-up. The between-group estimates favored endoscopic treatment and ranged from 19 points (95% confidence interval [CI]: 1-38) at 3 months, 14 points (-7 to 34) at 6 months and 5 points (95% CI: -19 to 28) at 12 months. After 12 months, the tendoscopic group improved 47 points (95% CI: 29-65) versus 40 points (95% CI: 22-57) in the placebo-operated group. Despite a smaller sample size due to adverse events, VISA-A indicate faster recovery from tendoscopic treatment compared to placebo. These data suggest that tendoscopic treatment of midportion Achilles tendinopathy should be tested in further research; however, the technique needs to be refined to avoid sural nerve injuries.
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Affiliation(s)
- Søren Kaalund
- Center for General Practice, Aalborg University, Aalborg, Denmark.,Center for Sports Medicine, Regional Hospital of Northern Denmark, Hjørring, Denmark
| | - Søren G Kjaer
- Diagnostic Centre, University Research Clin of Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Michael S Rathleff
- Center for General Practice, Aalborg University, Aalborg, Denmark.,Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.,Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg, Denmark
| | - Ulrich Fredberg
- Diagnostic Centre, University Research Clin of Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Rheumatology, Odense University Hospital, Odense, Denmark
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Lalumiere M, Perrino S, Nadeau MJ, Larivière C, Lamontagne M, Desmeules F, H. Gagnon D. To What Extent Do Musculoskeletal Ultrasound Biomarkers Relate to Pain, Flexibility, Strength, and Function in Individuals With Chronic Symptomatic Achilles Tendinopathy? FRONTIERS IN REHABILITATION SCIENCES 2021; 2:726313. [PMID: 36188777 PMCID: PMC9397971 DOI: 10.3389/fresc.2021.726313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022]
Abstract
Introduction: Achilles tendinopathy (AT) is a chronic musculoskeletal pathology best evaluated by ultrasound imaging. This cross-sectional study aimed at better understanding the relationship between musculoskeletal ultrasound biomarkers (MUBs) of Achilles tendon and localized pain, ankle flexibility, ankle strength, and functional abilities. Method: Forty-one participants with unilateral midportion chronic AT had their tendon images analyzed bilaterally in the longitudinal and transverse planes. The Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) and Lower Extremity Functional Scale (LEFS) assessed pain and function, respectively, during standing and walking-related activities. Ankle flexibility was evaluated by weight-bearing lunge tests, while ankle isometric peak strength was measured using an instrumented dynamometer. Achilles tendon ultrasonographic images were analyzed using geometric (thickness), composition (echogenicity), and texture (homogeneity) MUBs. Discriminative validity was evaluated using paired Student's t-tests to compare MUBs between symptomatic and asymptomatic sides. Predictive validity was evaluated by computing the Pearson product-moment correlations coefficient between MUBs and pain, ankle flexibility, ankle strength, and function. Results: Significant differences were found in MUBs between the symptomatic and asymptomatic sides, confirming the discriminative validity of the selected MUBs. On the symptomatic side, thickness was found 29.9% higher (p < 0.001), echogenicity 9.6% lower (p < 0.001), and homogeneity 3.8% higher (p = 0.001) when compared with the asymptomatic side. However, predictive validity was scarcely confirmed, as most of the correlation coefficients were found negligible for the associations investigated between MUBs with localized pain, ankle flexibility, strength, and function. Only 14 statistically significant low to moderate associations were found, with negative and positive correlations ranging between −0.31 and −0.55 and between 0.34 and 0.54, respectively. Discussion: Musculoskeletal ultrasound biomarkers have a clinical utility in visualizing in vivo tendon integrity and diagnosing AT. MUBs should be valued as part of a comprehensive neuro-musculoskeletal assessment as they complement pain, flexibility, strength, and function measures. Altogether, they may inform the development and monitoring of a personalized rehabilitation treatment plan.
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Affiliation(s)
- Mathieu Lalumiere
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montreal, QC, Canada
| | - Sarah Perrino
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | | | - Christian Larivière
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montreal, QC, Canada
- Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST), Montreal, QC, Canada
| | | | - François Desmeules
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Centre de recherche de l'Hôpital Maisonneuve-Rosemont (CRHMR), Montreal, QC, Canada
| | - Dany H. Gagnon
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montreal, QC, Canada
- *Correspondence: Dany H. Gagnon orcid.org/0000-0003-3464-4667
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