Lower Limb Tendinopathy Assessment

Original Editor - Mandy Roscher Top Contributors - Mandy Roscher, Tarina van der Stockt and Kim Jackson

Introduction

The correct diagnosis is crucial in the management of lower limb tendinopathy. A thorough assessment is required to not only diagnose tendinopathy in the lower limb but also to identify the contributing and aggravating factors that have resulted in the tendinopathy. Clinical reasoning around various differential diagnosis is also important to make sure the diagnosis is accurate.

Pathology can occur in any tendon but in the lower limb, it commonly occurs in the Achilles, Patella, Hamstring and Gluteal Tendons.

Key Questions to Ask in the Interview / Subjective Assessment

Pain Behaviour

Where is your pain?

A key feature of tendinopathy is localised pain that increases with dose-dependent loading.[1][2][3] A person with tendinopathy will usually have pain that is extremely localized and this pain increases but does not spread when load is placed upon it. (Gluteal tendinopathy is an exception where there can be referred pain down the leg)[3]

What aggravates your pain? / What makes your pain worse?

High tensile load, compressive loads or a combination of both normally aggravate pain in tendinopathy. The pain will normally increase as the increased load is placed upon it (but stay very localised to that area).

24 Hour Pattern

Do you have night pain?

Tendons do not generally present with night pain. The exception being a Gluteus Medius tendinopathy, where night pain can occur due to compressive loads of lying on it or the leg hanging down into adduction is it is on top.[3]

Do you have any stiffness in the morning?

Tendinopathies often present with morning pain and stiffness but this normally eases relatively quickly with movement. Patients with various arthritic conditions also tend to have morning pain but this pain normally takes more than 30 minutes to ease or doesn't ease off.[4] It can be helpful to screen for any metabolic, systemic or inflammatory conditions to rule out other diagnoses.[4]

24-Hour Response

Does your pain subside or increase during an activity?

Tendons generally have a warm-up phenomenon. Pain that subsides during an activity is generally a strong indicator of tendinopathy.[1][3] If pain increases during activity then looking at other differential diagnoses of structures around the tendon such as the sheath and paratendon.

How do you feel the day after?

Tendons are generally painful the day after energy storage activities.[1] The irritability of a painful tendon is normally determined by its 24-hour response to activity.[3] If the pain is aggravated 24 hours after an activity, it is classified as irritable. If the pain is the same or settles within 24 hours then it is stable[1] [3]. This is an important factor to consider in terms of what stage the tendinopathy is at and where you will rehabilitation should start.

Present History

What have you changed? / What load have you added?

A new flare-up of tendon pain is normally as a result of changes to loading. A tendons capacity only ever exceeds the loads placed upon it and small changes can make a difference. Careful questioning around what someone has changed recently will help identify the contributing factors of the tendinopathy. Changes in load can result from a number of factors be it and increase in training intensity, footwear changes, recent participation in a tournament, increase in speed or plyometrics.

Past History

A thorough investigation into past history is important to establish from where the tendinopathy has originated. Is this is the first event? Are there any pre-existing injuries? Is this a long term problem? Comprehensive questioning into previous injuries, rest period etc will help to give a good clinical picture.

Red Flags and Risk Factors

As with all conditions screening for Red Flags and General Health is extremely important so as not to miss any serious or sinister conditions.

Some Risk Factors Identified in the Development of Tendinopathies (for references see Tendon Pathophysiology Page)

  • Hormone Replacement Therapy
  • Contraceptive medication
  • Diabetes
  • Obesity
  • High adiposity in lower limb tendinopathies
  • Use of Fluoroquinolones
  • Lack of range of movement
  • Inflexibility
  • Strength imbalance
  • Poor vascularity
  • Blood Type O
  • Altered lower limb biomechanics
  • Low-temperature training

Goals and Expectations

It is important to know what is expected from physiotherapy as well as what the person is wanting to return to. This helps with the planning of a comprehensive management programme. A sedentary 60 year old’s goals will be very different from an elite athlete

Patient-Reported Outcomes

The Victoria Institute of Sport Assessment has developed self-administered questionnaires for tendinopathy.[5] They are scored out of 100 and a change in 13 points is considered clinically significant. [1] The VISA Questionnaires do not detect small changes and as such it is advised to only use them every 4 weeks to record progress.[1]

Patella Tendinopathy- VISA- P

Achilles Tendinopathy- VISA- A

Hamstring Tendinopathy- VISA-T

Gluteal Tendinopathy- VISA- G

Physical Examination / Objective Examination

The Physical Examination is used to test your hypothesis that has been developed through clinical reasoning with information obtained in the interview.

Pain-provocation testing

Dose-dependent loading is a helpful way to confirm the diagnosis of tendinopathy.[1] Pain that remains localised to the tendon and increases with increasing loads is a strong indicator of tendinopathy.[1][3]

During progressive loading tests, the 2 important questions to keep asking are

1. Is that painful?

2. Where is the pain?

Each tendon has specific movements that place them under compressive and tensile loads. The progressive loads will vary depending on which tendon is being assessed. It is only necessary to load them to a point that confirms a diagnosis and not to overload the tendon and aggravates the condition.[4]

Muscle Strength, Joint Range and Functional Assessment

Assessment of the entire kinetic chain is extremely important to determine contributing factors. This is again unique to each tendinopathy and there is no “recipe” for assessment. Assessing muscle strength and range of movement of involved muscles and joints respectively will help to guide management.

Palpation

Painful palpation of the tendon has low specificity in the diagnosis of tendinopathy. Pathological tendons are usually painful on palpation but other conditions can also result in tendons being painful on palpation.  A tendon may be painful on palpation and not of the cause of the presenting symptoms. Absence of pain on palpation can be a way to rule out tendinopathy.

Imaging

Ultrasound and MRI are used to image tendons. MRI is more specific and can give more information but it also significantly more expensive. Imaging to confirm tendons as a source of symptoms should be used with caution. Abnormalities and pathology found on imaging have been shown to have little correlation to pain and function and similarly, tendons that have no pathological changes on imaging can present as painful. (3) Imaging can be helpful in complicated clinical presentation to include or exclude other differential diagnoses[1]

Key findings in Specific Tendinopathies

[1]

Pain localised to the inferior pole of the patella

Pain increases with knee extension activities that store and release energy eg jumping or quick changes in direction

Often in Athletes between 15-30 years old that compete in basketball, volleyball, jumping athletic events, tennis and football or any sport with jumping/ direction changes

Progressive Load Assessment (Pain should stay localised and increase with increase load to confirm the diagnosis)

  • Shallow squat
  • Deep squat
  • Small hop
  • Big hop

Midportion [6] [7]

Pain localised 2-6cm proximal to Achilles tendon insertion

Aggravated by energy storage and release exercises (eg jumping, running) and not normally repetitive movements (eg swimming, cycling)

Morning stiffness is a hallmark sign[4]

Progressive Load Assessment

  • Double leg calf raise
  • Single leg calf raise
  • Double leg jump
  • Single leg small hop
  • Single leg big hop
  • Big hops in a row
  • Forward hopping

Gluteal Tendinopathy[2]

Pain at the greater trochanter

More common in sedentary women over 49 years old

Pain often refers down the lateral thigh

Single leg tasks often painful

Aggravated by compressive loads

  • Hanging on a hip in standing - relative hip adduction
  • Sitting legs crossed
  • Single leg tasks with excessive lateral pelvic tilt (hip moves into relative adduction)
  • Crossing the midline during running
  • Sleeping on side, Bottom leg- sleeping on the painful side (direct compression)
  • Sleeping on side, Top leg moves into relative adduction if it drops down

Proximal Hamstring Tendinopathy[3]

Pain localised to the ischial tuberosity

Warm-up phenomenon

Provoked in actives with deep hip flexion (compressive load)

  • Squatting
  • Lunging
  • Sitting (especially harder surfaces)
  • Painful during energy storage activities but not normally with slow walking, standing or lying

Progressive Load Assessment

  • Single leg bent knee bridge (low load)
  • Long lever bridge (moderate load)
  • Arabesque movement (high load)
  • Single leg deadlift (high load)
Single Leg Long Lever Bridge
Arabesque

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Malliaras P, Cook J, Purdam C, Rio E. Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):887-98.
  2. 2.0 2.1 Grimaldi A, Mellor R, Hodges P, Bennell K, Wajswelner H, Vicenzino B. Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Medicine. 2015 Aug 1;45(8):1107-19.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Goom TS, Malliaras P, Reiman MP, Purdam CR. Proximal hamstring tendinopathy: clinical aspects of assessment and management. journal of orthopaedic & sports physical therapy. 2016 Jun;46(6):483-93
  4. 4.0 4.1 4.2 4.3 Rio E. Lower Limb Tendinopathy Assessment Course. Physioplus. 2019
  5. MacDermid JC, Silbernagel KG. Outcome evaluation in tendinopathy: foundations of assessment and a summary of selected measures. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):950-64.
  6. Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR. Achilles pain, stiffness, and muscle power deficits: Midportion achilles tendinopathy revision 2018: Clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the american physical therapy association. Journal of Orthopaedic & Sports Physical Therapy. 2018 May;48(5):A1-38.
  7. Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR. Achilles pain, stiffness, and muscle power deficits: Midportion achilles tendinopathy revision 2018: Clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the american physical therapy association. Journal of Orthopaedic & Sports Physical Therapy. 2018 May;48(5):A1-38.