Achilles Assessment Toolkit: From Diagnosis to Outcome Tracking

"With diagnosis: it’s more of an iterative process…alternating between confidence going through the criteria of Achilles tendinopathy and confidence in ruling out the differential diagnoses.” -Ruth Chimenti

The field of physical therapy continues to struggle with the most basic aspect of tendinopathy management: correctly identifying it. While everyone reading this newsletter likely considers themselves above average when it comes to clinical practice patterns, it is sometimes necessary to take an honest look in the mirror regarding our day to day processes.

You can never be too good at the basics. While this information may not be on the cutting edge, sometimes we just need to ‘eat our vegetables’ and ensure our foundation is solid. In her talk at the inaugural Tendon Summit, Ruth Chimenti walked through the primary diagnostic features of Achilles tendinopathy, key differentials, clinical anecdotes, and the role of imaging. We won’t explore every aspect of her presentation in this newsletter, but we will dive into agreed-upon criteria to diagnose Achilles tendinopathy while zooming in on one aspect Ruth singled out: movement-evoked pain (MEP).

Where We Stand: Diagnostic Criteria

A recent scoping review, examining 159 studies, reported substantial discrepancies in how Achilles tendinopathy is diagnosed [1]. A Delphi study among tendinopathy experts [2] found only two criteria with >90% agreement:

1) Pain location (93%)
2) Pain during activity (97%)

And two others of >70% agreement:

1) Tests that provoke pain (87%)
2) Palpation to assess pain (83%)

Yet practicing clinicians report a different pattern.

An international survey among practicing clinicians [3] showed the top four tests were:

1) Symptom response to a series of progressive loading tests (84-92%)
2) Pain tolerance with palpation (77-84%)
3) Visual comparison of the Achilles Tendon (63-65%)
4) Symptom modification in response to isometric exercise (60-64%)

This contrast between expert consensus and clinical practice should give us pause. Our confidence in collective diagnostic accuracy should be questioned; especially considering two of the most used criteria run counter to, or lack support from, expert guidance.

Visual comparison, depending on the interpretation, is either neutral (no consensus reached among experts) or negative (>70% recommend NOT using). 

Symptom modification to exercise is also a consensus “do not use” as part of the diagnostic process. Pain behavior (not the dichotomous provocation of pain, but the pattern of pain) is viewed as too non-specific to be useful to differentiate tendinopathy from other conditions.

So while “pain during activity” and “provocation testing” appear in some fashion in both expert and clinician lists, these categories are broad and introduce substantial variability.

Both in Ruth’s talk and within the CPGs she authored on the subject, she mentions the introduction and emphasis of movement-evoked pain (MEP) as being a key feature for diagnostic and monitoring purposes [4].

What is MEP and how does it fit within the current tendinopathy landscape? Does it assist in improving our diagnostic accuracy?

Worth a quick distinction: the guidelines invoke MEP in a general sense without reference to the more established construct. The terminology discussed within the lecture (structured pain measurement before, during, and after a task) is in reference to a more specific tool which we discuss below.

Movement-Evoked Pain:

Traditional pain questionnaires focus on resting pain or are relatively dependent upon patient recall. These features introduce noise and reduce specificity. MEP was proposed to address these limitations.

MEP refers to the assessment of pain during a movement or functional task that reflects the specific contexts in which an individual typically experiences their symptoms (for our purposes, that could mean during walking or heel raises). Pain is measured at multiple timepoints (before, during, and after the task) to capture the dynamic, temporal nature of the pain response and provide an ecologically valid representation of the person’s lived pain experience. By structuring pain assessment within this movement–pain interface, MEP aims to capture the biological, psychological, and social influences that shape symptom expression in real time [5,6].

Janowski examined this general measure within the specific confines of Achilles tendinopathy to explore its utility further [6,7]. What his group found was that MEP is a valid, sensitive, clinically meaningful measure for tracking progress and characterizing irritability in both mid-portion and insertional tendinopathy.

However, we should not confuse a useful measure of change with a diagnostic tool. The construct has not been directly compared in cohorts presenting with similar but distinct musculoskeletal conditions. We are in the dark if MEP offers any discriminative value over other measures.

In their data, they show the combination of movement strategy, psychological factors, symptom irritability, and task intensity only account for approximately half the variance observed in MEP metrics. Most importantly, tendon force did not determine the intensity of pain experienced [6].

If direct loading of a pathological tendon does not reliably scale with dynamic measures of pain, there is little reason to believe MEP will provide tendon-specific signals. Pain is a multifactorial phenomenon with significant inter and intra-individual variance that extends well beyond what we’re able to currently capture in the clinic. None of these features are unique to tendinopathy and our confidence should not change based on the dynamic response during or following loading.

Conclusion:

Pain characteristics remain central to tendinopathy management, and MEP offers a more encompassing, and ecologically valid way to interact with a patient’s lived pain experience. It contextualizes symptoms and captures dimensions that static measures miss.

But, as pointed out by the expert consensus, pain behavior and loading responses overlap too heavily with other MSK conditions to serve as reliable diagnostic markers. Clinicians often rely on patterns such as “pain proportional to the load placed on the tendon” or “pain that appears at the initiation of loading and improves as activity continues.” These features are commonly associated with tendinopathy, yet current evidence suggests they should not meaningfully influence our differential diagnosis. 

MEP appears to be an excellent addition to directly interact with and track a patient’s pain experience across time. It puts symptoms into appropriate context and allows insight into the more insidious aspects of the widespread impacts that more static measures fail to capture. However, because MEP is primarily a structured way of measuring pain behavior rather than a tendon‑specific signal, it is unlikely to improve our initial diagnostic process.

Our responsibility is to anchor diagnosis in the best available evidence while integrating emerging constructs like MEP to guide management, monitor progress, and better understand the patient’s condition over time.

Next up, we review the lecture from Seth O’Neill — a look at practical application of evaluation and diagnosis for Achilles tendon disorders.

Debrief written by: Jason Eure, PT, DPT, OCS, CSCS

Reference List

1. Matthews W, Ellis R, Furness J, et al. The clinical diagnosis of Achilles tendinopathy: a scoping review. PeerJ 2021;9:e12166

2. Malliaras P, et al. 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 Jun 18;59(13):891-901. doi: 10.1136/bjsports-2024-109185. PMID: 40240126.

3. Cross ND, Wirdnam M, Purdam C, Sayer TA, Rio E, Bonello C. Provocation with progressive loading is the most common diagnostic method for Achilles tendinopathy: an international cross-sectional study of 1048 physiotherapists. JOSPT Open. 2025;3(1):93-98. doi:10.2519/josptopen.2024.0080.

4.  Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, Martin RL. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision - 2024. J Orthop Sports Phys Ther. 2024 Dec;54(12):CPG1-CPG32. doi: 10.2519/jospt.2024.0302. PMID: 39611662.

5. Butera KA, Chimenti RL, Alsouhibani AM, Berardi G, Booker SQ, Knox PJ, Post AA, Merriwether EN, Wilson AT, Simon CB. Through the Lens of Movement-Evoked Pain: A Theoretical Framework of the "Pain-Movement Interface" to Guide Research and Clinical Care for Musculoskeletal Pain Conditions. J Pain. 2024 Jul;25(7):104486. doi: 10.1016/j.jpain.2024.01.351. Epub 2024 Feb 3. PMID: 38316243; PMCID: PMC11180580.

6. Janowski AJ, Post AA, Heredia-Rizo AM, Mosby H, Dao M, Law LF, Bayman EO, Wilken JM, Sluka KA, Chimenti RL. Patterns of movement-evoked pain during tendon loading and stretching tasks in Achilles tendinopathy: A secondary analysis of a randomized controlled trial. Clin Biomech (Bristol). 2023 Oct;109:106073. doi: 10.1016/j.clinbiomech.2023.106073. Epub 2023 Aug 18. PMID: 37657267; PMCID: PMC10543613.

7. Janowski AJ, Post AA, Heredia-Rizo AM, Frey-Law LA, Bayman EO, Sluka KA, Chimenti RL. Exploring biomarkers of change in movement-evoked pain in Achilles tendinopathy: A secondary analysis of a randomized controlled trial. Clin Biomech (Bristol). 2026 Jan;131:106706. doi: 10.1016/j.clinbiomech.2025.106706. Epub 2025 Nov 7. PMID: 41207117; PMCID: PMC12626106.