Over the next several weeks, this newsletter series will serve as your runway to the Traverse City Tendon Summit.

Each installment highlights key ideas across the Summit’s three major content areas:

1. Foundational Science

2. Evaluation and Diagnostics

3. Management and Decision Making

The goal is simple. We want everyone arriving in April with a shared platform of understanding so that the conversations can move quickly past the basics and into the deeper, more meaningful discussions that drive real progress. None of the ideas introduced here should be taken as settled science. These nuances invite debate and discussion, and that exchange is central to the purpose of the Summit.

In our previous installments, we outlined a gold standard framework for evaluating pathological tendons. We explored what is known about tendon pathology and the domains that matter most during clinical encounters. Understanding the scope of the problem is essential for maximizing the chance of successful intervention. But for clinicians operating in this space, the sheer number of available tests, measures, and conceptual models can feel overwhelming. This installment zooms down and in. We will draw heavily from the work of Seth O’Neill and contemporary scholars to distill what is essential, what is useful, and what is unnecessary.

Evaluation & Diagnostics: Part II

KEY TAKEAWAYS

• Evaluation happens in the real world, not in ideal conditions. Clinicians work within limits on time, attention, and available tools. We must be deliberate and efficient with our choices. Each measure must contribute reliable, decision‑shaping data rather than adding noise to our process. The Core Outcome Set (COS) developed through expert Delphi consensus distills our options and provides an avenue to apply the ideal framework from Newsletter 4.

• Patient reported outcomes anchor the lived experience of tendinopathy. The VISA‑A remains widely used but faces growing concerns about structural, content, and construct validity. It can still support clinical reasoning, but its limitations require contextual interpretation. Newer instruments such as the TENDINS‑A may offer conceptual improvements, yet they should be adopted thoughtfully until validated across broader settings.

• The Single Leg Heel Rise Test is only valuable when standardized. As the second component of the Core Outcome Set, the SLHR offers an accessible indicator of plantarflexor capacity. However, its value depends entirely on consistent foot position, cadence, and height criteria. Without strict standardization, the test shifts from a reliable performance measure to a misleading or nearly meaningless data point. 

• Pain ratings during and after activity clarify irritability but require consistency. The final two COS elements capture symptom behavior across time, yet the literature shows wide variation in thresholds, timeframes, and monitoring rules. Without a defined provocation task and consistent timing, VAS scores lose interpretive power. Establishing a reproducible task and timeframe with the patient strengthens their clinical utility.

• A multidomain perspective ensures the evaluation remains complete and individualized. The Core Outcome Set provides a stable foundation, but clinicians may need to expand the assessment to include tendon specific measures, broader strength profiling, and relevant multisystem or contextual contributors. Integrating these findings with clear communication and patient centered reasoning ensures the evaluation remains efficient, holistic, and responsive to the individual.

Core Outcomes

In an ideal world, you would have unlimited time to explore every clinical correlate and chase every hypothetical mechanism. Real practice is not afforded this luxury. Every interaction carries a cost–benefit tradeoff. We need to concern ourselves with more than simply time and resources. Each decision also influences how the patient interprets their care, how confident they feel, and how willing they are to participate in the plan. Research in other domains of patient care shows that reassurance, clear explanations, and a strong therapeutic alliance meaningfully shape engagement and functional outcomes [1,2]. Patients also arrive with expectations about what “good care” should look like, often prioritizing diagnosis, clarity, and structured guidance. These pre‑determined conceptions shape their sense of safety and their readiness to engage [3].

When the interaction itself can alter the trajectory of care, we face the challenge of threading the needle between efficiency and thoroughness. The tests we choose must not only be clinically justified but must also align with, or thoughtfully reshape, the patient’s beliefs about what constitutes optimized care.

Multiple tests that provide corroborating information can be helpful, and in some regions they are encouraged because individual tests are notably fallible. The shoulder is a prime example. Across shoulder‑specific pathologies, individual orthopedic special tests rarely demonstrate strong diagnostic metrics, and clusters are intentionally used to improve post‑test probability [4]. But redundancy becomes counterproductive when it adds information without improving clarity. The goal is not to collect data. The goal is to inform our decision‑making process.

In this light, every test should be deliberate. A finding should do one or more of the following to warrant inclusion:

• Meaningfully shift diagnostic probability

• Illuminate a potential causative or contributory factor

• Serve as a key performance indicator to anchor progress

• Clarify a confounding variable that would alter the timeline or nature of care

A recent Delphi study led by de Vos and colleagues (with two of our Summit presenters contributing) has done much of the heavy lifting for us in this regard. The group identified a Core Outcome Set for Achilles tendinopathy, outlining the minimum effective dose of evaluation [5]. It captures the complexity of the condition without drifting into unnecessary detail. It streamlines assessment while preserving the breadth required to understand the full impact of the disorder.

The Delphi group ultimately converged on four measures:

1. VISA‑A questionnaire (captures disability)

2. Single‑leg heel rise test (captures physical function capacity)

3. VAS pain during activity/loading (0–10) (indexes symptom provocation)

4. VAS pain after activity/loading (0–10) (indexes symptom persistence)

Together, these provide a concise yet comprehensive snapshot of symptom severity, disability, physical function capacity, and pain on loading. For the busy clinician, they represent a practical minimum viable product of tendon assessment that is efficient, evidence aligned, and consistent with the holistic, multidomain evaluation emphasized in the 2024 Clinical Practice Guideline [7].

VISA-A Questionnaire: What It Is and What It Captures

The Victorian Institute of Sport Assessment–Achilles (VISA‑A) is a specific patient‑reported outcome measure designed to quantify the impact of Achilles tendinopathy on pain, function, and activity participation. It evaluates physical limitations through questions about pain during daily activities, functional capacity, and sport‑related loading tasks [6]. The questionnaire creates a composite score: ranging from 0 to 100 points, with higher scores indicating fewer symptoms and less functional restriction. A meaningful change on the VISA‑A has been estimated at 14 points over 12 weeks and 7 points over 24 weeks in active individuals with midportion Achilles tendinopathy [6].

Within the multidomain structure emphasized in the 2024 Clinical Practice Guideline, the VISA‑A is positioned within the domains of disability, symptom severity, and participation [7]. In clinical practice, it is often used as a broad indicator of how symptoms are affecting daily life rather than only how the tendon behaves under load. This usage assumes that the questionnaire reflects the downstream consequences of psychological and contextual influences that shape pain, function, and disability.

Evidence investigating the links between psychological variables and tendinopathy‑related concerns is complex. Pain is a complicated phenomenon that requires more nuance than this newsletter can fully provide. The language used to describe different aspects of pain and the human experience is not a semantic afterthought. Each term reflects a distinct construct that shapes both research and clinical reasoning.

Even with these distinctions in mind, the evidence remains mixed. Some studies report clear associations between psychological factors and pain or disability, while others find small or inconsistent effects [8,9]. Anxiety and depressive symptoms appear at higher rates in individuals with Achilles tendinopathy compared with healthy peers [9]. Anxiety shows positive associations with pain, symptoms, and physical function, whereas depression is negatively associated with symptoms but not pain or function [9]. Generalized kinesiophobia does not appear to correlate with pain, symptoms, or function, but tendon‑specific “fear of rupture” shows a modest association with pain only [8]. More stable psychological traits such as catastrophizing and negative pain beliefs also present at higher rates in this population [9].

This admittedly muddy picture reflects the challenge clinicians face when trying to act on these variables in real time. While far from easily defined or robust, the cumulative evidence still suggests that psychological states and traits influence the lived experience of tendinopathy [8,9]. These characteristics can shape how symptoms are interpreted, how quickly individuals disengage from activity, and how confident they feel in their ability to recover [9].

Knowing this, accurate capture and tracking of these concerns can directly shape the nature of our patient interactions. Measures that reflect changes in symptom burden, functional tolerance, and the behavioral consequences of threat appraisal can guide how we pace loading and how we support patients in staying engaged with their program. This aligns with evidence showing that expectations, beliefs about recovery, perceived capability, and clarity of the plan influence whether patients follow through with treatment and maintain the behaviors required for improvement [10,11].

In theory, a VISA‑A score can clarify whether psychological or contextual factors are likely to alter the timeline or nature of care [7]. It can anchor progress across time, illuminate contributory factors that may not be obvious during physical examination, and it can meaningfully shift clinical reasoning by helping clinicians differentiate between mechanical limitation and the broader lived experience of the condition [6].

Yet the degree to which the VISA‑A accurately represents these constructs depends on the validity of its items, and this assumption has been increasingly questioned.

Limitations and Contentions

To serve as an effective measure of function and participation, a questionnaire must demonstrate that its items consistently represent these concepts in an accurate and comprehensive fashion. Recent work has raised substantial concerns about whether the VISA‑A meets this standard, with critiques spanning multiple core aspects of measurement validity.

Structural validity. Travers found that the VISA‑A’s items do not consistently group together in a way that reflects a single underlying concept [12]. In practical terms, this means the total score may blend unrelated elements rather than representing one coherent construct. That conflation makes it harder to interpret what a change in score actually reflects.

Content validity. Travers also noted that several items are outdated, overly sport‑centric, or only loosely related to disability in Achilles tendinopathy [12]. Korakakis and colleagues expanded on this, showing that the VISA‑A omits domains patients identify as meaningful, including psychological factors, participation, and broader quality‑of‑life impacts [13].

Construct validity. Korakakis and colleagues questioned whether the VISA‑A behaves as a measure of tendinopathy severity should, including whether it correlates with related constructs and discriminates between known groups [13]. For example, people with more severe symptoms do not always score meaningfully lower than those with milder presentations, and VISA‑A scores do not consistently align with other indicators of disability. When construct validity is limited in this way, the score may not reflect the condition it is intended to quantify.

Responsiveness. Travers reported that changes in VISA‑A scores do not consistently align with meaningful changes in patient‑perceived improvement across different stages of recovery [12]. This helps explain why the MCID appears to shift over time and why its confidence intervals are wide. When a measure does not track perceived improvement reliably, estimates of clinically important change become unstable, and the score may misrepresent progress.

Taken together, these concerns raise questions about whether the VISA‑A represents the lived experience of Achilles tendinopathy or the constructs it is commonly used to infer. VISA‑A scores should therefore be interpreted within context rather than treated as a complete representation of the condition.

Introducing TENDINS-A

Given these limitations, it is reasonable to consider whether alternative instruments offer a clearer and more comprehensive representation of Achilles tendinopathy. In response to these concerns, Murphy developed the Tendinopathy Severity Assessment Achilles, a patient‑reported outcome measure designed to address gaps in content validity and conceptual alignment with contemporary models of tendinopathy [14]. The development process centered on domains that patients and clinicians identified as essential to the lived experience of the condition. Deliberate consideration was given to symptom severity, functional impact, and contextual influences.

Bright subsequently evaluated the TENDINS‑A and reported strong structural validity, construct validity, and reliability, suggesting that it may offer a more coherent and comprehensive representation of Achilles tendinopathy severity than the VISA‑A [15]. These findings directly counter several of the limitations raised by Travers and Korakakis, particularly in the areas of item relevance, conceptual coherence, and the ability to reflect meaningful change.

However, external validation across diverse settings and populations remains limited. It is important not to assume that an instrument validated in one context automatically generalizes to all others. For now, the TENDINS‑A represents a promising alternative, particularly when clinicians want a measure that better reflects the multidomain nature of the condition, but its use should remain thoughtful, context dependent, and grounded in the available evidence.

Single-Leg Heel Rise Test: Mastering the Mundane

Technology to objectively measure and monitor strength qualities has become increasingly available across settings. Best practice for integrating and leveraging those tools is an expansive topic on its own. Entire courses have been created specifically around this idea.

Our focus here is different. We are zooming in on a low‑tech test with no barrier to entry and enormous clinical value when performed and interpreted correctly: the single‑leg heel‑raise test.

In previous installments, we outlined how the Achilles tendon contributes to dynamic function, particularly its role in storing and releasing elastic energy during forward propulsion to manage load across the gait cycle. In most cases, clinicians cannot directly assess internal tendon characteristics such as stiffness, energy‑storage efficiency, or force‑transfer capacity during routine encounters. These internal qualities matter, but they remain inaccessible in day‑to‑day practice.

Because we cannot peel back the curtain, we rely on surrogate interfaces that approximate the demands placed on the system. The single‑leg heel‑raise test is one such interface. It is implemented as an indicator of strength endurance, attempting to replicate the cyclical, submaximal, repetitive loading that characterizes walking, running, and change‑of‑direction tasks.

To perform the test, the patient stands on one leg with the knee extended, places fingertips lightly on a wall for balance, and raises the heel through the full available range until failure. The clinician counts repetitions performed as their assessment of the strength quality.

This is deceptively simple. Without thoughtful consideration, the test can provide inaccurate information or, worse, create the illusion of progress without true adaptation. To use the heel‑raise test as a meaningful performance indicator, we need to understand what it measures, what it does not measure, and how to interpret it with precision.

Below, we break down the elements that determine whether this test functions as a reliable marker of plantarflexor capacity.

Normative Values and Interpretation: Why You Cannot Rely on Contralateral Limb Performance

Clinicians often default to side‑to‑side comparisons, assuming the uninvolved limb represents a stable benchmark. This assumption is convenient, but it is not always valid. Evidence from other lower‑extremity conditions demonstrates that the contralateral limb is a dynamic data point rather than a fixed control. Moran and colleagues showed that 24–38% of patients recovering from ACL reconstruction experienced more than a 10% increase in contralateral limb strength between 6 and 9 months postoperatively, driven by early deficits in the “uninjured” limb [16]. This artificially inflated limb‑symmetry indices and overstated recovery. While this work is not specific to Achilles tendinopathy, the principle is directly relevant. If the contralateral calf is deconditioned, inhibited, or simply undertrained, side‑to‑side comparisons can underestimate true impairment and obscure meaningful deficits in plantarflexor capacity.

This is reinforced by recent Achilles‑specific work. Visser [17] demonstrated that individuals with unilateral Achilles tendinopathy often show bilateral deficits in plantarflexor endurance and peak heel‑rise height, even when symptoms are unilateral. Green [18] similarly reported that the “uninvolved” limb frequently underperforms relative to normative values, suggesting that contralateral comparison alone may mask meaningful deficits.

While these findings highlight the limitations of relying solely on the contralateral limb, its usefulness depends on the clinical context. In acute presentations, where symptoms are recent and compensatory strategies have not yet developed, the uninvolved limb can still serve as a reasonable patient‑specific anchor. In more chronic or long‑standing cases, bilateral adaptations are common. Deconditioning, altered loading patterns, and protective movement strategies can depress performance on both sides, which makes the contralateral limb an insufficient benchmark.

For this reason, absolute performance benchmarks and population‑based normative values are essential.

Normative values for the general adult population have been estimated at approximately 25 repetitions in traditional heel‑rise protocols [17] and 28 repetitions when performed on a flat surface with standardized criteria [19].

Athletic populations typically demonstrate higher capacity. For example, Australian football players in Green’s cohort averaged 33.9 repetitions when assessed in an uncontrolled manner [18].

These numbers provide a useful reference point, but they are only meaningful when the test is performed in a consistent and clearly defined manner. This caveat of “uncontrolled manner” above should not be understated. Heel‑rise performance is highly sensitive to how the test is set up and executed, and different protocols can yield very different results. Green et al. repeated their assessment while controlling for key variables and found rep performance fell by over 30% across the board. The specific factors that influence performance are addressed in the sections that follow.

Technical Considerations That Determine Test Quality

Foot Position

Starting foot position meaningfully alters the mechanical demands of the heel‑rise test, and the differences are large enough to change clinical interpretation. In a 2024 study, Hébert‑Losier and colleagues demonstrated that healthy adults performed 28 ± 8 repetitions on a flat surface, 22 ± 7 on a 10° incline, and 18 ± 8 from a forefoot‑supported step [19].

Total vertical displacement and total positive work followed the same pattern, decreasing progressively from flat → incline → step.

These differences are not trivial. A shift of 10 repetitions and several hundred joules of work can easily be misinterpreted as a meaningful deficit when, in reality, it reflects a change in test configuration. More importantly, these data show that repetition count alone cannot be interpreted without knowing the starting position. Without standardization, repetition totals risk being compared across fundamentally different tasks, and the underlying functional capacity of the plantarflexors remains obscured.

Pacing

Cadence is another parameter that substantially alters heel‑rise performance [20]. Heel‑raise performance has been assessed across different velocity constraints, with pacing compared between 30, 60, and 120 bpm (equating to 15, 30, and 60 reps per minute respectively). Importantly, repetition count did not differ significantly across cadences. However, every other meaningful quality metric did. Total vertical displacement, total work, peak height, and peak power were all significantly affected by tempo.

This finding is critical: repetition number remained stable, but the underlying performance changed dramatically. Two individuals may complete the same number of repetitions, yet one may produce substantially more height, displacement, and work.

Pacing exposes deficits in movement quality that uncontrolled testing conceals. Viewed through this lens, accounting for repetition count alone is a poor indicator of true plantarflexor capacity.

Height

Height is the most sensitive indicator of plantarflexor function across all major datasets. This quality is affected by the aforementioned concerns, as height is a dynamic, load‑dependent variable that responds to both mechanical setup and neuromuscular demand.

Hébert‑Losier’s 2024 work shows that peak height varies meaningfully with foot position, ranging from 8.44 to 10.64 cm depending on the starting configuration [19].

Their 2025 cadence trial demonstrates that peak height is also influenced by movement velocity [20]. Significantly lower values were observed at 30 bpm and higher values at 60 and 120 bpm, consistent with earlier discussions on how faster stretch rates improve force transmission through the muscle–tendon unit.

Green’s 2024 study provides the strongest clinical reinforcement of this concept [18]. When athletes performed the test under standardized pacing and technical criteria, the test did not end because they chose to stop; it ended because they failed to meet the required movement standards. In their cued condition, loss of plantarflexion height was the most common technical failure, accounting for 49.1 percent of all terminations. This means the test ends when the contractile elements can no longer generate sufficient force to lift the body to the required height.

Heel Rise Test Takeaways:

In total, these data reveal several foundational principles that determine the utility of the heel‑rise test and the accuracy of its interpretation:

1. Technical precision is non‑negotiable.  

Consistent foot placement, cadence, and range of motion must be deliberately controlled to ensure that repetition totals and quality metrics reflect true plantarflexor capacity rather than protocol variation.

2. Repetition number alone is an insufficient metric.  

Individuals may achieve “normal” repetition counts while showing early and pronounced declines in height, displacement, and work. Height loss reflects impaired end‑range plantarflexor strength, reduced tendon stiffness, or diminished force‑generating capacity. These are deficits that repetition count alone cannot detect. 

Monitoring height is essential to ensure the metric holds more weight, because repetition performance only becomes interpretable when each repetition meets an adequate and consistent height standard.

3. Perceived fatigue is a poor indicator of true capacity.  

As demonstrated by Green, technical failure often precedes self‑termination [18]. Relying on patient‑directed stopping points risks missing the very deficits the test is designed to reveal. Establishing clear cutoff criteria for testing is essential to maintain consistency of the measure.

Symptom Irritability and Persistence

The final two measures included in the Delphi consensus were visual analog scales of pain during and following loading. The panel recommended that patients rate symptom severity on a 0–10 Likert scale during activity and again after activity. These ratings are intended to provide a simple, repeatable method for capturing symptom behavior across time.

Irritability is a central concept in tendinopathy management, and Chimenti devoted an entire component of the multidomain model to its interpretation [7]. In the CPG, classifying symptom characteristics is essential for guiding decisions about treatment frequency, intensity, duration, and type. Collecting this information during an evaluation serves several purposes:

1. Establish a defensible entry point for loading.  

Irritability determines where a loading program should begin and how aggressively it can progress. Without this information, early prescription becomes guesswork.

2. Provide a stable anchor against which change can be interpreted.  

Repeated ratings of pain during and after activity offer a consistent reference point for monitoring progress across sessions. The scale can be used to track meaningful improvements, plateaus, or regressions in symptom severity, allowing the VAS to function as a simple but reliable indicator of change over time.

3. Identify symptom behaviors that meaningfully influence planning.  

Pain ratings during and after activity help clinicians observe how symptoms behave in response to load, including how quickly they settle and how predictable they are from day to day. These patterns inform decisions about loading frequency, intensity, and progression.

While these intended functions justify the inclusion of pain ratings during evaluation, the transition from concept to practice is not seamless. When we examine how these measures are defined and used across studies, several limitations become apparent. Recent reviews highlight that pain‑related prescription parameters in tendinopathy research are inconsistently defined. Ullern’s 2025 scoping review found wide variation in thresholds, monitoring windows, and progression rules, with most studies offering little justification for how pain should be interpreted or used in decision‑making [21]. This lack of standardization creates several challenges for implementing the Delphi Group’s recommendations in clinical practice.

First, we need to operationally define what the pain scale means if we are to use it to determine appropriate levels of tolerance or base progressions on their rating. What is an acceptable level of pain to experience during loading and what levels indicate our dosage is missing the mark? Numbers without context offer little value.

To address this, we can expand to recent work by Challoumas and colleagues. Their systematic review helps clarify what a VAS score actually represents. Using large pooled datasets across shoulder, Achilles, patellar, and lateral elbow tendinopathies, they estimated that a change of roughly 1.0 to 1.3 points on a VAS corresponds to a minimal important difference [23]. They also showed that pain at rest, pain with activity, and pain at night behave as distinct constructs, each with its own distribution and variability. “Acceptable” levels of pain will always be individually defined, but using this framework helps contextualize our findings across time.

Second, we need clearer temporal guidelines. Although the Delphi group endorsed pain “after activity” as a core symptom measure, they did not specify when that rating should be taken or how long after loading symptoms should be expected to settle. Without a defined timeframe, the same VAS score can be interpreted very differently across clinicians and studies.

Although the common convention is to assume a 24‑hour testing window, this appears to reflect clinical heuristics rather than objectively verified findings. In tendinopathy management frameworks, such as those summarized by Malliaras, the 24‑hour mark is treated as a central decision point for judging load tolerance [22]. However, when tracing the citations that underpin this recommendation, the empirical basis becomes less clear. The sources typically referenced rely on next‑day symptom behavior as a practical guide, but they do not test the 24‑hour cutoff in a controlled or comparative fashion. Instead, they offer qualitative distinctions about whether symptoms have settled by the following morning, without specifying why that time frame should serve as a universal boundary.

Recent reviews reinforce this broader ambiguity. Ullern’s 2025 scoping review found that pain‑related prescription parameters are frequently used but inconsistently described, with wide variation in thresholds, monitoring windows, and progression rules [21]. Trials comparing painful and non‑painful exercise also employ heterogeneous pain‑monitoring strategies and rarely justify specific temporal cutoffs. Taken together, these observations suggest that while pain ratings are recognized as important for characterizing irritability, the field has not yet converged on tendon‑specific, temporally explicit parameters for capturing symptom behavior after loading. As a result, “after activity” remains conceptually meaningful but operationally loose.

The underlying principle of delayed sensitivity is widely acknowledged in practice, yet the time course itself has not been rigorously examined [22]. This gap likely contributes to the absence of specific temporal guidance in the Core Outcome Set and leaves clinicians without a shared framework for interpreting “after activity” ratings. Defining typical recovery trajectories and the extent of interindividual variability would help distinguish expected symptom behavior from signs of excessive load. Until such parameters exist, the most defensible approach is to establish a consistent timeframe collaboratively with the patient and anchor all follow‑up ratings to that reference point.

Third, we lack standardization of the tasks used to elicit pain. The Delphi group recommends rating pain “during activity” and “after activity,” but does not specify which activities should be used, at what intensity, or under what loading conditions. Without a defined task, clinicians may assess pain during entirely different movements, producing scores that are not comparable across sessions or between patients. This variability further limits the interpretability of VAS ratings and weakens their value as standardized outcome measures.

As outlined throughout this series, loading parameters shape tendon behavior across the entire hierarchy [30]. If we want VAS ratings to reflect true changes in irritability rather than differences in task selection, we must account for the loading context and ensure that symptom provocation occurs under comparable strain environments. One practical solution is to integrate these ratings into the highly controlled Single‑Leg Heel Raise test described above. This approach incorporates multiple facets of tendon loading and allows clinicians to reproduce the same constraints across sessions, improving the interpretability of “during activity” and “after activity” scores.

Additional Evaluation Considerations:

Specific to the tendon itself, additional quantification of tendon structure and the broader strength profile can offer meaningful insight. While heel‑raise endurance tests remain clinically accessible and valuable, recent work has highlighted important limitations. They likely fail to capture the full extent of neuromuscular deficits across the strength spectrum. Individuals with Achilles tendinopathy demonstrate measurable reductions in maximal, explosive, and reactive strength when assessed using isokinetic or hopping‑based methods [24]. Emerging approaches such as ultrasound tissue characterization and isokinetic dynamometry provide even greater resolution of tendon behavior and plantarflexor capacity. Our contributing speaker, Seth O’Neill, will expand on their clinical utility and application.

When considering the patient or athlete in front of us, it is easy to zoom in too narrowly when addressing a condition as specific as Achilles tendinopathy. Several studies have identified correlates that warrant further attention, including weight‑bearing dorsiflexion limitation [25–28], hip muscle strength deficits [29,25], and mid‑foot postural deviations [25,27,28]. The evidence is mixed and does not support causal conclusions, but these findings are likely still relevant. These considerations may represent actionable avenues for modifying loading patterns over time. In other cases, they may serve as indirect indicators of functional restoration (as movement and load distribution often self‑organize as symptoms resolve and capacity improves).

Beyond these physical measures, every evaluation benefits from thoughtful biopsychosocial layering. The language clinicians choose, the explanations they offer, and the sense of direction they create all shape how patients interpret the encounter and how willing they are to engage with the plan. Earlier in this newsletter, we noted that interactions themselves can influence confidence, expectations, and readiness to participate. The broader literature reinforces this point, showing that reassurance, clarity, and a strong therapeutic relationship meaningfully support engagement and functional outcomes [1,2], and that patients often arrive with their own ideas about what effective care should look like [3]. More pertinently, recent qualitative work in Achilles tendinopathy adds further support. It shows that helping patients interpret load and pain, supporting the uptake of new knowledge, and fostering a strong therapeutic relationship are active mechanisms influencing adherence across rehabilitation [11].

 This is why, even when deliberately integrating standardized tests and measures, each encounter should remain adaptable to the individual. Tailoring your approach strengthens adherence and reinforces the patient’s sense of agency as they move through rehabilitation.

Closing Synthesis

Evaluating Achilles tendinopathy requires more than implementing an endless list of tests. Effective management under real‑world constraints depends on a deliberate understanding of how each measure contributes and what value it adds. The Core Outcome Set offers a defensible foundation that aligns with the broader framework outlined earlier in this series, but its utility rests on how these elements are interpreted and applied. Pain ratings, strength‑endurance assessments, and patient‑reported function each provide partial information. Their meaning emerges only when they are integrated, contextualized, and interpreted through a structured clinical process.

This installment has emphasized that clarity and consistency matter. Inattention to detail or vague operational criteria can undermine the very constructs we aim to measure. At the same time, the evaluation must remain responsive to the individual. Physical findings, movement strategies, expectations, and beliefs all shape how patients experience their condition and how they respond to care. A comprehensive assessment acknowledges these layers without losing sight of the core measures that support sound clinical reasoning.

Taken together, these principles support an approach that is both systematic and adaptable. The goal is not to reduce evaluation to a rigid checklist, but to create a stable framework that guides interpretation while leaving room for clinical judgment. This balance allows the evaluation to be reproducible across clinicians yet personalized to the patient in front of you. It also sets the stage for the applied reasoning that follows.

Looking Ahead

This installment concludes the Evaluation and Diagnostics section of the series. The goal has been to outline a modern, defensible framework for assessment and to offer pragmatic solutions for applying these principles in clinical practice.

The next installment begins our final section of the newsletter series: Management and Decision Making. We will shift from evaluating the problem to navigating it across time. This section begins by looking at contributions by Scot Morrison and others regarding mental models and frameworks which allow for consistent, informed decisions throughout the course of tendinopathy care.

- Research review written by: Jason Eure, PT, DPT, OCS, CSCS

*If you plan to attend the Summit, but haven't yet registered, we recommend doing so soon—we're limited to 40 attendees.

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Reference List 

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30. Tendon Summit Insider: Installment 1 — Foundational Tendon Dynamics. Traverse City Tendon Summit. Published 2025. Accessed February 19, 2026. https://www.traversecitytendonsummit.com/campaigns/view-campaign/2cF1oAFrfoI2SvH3tCAoaBisqVRxVCZgTIbkLGcY9Q3-QIaoV09HE7K7Z1RVE-rrTolQMCZOgbVmEyFEp1gwJ2gHXUQqZ-HO