Lower-limb tendinopathy diagnosis is tricky but important, as an incorrect diagnosis may lead athletes down the wrong rehabilitation path. Ebonie Rio and Myles Murphy unpack an evidence-informed approach to diagnosing lower-limb tendinopathy.
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The most common tendinopathy sites in the lower limb are the Achilles tendon, patellar tendon, hamstring tendon, and gluteal tendon. Specifically, when referring to tendinopathy, practitioners refer to localized tendon pain that results in functional impairments(1). This can occur in both physically active and more sedentary populations. Individuals experience tendon pain when the load exceeds capacity – which can occur at nearly any activity level(2).
Clinicians typically think of tendinopathy as a problem for athletes. However, they are beginning to recognize the growing burden of tendon pain in non-athletic populations. Using the Achilles tendon as a single example, in running athletes, tendinopathy of the Achilles is one of the most prevalent general running-related injuries (~10% of all injuries)(3). Conversely, in the general population, Achilles tendinopathy has an incidence of 2.16 occurrences per 1000 person-years(4). Therefore, clinicians must be ready to diagnose tendinopathy in athletic and non-athletic populations.
The tendinopathy model continuum is the most contemporary model of the underlying tendinopathy pathophysiology(5,6). The main takeaway from the continuum model is that tendinopathy occurs in a chronically underloaded or acutely overloaded tendon. The specific types of load that contribute to the onset of tendinopathy are the tensile and compressive forces (and often in combination), as opposed to shear loads that are typically associated with other pathologies such as peritonitis (see figure 1). In particular, the combination of high tensile and compressive loads appears to be the primary driver of structural tendon changes(7). Furthermore, the interfascicular matrix plays a role in the pathology(8). So, while the continuum model helps understand pathology (a known risk factor for tendinopathy), it is important to remember that asymptomatic pathology is common, and imaging is not required for the diagnosis(1,9).
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