Diagnostic domains, differential diagnosis and conditions requiring further medical attention that are considered important in the assessment for Achilles tendinopathy: a Delphi consensus study

Peter Malliaras¹, Karin Gravare Silbernagel², Robert-Jan de Vos³, Jaryd Bourke⁴, Igor Sancho⁵, Shawn L Hanlon⁶, Anne-Sofie Agergaard⁷, Roald Bahr⁸, Natália Franco Netto Bittencourt^{9

10}, Marcelo Bordalo¹¹, Annelie Brorsson¹², Victoria Tzortziou Brown¹³, Tanusha Cardoso¹⁴, Sally Child¹⁵, Ruth L Chimenti¹⁶, Emma Cowley¹⁷, Pieter D'Hooghe¹⁸, Wayne Derman¹⁹, Jonathan T Finnoff^{20

21}, Siu Ngor Fu²², Jill Halstead^{23

24}, Bruce Hamilton²⁵, Katarina Maria Nilsson-Helander²⁶, Per Hölmich²⁷, Jonathan Houghton²⁸, Alicia M James²⁹, Kornelia Kulig³⁰, Amanda Lau³¹, Samuel Ling³², Nicola Maffulli^{33

34}, Lorenzo Masci³¹, Sue Mayes³⁵, Sean Mc Auliffe³⁶, Carol McCrum³⁷, Dylan Morrissey^{38

39}, Shannon E Munteanu⁴⁰, Myles Calder Murphy^{41

42}, Richard Newsham-West³⁵, Seth O'Neill⁴³, Nat Padhiar⁴⁴, Theodora Papadopoulou⁴⁵, Jonathan D Rees²⁸, Ebonie Kendra Rio⁴⁶, Diego Ruffino⁴⁷, Alex Scott⁴⁸, Suzy Speirs⁴⁹, Yang Sun⁵⁰, Kristian Thorborg⁵¹, Larissa Trease³⁵, Jan A N Verhaar⁵², Evi Wezenbeek⁵³, Sue White⁵⁴, Jennifer A Zellers⁵⁵, S Zhang⁵⁶, Vasileios Korakakis⁵⁷, Bill Vicenzino⁵⁸

Affiliations

¹ Physiotherapy Department, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia peter.malliaras@monash.edu.
² Department of Physical Therapy, University of Delaware, Newark, Delaware, USA.
³ Department of Orthopaedics and Sports Medicine, Erasmus Medical Center, Rotterdam, Netherlands.
⁴ Physiotherapy Department, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia.
⁵ Deusto Physical TherapIker Group, Physical Therapy Department, University of Deusto Faculty of Health Sciences, Donostia - San Sebastian, Spain.
⁶ Department of Kinesiology, California State University Fullerton, Fullerton, California, USA.
⁷ Department of Orthopedic Surgery, and Department of Physical and Occupational Therapy, Copenhagen University Hospital-Bispebjerg and Frederiksberg Institute of Sports Medicine Copenhagen, Copenhagen, Denmark.
⁸ Norwegian School of Sport Sciences, Oslo Sports Trauma Research Center, Oslo, Oslo, Norway.
⁹ Esporte Clube Bahia, Salvador, Brazil.
¹⁰ Soccer Science Center, Federal University of Minas Gerais, Belo Horizonte, Brazil.
¹¹ Aspetar Orthopedic and Sports Medicine Hospital, Doha, Qatar.
¹² Department of Orthopaedics, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden.
¹³ Queen Mary University of London Wolfson Institute of Population Health, London, UK.
¹⁴ Alphington Sports Medicine, Northcote, Victoria, Australia.
¹⁵ Olympic Park Sports Medicine Centre, Melbourne, Victoria, Australia.
¹⁶ Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, Iowa, USA.
¹⁷ University of Southampton School of Health Sciences, Southampton, UK.
¹⁸ Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Ad Dawhah, Qatar.
¹⁹ 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.
²⁰ United States Olympic and Paralympic Committee, Colorado Springs, Colorado, USA.
²¹ Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Denver, Colorado, USA.
²² Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong.
²³ Leeds Community Healthcare NHS Trust, Leeds, UK.
²⁴ University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, West Yorkshire, UK.
²⁵ High Performance Sport New Zealand, Auckland University of Technology, Auckland, New Zealand.
²⁶ Department of Orthopaedics, Sahlgrenska University Hospital Mölndal, Institute of Clinical Science at Sahlgrenska Academy, Goteborg, Sweden.
²⁷ 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.
²⁸ Fortius Clinic, London, UK.
²⁹ Podiatry, Peninsula Health, Frankston, Victoria, Australia.
³⁰ Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California, USA.
³¹ Institute of Sport Exercise and Health, London, UK.
³² Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong.
³³ Department of Trauma and Orthopaedic Surgery, University of Rome La Sapienza Faculty of Medicine and Psychology, Roma, Italy.
³⁴ Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, London, UK.
³⁵ La Trobe University La Trobe Sport and Exercise Medicine Research Centre, Melbourne, Victoria, Australia.
³⁶ Department of Physiotherapy, University of Limerick, Limerick, Ireland.
³⁷ Rheumatology Department, Canberra Health Services, Canberra, Australian Capital Territory, Australia.
³⁸ Sport and Exercise Medicine, Queen Mary University of London, London, UK.
³⁹ Physiotherapy Department, Barts Health NHS Trust, London, UK.
⁴⁰ Discipline of Podiatry, La Trobe University School of Allied Health, Human Services, and Sport, Melbourne, Victoria, Australia.
⁴¹ Nutrition and Health Innovation Research Institute, Edith Cowan University, Joondalup, Western Australia, Australia.
⁴² School of Health Sciences, The University of Notre Dame Australia, Fremantle, Western Australia, Australia.
⁴³ School of Healthcare, College of Life Sciences, University of Leicester, Leicester, UK.
⁴⁴ Barts and The London School of Medicine and Dentistry, London, UK.
⁴⁵ Stanford Hall Defence Medical Rehabilitation Centre, Loughborough, UK.
⁴⁶ La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia.
⁴⁷ Universidad Nacional de Córdoba, Cordoba, Argentina.
⁴⁸ Physical therapy, The University of British Columbia - Vancouver Campus, Vancouver, British Columbia, Canada.
⁴⁹ One Welbeck Surgery Centre, London, UK.
⁵⁰ Huashan Hospital Fudan University Department of Sports Medicine, Shanghai, China.
⁵¹ Sports Orthopaedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark, Hvidovre Hospital, Hvidovre, Denmark.
⁵² Department of Orthopedics and Sports Medicine, Erasmus MC, Rotterdam, Netherlands.
⁵³ Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerpen, Belgium.
⁵⁴ Victorian Institute of Sport, Albert Park, Victoria, Australia.
⁵⁵ Program in Physical Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri, USA.
⁵⁶ Sports Medicine, Fudan University, Shanghai, Shanghai, China.
⁵⁷ Department of Health Sciences, University of Nicosia, Nicosia, Nicosia, Cyprus.
⁵⁸ Physiotherapy, The University of Queensland, Brisbane, Queensland, Australia.

PMID: 40240126
DOI: 10.1136/bjsports-2024-109185

Diagnostic domains, differential diagnosis and conditions requiring further medical attention that are considered important in the assessment for Achilles tendinopathy: a Delphi consensus study

Peter Malliaras et al. Br J Sports Med. 2025.

. 2025 Jun 18;59(13):891-901.

doi: 10.1136/bjsports-2024-109185.

Authors

Affiliations

¹ Physiotherapy Department, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia peter.malliaras@monash.edu.
² Department of Physical Therapy, University of Delaware, Newark, Delaware, USA.
³ Department of Orthopaedics and Sports Medicine, Erasmus Medical Center, Rotterdam, Netherlands.
⁴ Physiotherapy Department, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia.
⁵ Deusto Physical TherapIker Group, Physical Therapy Department, University of Deusto Faculty of Health Sciences, Donostia - San Sebastian, Spain.
⁶ Department of Kinesiology, California State University Fullerton, Fullerton, California, USA.
⁷ Department of Orthopedic Surgery, and Department of Physical and Occupational Therapy, Copenhagen University Hospital-Bispebjerg and Frederiksberg Institute of Sports Medicine Copenhagen, Copenhagen, Denmark.
⁸ Norwegian School of Sport Sciences, Oslo Sports Trauma Research Center, Oslo, Oslo, Norway.
⁹ Esporte Clube Bahia, Salvador, Brazil.
¹⁰ Soccer Science Center, Federal University of Minas Gerais, Belo Horizonte, Brazil.
¹¹ Aspetar Orthopedic and Sports Medicine Hospital, Doha, Qatar.
¹² Department of Orthopaedics, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden.
¹³ Queen Mary University of London Wolfson Institute of Population Health, London, UK.
¹⁴ Alphington Sports Medicine, Northcote, Victoria, Australia.
¹⁵ Olympic Park Sports Medicine Centre, Melbourne, Victoria, Australia.
¹⁶ Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, Iowa, USA.
¹⁷ University of Southampton School of Health Sciences, Southampton, UK.
¹⁸ Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Ad Dawhah, Qatar.
¹⁹ 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.
²⁰ United States Olympic and Paralympic Committee, Colorado Springs, Colorado, USA.
²¹ Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Denver, Colorado, USA.
²² Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong.
²³ Leeds Community Healthcare NHS Trust, Leeds, UK.
²⁴ University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, West Yorkshire, UK.
²⁵ High Performance Sport New Zealand, Auckland University of Technology, Auckland, New Zealand.
²⁶ Department of Orthopaedics, Sahlgrenska University Hospital Mölndal, Institute of Clinical Science at Sahlgrenska Academy, Goteborg, Sweden.
²⁷ 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.
²⁸ Fortius Clinic, London, UK.
²⁹ Podiatry, Peninsula Health, Frankston, Victoria, Australia.
³⁰ Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California, USA.
³¹ Institute of Sport Exercise and Health, London, UK.
³² Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong.
³³ Department of Trauma and Orthopaedic Surgery, University of Rome La Sapienza Faculty of Medicine and Psychology, Roma, Italy.
³⁴ Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, London, UK.
³⁵ La Trobe University La Trobe Sport and Exercise Medicine Research Centre, Melbourne, Victoria, Australia.
³⁶ Department of Physiotherapy, University of Limerick, Limerick, Ireland.
³⁷ Rheumatology Department, Canberra Health Services, Canberra, Australian Capital Territory, Australia.
³⁸ Sport and Exercise Medicine, Queen Mary University of London, London, UK.
³⁹ Physiotherapy Department, Barts Health NHS Trust, London, UK.
⁴⁰ Discipline of Podiatry, La Trobe University School of Allied Health, Human Services, and Sport, Melbourne, Victoria, Australia.
⁴¹ Nutrition and Health Innovation Research Institute, Edith Cowan University, Joondalup, Western Australia, Australia.
⁴² School of Health Sciences, The University of Notre Dame Australia, Fremantle, Western Australia, Australia.
⁴³ School of Healthcare, College of Life Sciences, University of Leicester, Leicester, UK.
⁴⁴ Barts and The London School of Medicine and Dentistry, London, UK.
⁴⁵ Stanford Hall Defence Medical Rehabilitation Centre, Loughborough, UK.
⁴⁶ La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia.
⁴⁷ Universidad Nacional de Córdoba, Cordoba, Argentina.
⁴⁸ Physical therapy, The University of British Columbia - Vancouver Campus, Vancouver, British Columbia, Canada.
⁴⁹ One Welbeck Surgery Centre, London, UK.
⁵⁰ Huashan Hospital Fudan University Department of Sports Medicine, Shanghai, China.
⁵¹ Sports Orthopaedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark, Hvidovre Hospital, Hvidovre, Denmark.
⁵² Department of Orthopedics and Sports Medicine, Erasmus MC, Rotterdam, Netherlands.
⁵³ Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerpen, Belgium.
⁵⁴ Victorian Institute of Sport, Albert Park, Victoria, Australia.
⁵⁵ Program in Physical Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri, USA.
⁵⁶ Sports Medicine, Fudan University, Shanghai, Shanghai, China.
⁵⁷ Department of Health Sciences, University of Nicosia, Nicosia, Nicosia, Cyprus.
⁵⁸ Physiotherapy, The University of Queensland, Brisbane, Queensland, Australia.

PMID: 40240126
DOI: 10.1136/bjsports-2024-109185

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.

Keywords: Achilles Tendon; Consensus; Diagnosis; Tendinopathy.

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Competing interests: None declared.

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Diagnostic domains, differential diagnosis and conditions requiring further medical attention that are considered important in the assessment for Achilles tendinopathy: a Delphi consensus study

Affiliations

Diagnostic domains, differential diagnosis and conditions requiring further medical attention that are considered important in the assessment for Achilles tendinopathy: a Delphi consensus study

Authors

Affiliations

Abstract

Conflict of interest statement

MeSH terms

LinkOut - more resources

Full Text Sources

Medical

Miscellaneous