Achilles Tendinopathy Load Tolerance, Diagnosis and Differentials

Peter starts with load tolerance: how much pain the patient reports with daily activities, how much pain clinic load tests provoke as they progress from walking and running to calf raise variations and hopping, including stiff-knee pogo hops, and how long any flare takes to settle. Pain under 2/10 during loading is good and up to 5/10 is usually acceptable, or simply moderate pain or less. Rehab moves from a pain management phase, where reducing stretch-shortening cycle load matters most, to a load progression phase where symptoms can fluctuate. The key diagnostic features are localized tendon pain, morning stiffness that eases with activity, a proportional load-pain relationship and a recent change in stretch-shortening cycle load. Differentials include paratenon (diffuse, non-proportional pain), plantaris (medial pain), the sural nerve (lateral pain and paresthesia), rupture (positive Thompson test) and accessory soleus. Tears are a clinical diagnosis, and ultrasound delaminations alone do not confirm one.