10 Chapter 1 DIAGNOSTIC IMAGING Achilles tendinopathy can affect both the insertional and midportion region of the tendon (Figure 1), which have different anatomical features and loading profiles.22 Achilles tendinopathy is mainly a clinical diagnosis, with imaging being used to confirm the diagnosis.2,10 The diagnostic criteria for Achilles tendinopathy (local pain, thickening and impaired load-bearing capacity) are considered to be reliable.23 A key diagnostic criterion is the location of pain, as distinguishing between midportion and insertional Achilles tendinopathy affects initial treatment and prognosis.23,24 As subjective self-reported pain is one of the clinical criteria for establishing the diagnosis, it is essential to know if patients with Achilles tendinopathy can accurately localize their pain, information which is currently unknown. Figure 1. Visual presentation of the Achilles tendon with the light blue region representing the midportion part of the tendon and the dark blue region indicating the insertional part of the Achilles tendon. Physical examination typically involves assessing the thickness of the tendon and determining if there is tenderness upon palpation.3 The tendon is examined by applying gentle pressure between the index finger and thumb along the entire length of the tendon, from the musculotendinous junction to the calcaneal insertion.3 Patients are then asked if they feel any pain during palpation.3,23 Pain on palpation and self-reported (location of) pain are considered valid clinical tests.23 As the presence of tendon thickening is not always necessary to diagnose Achilles tendinopathy, experts agree that the clinical diagnosis can be established when there is localized pain during tendon-loading activities and
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