Tendinopathy is a diagnostic term that describes various tissue conditions within injured tendons that worsen with increased mechanical loading. . Lower extremity tendinopathy is often caused by kinematic abnormalities and tendon overuse . Tendinopathy is characterized by The transmission of force from muscle to bone is secondary to pain. 
The clinical case of tendinopathy is individual, with each individual having a different presentation of weakness, functional capacity, swelling, and pain . A comprehensive evaluation is needed not only to diagnose lower extremity tendinopathy but also to identify factors that cause and exacerbate tendinopathy lead to tendinopathy. Clinical reasoning around the various differential diagnoses is also important to ensure an accurate diagnosis.
Pathology can occur in any tendon, but in the lower extremities it usually occurs in the Achilles, patellar, and gluteal tendons. Both active and sedentary people can be affected by lower extremity tendinopathy. 
Key Questions to Ask in Interviews/Subjective Assessments
Where is your pain?
A key feature of tendinopathy is an increase in localized pain with dose-dependent loading.  Individuals with tendinopathy typically present with extremely localized pain that worsens with load but does not spread. (Gluteal tendinopathy is an exception, Pain may occur in the legs)
What aggravates your pain? / What makes your pain worse?
Tendinopathy pain is often exacerbated by high tensile loads, compressive loads, or a combination of the two. The pain usually increases with the load placed on it (but can be very localized to the area).
24 Hour Pattern
Do you have night pain?
Tendons usually do not cause night pain. The only exception is gluteus medius tendinopathy, where nocturnal pain can occur due to the stress load of lying on it or the leg drooping into adduction. 
Do you have stiffness in the morning?
Tendinopathy usually presents with morning pain and stiffness, but this usually resolves relatively quickly with exercise. Patients with various arthritic conditions also tend to experience morning pain, but this pain often takes longer than 30 minutes to resolve or does not resolve.  It may help Screen for any metabolic or inflammatory conditions to rule out other diagnoses. 
Does your pain decrease or increase during activity?
Tendons are generally warmed up. Pain that subsides during activity is usually a strong indicator of tendinopathy.  If pain is exacerbated during activity, look at other differential diagnosis of peritendonous structures such as sheath and paratendinous structures.
How do you feel the day after?
Tendons are often sore the day after energy-charging activities.  The irritability of a painful tendon is often determined by its 24-hour response to activity.  Pain was classified as irritability if it worsened 24 hours after activity. If the pain is the same or resolves internally Stable after 24 hours  . This is an important factor in considering what stage of tendinopathy is and where recovery should begin.
what did you change / What payload did you add?
New episodes of tendon pain are often the result of a change in loading. The tendon’s capacity only exceeds the load placed on it, and small changes can make a difference. Asking carefully about recent changes in someone will help identify contributing factors Tendinopathy. Changes in load may be caused by a variety of factors, such as increased training intensity, footwear, changes in speed or plyometric training recently attended a competition.
A thorough investigation of the past medical history is important to determine the origin of the tendinopathy. Is this the first event? Are there any pre-existing injuries? Is this a long term problem? Fully asking about previous injury breaks etc will help give a good Clinical picture.
Red Flags and Risk Factors
As with all situations, it is important to screen for red flags and general health so as not to miss anything serious or sinister.
Some risk factors identified in the development of tendinopathy (for references see the Tendon Pathophysiology page)
- Hormone Replacement Therapy
- Contraceptive medication
- High fat in lower extremity tendinopathy
- Use of Fluoroquinolones
- Lack of range of movement
- Strength imbalance
- Poor vascularity
- Blood Type O
- Altered lower limb biomechanics
- Low-temperature training
Goals and Expectations
It is important to understand the expected effects of physical therapy and what state the patient wishes to return to. This helps in planning a comprehensive management plan. A sedentary 60-year-old will have very different goals than an elite athlete
The Victorian Institute for Sport Assessment developed the Tendinopathy Self-Assessment Questionnaire.  They were scored on a scale of 100, with a change of 13 points considered clinically significant.  The VISA questionnaire will not detect small changes, so it is recommended to use only They record progress every 4 weeks. 
Patella Tendinopathy- VISA- P
Achilles Tendinopathy- VISA- A
Hamstring Tendinopathy- VISA-T
Gluteal Tendinopathy- VISA- G
Physical Examination/Objective Examination
The physical examination is used to test your hypothesis, which is derived from clinical reasoning and information obtained during the interview.
Dose-dependent loading is a useful method to confirm the diagnosis of tendinopathy.  Pain that remains localized to the tendon and increases with loading is an important indicator of tendinopathy.  
2 important questions to keep asking during progressive load testing are
1. Is that painful?
2. Where is the pain?
Each tendon has a specific movement that puts them under compressive and tensile loads. Progressive loading will vary depending on the tendon being assessed. They just need to be loaded to the point where the diagnosis is confirmed, not overloading the tendon and making the condition worse. 
Muscle Strength Joint Range and Functional Assessment
Evaluation of the entire kinetic chain is extremely important to determine influencing factors. This is also unique to each tendinopathy and there is no “recipe” for evaluation. Assessment of muscle strength and range of motion for affected muscles and joints separately will help guide management.
Painful palpation of tendons is less specific in diagnosing tendinopathy. Pathological tendons are usually painful on palpation, but other conditions may also cause the tendon to be painful on palpation. Tendons may be painful on palpation, not the cause symptom. Absence of pain on palpation may be one way to rule out tendinopathy.
Ultrasound and MRI are used to image the tendon. MRI is more specific and can provide more information, but it is also more expensive. Imaging studies that identify the tendon as the source of symptoms should be used with caution. Abnormalities and pathology found on imaging have been shown to have few Correlations with pain and function and similar tendons with no pathological changes on imaging can manifest as pain. (3) Imaging can help complex clinical presentations to include or exclude other differential diagnoses 
Key findings in Specific Tendinopathies
Pain limited to the inferior pole of the patella 
Pain that increases with knee extension activities that store and release energy, such as jumping or rapid changes in direction
Athletes typically between the ages of 15-30 who play basketball, volleyball, jumping sports, tennis and soccer or any sport that requires jumping/change of direction
Progressive stress assessment (pain should remain localized and increase with increasing load to confirm the diagnosis)
- Shallow squat
- Deep squat
- Small hop
- Big hop
Midportion Achilles 
Pain localized 2-6 cm proximal to Achilles tendon insertion
Aggravated by energy storage and release movements (such as jumping and running) rather than usual repetitive movements (such as swimming and cycling)
Morning stiffness is a hallmark sign
Progressive Load Assessment
- Double leg calf raise
- Single leg calf raise
- Double leg jump
- Single leg small hop
- Single leg big hop
- Big hops in a row
- Forward hopping
Pain at the greater trochanter
More common in sedentary women over age 49
Pain often refers down the lateral thigh
Single leg tasks often painful
Aggravated by compressive loads
- Hangs over hips when standing – relative hip adduction
- Sitting legs crossed
- Single-leg tasks with excessive lateral pelvic tilt (hip moves into relative adduction)
- Crossing the midline during running
- Side Sleeping Bottom Leg – sleep on the side that hurts (direct compression)
- Sleeping on the side, if the upper leg is lowered, it will be relatively adducted
Proximal Hamstring Tendinopathy
Pain localised to the ischial tuberosity
Excited during activities with deep hip flexion (compressive load)
- Sitting (especially harder surfaces)
- Pain during energy-storing activities, but usually not when standing up slowly or lying down
Progressive Load Assessment
- Single leg bent knee bridge (low load)
- Long lever bridge (moderate load)
- Arabesque movement (high load)
- Single leg deadlift (high load)
Single Leg Long Lever Bridge
- ↑ Canosa-Carro, L., Bravo-Aguilar, M., Abuín-Porras, V., Almazán-Polo, J., García-Pérez-de-Sevilla, G., Rodríguez-Costa, I., López-López, D., Navarro-Flores, E. and Romero-Morales, C., 2022. Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice. Disease-a-Month, 68(10), p.101314.
- ↑ Sánchez Romero EA, Pollet J, Martín Pérez S, Alonso Pérez JL, Muñoz Fernández AC, Pedersini P, Barragán Carballar C, Villafañe JH. Lower Limb Tendinopathy Tissue Changes Assessed through Ultrasound: A Narrative Review. Medicina. 2020 Jul 28;56(8):378.
- ↑ dos Santos Franco YR, Miyamoto GC, Franco KF, de Oliveira RR, Cabral CM. Exercise therapy in the treatment of tendinopathies of the lower limbs: a protocol of a systematic review. Systematic Reviews. 2019 Dec;8(1):1-6.
- ↑ Burton I. Autoregulation in resistance training for lower limb tendinopathy: A potential method for addressing individual factors, intervention issues, and inadequate outcomes. Frontiers in Physiology. 2021;12.
- ↑ Mitham K, Mallows A, Debenham J, Seneviratne G, Malliaras P. Conservative management of acute lower limb tendinopathies: A systematic review. Musculoskeletal Care. 2021 Mar 1;19(1):110-26.
- ↑ Jump up to:6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 Malliaras P, Cook J, Purdam C, Rio E. Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):887-98.
- ↑ Jump up to:7.0 7.1 Grimaldi A, Mellor R, Hodges P, Bennell K, Wajswelner H, Vicenzino B. Gluteal tendinopathy: a review of mechanisms, assessment and management. Sports Medicine. 2015 Aug 1;45(8):1107-19.
- ↑ Jump up to:8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 Goom TS, Malliaras P, Reiman MP, Purdam CR. Proximal hamstring tendinopathy: clinical aspects of assessment and management. journal of orthopaedic & sports physical therapy. 2016 Jun;46(6):483-93
- ↑ Jump up to:9.0 9.1 9.2 9.3 Rio E. Lower Limb Tendinopathy Assessment Course. Plus. 2019
- ↑ MacDermid JC, Silbernagel KG. Outcome evaluation in tendinopathy: foundations of assessment and a summary of selected measures. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):950-64.
- ↑ Dan M, Parr W, Broe D, Cross M, Walsh WR. Biomechanics of the knee extensor mechanism and its relationship to patella tendinopathy: A review. J Orthop Res. 2018;36(12):3105-12.
- ↑ Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR. Achilles pain, stiffness, and muscle power deficits: Midportion achilles tendinopathy revision 2018: Clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the american physical therapy association. Journal of Orthopaedic & Sports Physical Therapy. 2018 May;48(5):A1-38.
- ↑ Murphy M, Rio E, Debenham J, Docking S, Travers M, Gibson W. EVALUATING THE PROGRESS OF MID-PORTION ACHILLES TENDINOPATHY DURING REHABILITATION: A REVIEW OF OUTCOME MEASURES FOR SELF- REPORTED PAIN AND FUNCTION. Int J Sports Phys Ther. 2018;13(2):283-92.
- ↑ Beatty NR, Félix I, Hettler J, Moley PJ, Wyss JF. Rehabilitation and Prevention of Proximal Hamstring Tendinopathy. Curr Sports Med Rep. 2017;16(3):162-71.