Calf and Achilles injuries: from strain to rupture

A graded clinical practice guideline, linked to the ICF, on the assessment and management of midportion Achilles tendinopathy characterised by pain, stiffness and muscle power deficits.

• Supports clinical diagnosis and outcome measurement rather than routine imaging.
• Grades mechanical loading exercise, including eccentric and heavy slow resistance, as the best-supported core treatment.
• Recommends patient education and load management, with many adjunct treatments carrying weaker evidence.

Our appraisal: A rigorously constructed guideline that grades the strength of each recommendation, which is its main value; the strongest recommendations sit behind loading exercise, while many popular adjuncts are graded on lower-certainty evidence and should be treated as optional.

An evidence-based multidisciplinary guideline covering risk factors, diagnosis, imaging, treatment and prognosis of Achilles tendinopathy, developed with patient involvement.

• Midportion Achilles tendinopathy is a clinical diagnosis based on load-related pain localised about 2 to 7 cm above the insertion, local thickening and pain on palpation, and imaging is not required to make it.
• Progressive exercise, or loading, is recommended as the core first-line treatment.
• Injections and surgery are reserved for cases that do not respond to an adequate course of loading.

Our appraisal: A formal multidisciplinary guideline with patient participation, so its diagnostic framework is trustworthy; many of its treatment recommendations rest on low-certainty evidence, so it is firmer on how to diagnose and structure care than on the comparative efficacy of specific protocols or adjuncts.

ACL-specific consensus defining return to sport as a criteria-based continuum rather than a time point, and setting out testing and shared decision-making for clearance after ACL injury.

• Return to sport is a criteria-based continuum, return to participation, then return to sport, then return to performance, not a single date.
• Clearance should rest on objective testing (strength, hop, movement quality, psychological readiness), not time since surgery alone.
• The decision is shared between clinician and athlete, accounting for the sport's demands and the athlete's risk tolerance.

Our appraisal: Consensus via modified Delphi, so it sets the decision framework rather than validating any single test battery or cut-off. It is most useful as a reminder that a passed clock is not a passed knee; the specific thresholds still lack strong prospective validation.

International consensus (ICON) standardising terminology for tendinopathy in research and practice.

• Recommends tendinopathy as the preferred term for persistent tendon pain and loss of function related to mechanical loading.
• Discourages routine use of tendinitis and tendinosis, since inflammation is not the dominant feature of most chronic presentations.
• Calls for consistent terminology to make research and clinical communication comparable.

Our appraisal: A terminology consensus reached by expert agreement, so it standardises language rather than validating any treatment; its practical value is that it lets you read the tendon literature consistently and steers management away from an inflammation-first framing towards loading.

Defines and operationalises 'return to sport' as a continuum (return to participation, return to sport, return to performance), with a shared decision-making framework (StARRT).

• Operationalises return to sport as a three-stage continuum applicable across injuries, not just ACL.
• Introduces the StARRT framework (Strategic Assessment of Risk and Risk Tolerance) for the return decision.
• Frames clearance as shared decision-making under uncertainty rather than a purely biological milestone.

Our appraisal: A foundational framework paper rather than an evidence synthesis. Its strength is a shared language for the return-to-sport decision: it tells you how to structure the decision, not what the pass criteria are, so pair it with injury-specific testing evidence.

An AAOS clinical practice guideline, based on systematic reviews, on the diagnosis and treatment of acute Achilles tendon rupture.

• Most recommendations were graded inconclusive or weak, reflecting limited high-quality evidence at the time.
• Moderate-strength recommendations support early postoperative protective weight-bearing and the use of protective devices that allow early motion.
• Both operative and non-operative pathways can be appropriate, framing the choice as individualised.

Our appraisal: Now dated and built mostly on low-strength recommendations, so it should be read as a floor rather than the last word; its durable message is that early functional rehabilitation matters and that the operative-versus-non-operative decision is a shared one, a position later functional non-operative protocols have reinforced.