Achilles Tendinopathy
Load-related Achilles pain from overload outpacing tendon adaptation. Midportion and insertional disease behave differently.
Two patterns
| Midportion | Insertional | |
|---|---|---|
| Site | 2 to 6 cm above insertion (most common) | At the calcaneal attachment |
| Associations | Diffuse thickening | Haglund deformity, calcification, cavus foot |
| Loading | Full-range eccentric or heavy slow resistance | Flat ground only. Step-edge loading increases compression and can worsen it |
Risk factors
- Modifiable: sudden load increase (dominant), weak calf, poor dorsiflexion, footwear, obesity
- Non-modifiable: age 30 to 60, male sex, genetics
- Systemic: diabetes, dyslipidaemia, hypertension, inflammatory arthropathy
- Drugs: fluoroquinolones (rupture risk), corticosteroids
- Sports: running, basketball, tennis, badminton, volleyball, dance. Also sedentary people who start abruptly.
Presentation
- Morning stiffness (“first steps are the worst”), warm-up phenomenon
- Pain on running, jumping, hopping, stairs
- Focal tenderness, possible nodular thickening
- Pain or weakness on single-leg heel raise
Always exclude rupture
Thompson (Simmonds) test shows absent plantarflexion on calf squeeze, and Matles test shows increased resting plantarflexion. A missed rupture is a classic medico-legal pitfall.
Management
- Progressive loading is the core treatment.
- Alfredson: 3 × 15, twice daily, knee straight and bent, 12 weeks
- Heavy slow resistance: 3 to 4 sets, 6 to 15 RM, 3 seconds up and down, 3 times weekly
- Load management. Avoid complete rest.
- Shockwave: reasonable for chronic midportion disease, used alongside loading.
- Heel lift: short-term help in insertional disease.
- Topical glyceryl trinitrate: modest benefit, headache limits use.
- Avoid: intratendinous corticosteroid (rupture risk). PRP shows no consistent benefit over placebo.
- Surgery (debridement, with or without insertional repair): after 3 to 6 months of failed structured care, usually at least 6 months.
Prognosis
Most improve with 12 weeks of structured loading. Full recovery usually takes 3 to 6 months. Recurrence is common if load management is abandoned.
References
- Silbernagel et al., J Athl Train 2020, doi:10.4085/1062-6050-356-19
- Eccentric exercise in Achilles tendinopathy, BMC Musculoskelet Disord 2026, doi:10.1186/s12891-026-09861-3
Related
Medical disclaimer: this article is general information, not personal medical advice. Always consult a qualified doctor about your own situation.