Achilles Tendinopathy

Patients typically report gradual onset of pain localised to the Achilles tendon, often described as stiffness in the morning or after periods of inactivity. Pain is commonly aggravated by increased loading activities such as running, jumping, and hill walking, and may improve with gentle activity (the so-called 'warm-up' phenomenon).

On examination, there may be a palpable thickening or nodule in the mid-portion of the tendon. The Royal London Hospital test (pain on palpation that decreases with the tendon under tension) may be positive. Insertional tendinopathy presents with pain at the calcaneal attachment, often with a prominent posterior heel. Single-leg heel raises may reproduce symptoms and assess tendon capacity.

Achilles tendinopathy is primarily a clinical diagnosis. However, imaging can be helpful to confirm diagnosis, assess severity, and exclude differential diagnoses.

Ultrasound is the first-line imaging modality and can demonstrate tendon thickening, hypoechoic areas, loss of fibrillar pattern, and neovascularisation on Doppler. MRI provides excellent soft tissue contrast and is useful for assessing intrasubstance tears, paratenon involvement, and insertional pathology including retrocalcaneal bursitis and Haglund's deformity.

Plain radiographs may show calcification at the insertion in chronic insertional tendinopathy. Blood tests are not routinely indicated unless systemic inflammatory or metabolic conditions are suspected.

Management of Achilles tendinopathy is predominantly conservative, with strong evidence supporting exercise-based rehabilitation as the cornerstone of treatment.

First-line management includes load management advice, activity modification, and a structured exercise programme. Eccentric exercises (the Alfredson protocol) have historically been the most studied, but recent evidence supports heavy slow resistance training and isometric loading for pain relief as equally effective alternatives.

Adjunctive treatments include shockwave therapy (ESWT), which has moderate evidence for mid-portion tendinopathy. GTN patches and peritendinous injections (high-volume image-guided injection) may be considered in refractory cases. Corticosteroid injections should be used with caution due to the risk of tendon rupture.

Surgical intervention is reserved for cases that fail 6-12 months of appropriate conservative management and may include open or minimally invasive procedures such as tendon debridement, ventral paratenon stripping, or Haglund's resection for insertional disease.

Rehabilitation follows a progressive loading approach, typically divided into four stages:

Timeline: Most patients require 3-6 months of rehabilitation. Athletes should be counselled that full recovery may take 6-12 months.

Insertional Achilles tendinopathy (IAT) requires a modified rehabilitation approach. Eccentric and heavy slow resistance loading for IAT should be performed on a flat surface rather than dropping below horizontal off a step - deep ankle dorsiflexion compresses the insertion against the posterior calcaneus, worsening the compressive component of the pathology.

A small heel lift (6-12 mm) is commonly used during symptomatic periods to reduce insertional compression and is particularly useful if there is coexisting Haglund deformity. This is distinct from mid-portion tendinopathy where full dorsiflexion loading off a step is well tolerated and part of the standard Alfredson protocol.

• •Cook & Purdam (2009) - The tendon continuum model: a framework for understanding tendinopathy pathology and guiding treatment decisions.

• •Alfredson et al. (1998) - The original eccentric exercise protocol for mid-portion Achilles tendinopathy, demonstrating significant pain reduction and return to activity.

• •Beyer et al. (2015) - Heavy slow resistance training shown to be as effective as eccentric training with greater patient satisfaction.

• •NICE CKS: Achilles Tendinopathy - Recommends conservative management as first-line, with referral for specialist opinion if no improvement after 3 months.

• •BJSM Expert Consensus (2019) - Shockwave therapy recommended as second-line treatment for mid-portion tendinopathy. PRP evidence remains inconclusive.

• •Know the difference between mid-portion and insertional tendinopathy - they have different risk factors, examination findings, and management approaches.

• •The tendon continuum model (reactive → dysrepair → degenerative) is commonly tested. Understand the clinical implications at each stage.

• •Be clear on the evidence for eccentric vs heavy slow resistance training - both are supported but HSR may have higher patient satisfaction.

• •Red flags: sudden onset pain with a 'pop', palpable gap, and positive Thompson test suggest acute rupture - not tendinopathy.

• •Corticosteroid injections into or around the Achilles tendon carry rupture risk and are generally avoided.

• •Shockwave therapy is second-line for mid-portion disease but is not recommended for insertional tendinopathy in most guidelines.