Evidence based treatment for Achilles tendinopathy
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"Achilles Tendon" AND tendinopathy
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2024 2025 Achilles tendinopathy clinical practice guideline exercise treatment JOSPT
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https://www.jospt.org/doi/10.2519/jospt.2025.0501
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"Achilles Tendinopathy" AND treatment
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PMID: 42063301
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PMID: 41705493
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PMID: 39496560
Evidence-based treatment of Achilles tendinopathy
First distinguish:
- Midportion: pain and thickening 2-6 cm above the heel insertion.
- Insertional: pain at the tendon attachment to the heel, often aggravated by shoe pressure or deep dorsiflexion.
1. First-line: education, load modification, and progressive tendon loading
Progressive calf-loading exercise is the main treatment, rather than rest alone. The 2025 JOSPT clinical practice guideline identifies exercise and education as first-line care for midportion disease, with loading progressed to the highest level tolerable. JOSPT guideline
Practical principles:
- Reduce, but do not necessarily eliminate, provoking activity initially: cut back running volume, hills, speedwork, jumping, and other high tendon-load activities.
- Use pain response to guide dosage. Mild discomfort during exercise can be acceptable if it settles and is not substantially worse the next morning.
- Train the calf complex at least twice weekly, commonly 3 times weekly, and progress resistance over months rather than days.
- Either eccentric-only, heavy-slow resistance, or a progressive mixed loading program can work. Eccentric exercise is not the only effective option.
A classic eccentric option is heel-lowering exercise, but heavy-slow calf raises are often easier to individualize:
| Phase | Typical exercise goal |
|---|---|
| Pain-irritable phase | Isometric plantar-flexion holds and double-leg calf raises |
| Strength phase | Progressive single-leg calf raises, seated and standing, with external weight |
| Energy-storage / return to sport | Faster calf raises, hopping, skipping, running drills, then graded return to sport |
Both the gastrocnemius and soleus should be loaded: use straight-knee and bent-knee calf raise variations. Textbook support for eccentric strengthening and activity modification is described in Miller's Review of Orthopaedics, p. 595.
2. Modify loading by location
For midportion tendinopathy
- Full-range heel drops can be used if tolerated.
- Progressive tendon loading is the cornerstone.
For insertional tendinopathy
- Initially avoid loading into marked dorsiflexion, such as lowering the heel far below a step.
- Start heel raises on level ground, or with a small heel lift.
- Avoid rigid shoes that rub the insertion. A temporary heel lift can reduce compressive load and symptoms.
- Gradually restore range and strength as pain settles.
3. Adjuncts that may help
- Footwear and heel lifts: useful short term, especially in insertional disease or when walking is painful. They are symptom aids, not definitive treatment.
- Stretching: may help if calf tightness is present, but should not be forced into painful end-range dorsiflexion, particularly in insertional disease.
- Physical therapy: helpful for supervised progression, gait/running-load review, calf capacity, balance, and return-to-sport planning.
- Short-term analgesia: ice for symptom relief and a short course of an NSAID can be considered if appropriate for the individual. NSAIDs do not repair tendon degeneration and should not replace loading rehabilitation. Textbook of Family Medicine, pp. 842-843.
- Imaging: ultrasound or MRI is usually unnecessary at the outset. Consider it for diagnostic uncertainty, suspected partial tear, unusual symptoms, or failure of a good rehabilitation program. Textbook of Family Medicine, p. 842.
4. Treatments not recommended routinely
Corticosteroid injection into or around the Achilles tendon: avoid. It can weaken tendon tissue and raises concern for rupture. Textbook of Family Medicine, p. 843.
PRP injection: not routine. A 2026 systematic review of 8 studies (507 patients) found only a small short-term functional difference, without sustained functional, pain, or structural benefit. PRP systematic review
Shockwave therapy: not routine. Earlier practice often used ESWT for persistent cases, but a 2026 systematic review and meta-analysis of 9 RCTs (557 participants) found no clinically meaningful overall benefit for either midportion or insertional tendinopathy and reported two ruptures after focused shockwave treatment. Shockwave meta-analysis
High-volume injection: evidence remains uncertain and study protocols often include corticosteroid. A 2024 review found possible early symptomatic benefit but calls for better trials, so it should be a specialist-level, selective option rather than standard care. Injection review
Other passive modalities, including therapeutic ultrasound, massage, and iontophoresis, have weaker evidence than a structured loading program.
5. When to consider surgery
Refer to a foot-and-ankle orthopaedic surgeon or sports-medicine specialist if there is persistent function-limiting pain despite a well-adhered-to, progressive rehab program, usually at least 3-6 months and often longer, or if imaging/clinical assessment suggests substantial tendon degeneration or partial tear.
Procedures vary with pathology and may include debridement of diseased tendon, removal of insertional calcification or Haglund prominence, and tendon reconstruction or flexor hallucis longus transfer when a large portion of the tendon is nonviable. Miller's Review of Orthopaedics, pp. 595-596.
Important red flags
Seek urgent assessment for a sudden “pop” or kicked-in-the-calf sensation, a palpable tendon gap, abrupt loss of push-off strength, or a positive Thompson test. These may indicate Achilles rupture, not routine tendinopathy. Also mention fluoroquinolone antibiotic use, systemic steroid exposure, or inflammatory arthritis, as these can increase tendon risk.
Bottom line: build calf and tendon capacity through a graded loading plan, adjust sport load rather than fully resting, modify exercises for insertional versus midportion disease, and avoid routine injections or shockwave therapy. Recovery commonly takes several months, with functional improvement more meaningful than ultrasound or MRI appearance.
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