Author(s): Richard G. Chang, MD, MPH, Marya Ghazzi, DO, Jacob Levine, MD
Originally published: July 20, 2012 Last updated: January 23, 2025
Jump to:

Disease/Disorder

Definition

The Achilles tendon is the largest and strongest tendon in a human being’s body.45 Achilles tendinopathy (AT) is an umbrella term used to describe a spectrum of tendon disorders including tendinosis and paratendinopathy, which all present with similar clinical symptoms of pain, swelling and impaired Achilles tendon function. Tendinopathy can be acute or chronic (lasting longer than 12 weeks). The two anatomical classifications include insertional (at the calcaneus-Achilles tendon junction) and non-insertional (2 – 6 cm proximal to the insertion of the Achilles tendon onto the calcaneus).4,5

Etiology

AT is frequently associated with overuse injury despite the tendon being able to bear loads in excess of 3500N.3 In addition to sporting activities, there are other intrinsic and extrinsic factors contributing to development of this condition. Intrinsic factors include increasing age, gender, systemic diseases (diabetes, rheumatologic conditions, and metabolic disorders), biomechanical abnormalities (foot pronation, leg length discrepancy, pes cavus, and/or varus foot deformity) and obesity. Extrinsic factors include drugs (fluoroquinolones), excessive mechanical overload, and training errors such as excessive hill training and poor shock absorption.4,5

Epidemiology including risk factors and primary prevention

Achilles tendon pathology is associated with 50% of all sports related injuries. About 75% of Achilles tendon ruptures occur in middle aged men participating in sports.3 It is one of the most common musculoskeletal injuries seen in running sports, with an incidence of around 9.1% to 10.9% in runners.44 One study described the prevalence of non-insertional AT as 2.01 per 1000 patients.3 AT may cause 5% of professional athletes to end their careers.5 Up to 4% of active adults may have asymptomatic degeneration. Other causes of AT include fluoroquinolone use (0.2-2.0%) and systemic diseases (2.0 %) such as ankylosing spondylitis, psoriatic and rheumatoid arthritis.

Patho-anatomy/physiology

The Achilles tendon originates from the gastrocsoleus complex and inserts onto the calcaneus distally. Histologically, it is composed of tenoblasts and tenocytes (90-95%), chondrocytes (5-10%) and some synovial cells. The extracellular matrix is made up of glycosaminoglycans, proteoglycans, and glycoproteins. While elastin accounts for 2% of the dry weight of the tendon, collagen accounts for 70-80% and is composed of type I (95%), type III, V, and XII collagen. Collagen forms fibrils, fibers, and fascicles which come together to form bundles surrounded by a paratenon. The bundled structures allow the tendon to undergo 200% strain before failing. The paratenon carries the blood supply, nerves and lymphatics to the tendon.3 The paratenon supplies blood flow more to the anterior portion of the tendon compared to the middle and posterior portions, with the midportion of the tendon containing a watershed zone 2cm to 6cm proximal to the insertion. The poor vascularity contributes to difficulty in healing following microtrauma.44

Biomechanical intrinsic factors which contribute to AT include hyperpronation of the foot, along with ankle equinus (frequently caused by pes planus). Ankle equinus is defined by ankle dorsiflexion limited to 10-20°. This causes increased foot pronation in order to gain the added benefit of increased dorsiflexion in order to maintain proper gait mechanics. This excessive hyperpronation at the subtalar joint causes the gastrocnemius-soleus complex and tibialis posterior to eccentrically contract with greater force. This compensation occurs to decelerate the rotation of the lower extremity and pronation of the foot. The frequent forceful contraction contributes to the development of AT.14

In AT, the tendon becomes thickened, and can appear brown and uneven. At the cellular level, there is an increase in the number of tenocytes, concentration of glycosaminoglycans, disorganization of the collagen fibers, and neovascularization. In chronic AT, there is an increased concentration of type III collagen, fibronectin, tenascin C, aggrecan, and biglycan.4 An increase in pain receptors has also been found, which is thought to play a role in pain generation.44

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

The majority of patients with AT recover fully and are able to return to sports participation. Grading is based on the severity of symptoms.

Grade 1: Morning discomfort in tendon, which resolves shortly after waking.
Grade 2: Pain during athletic activities that does not interfere with performance.
Grade 3: Pain that interferes with performance.
Grade 4: Pain that precludes sports participation.

In AT, tendon healing/repair occurs in three stages:4

Stage 1: Inflammatory – Lasts a few days with release of vasoactive and chemotactic factors
Stage 2: Proliferative – Lasts a few weeks and type III collagen levels peak
Stage 3: Modeling – Decreased collagen production and fibrous consolidation process beginning after 6 weeks.

Specific secondary or associated conditions and complications

Achilles tendon rupture is the most feared complication of AT. It may happen acutely or as an extension of a pre-existing partial tear of the tendon’s dorsal surface. Fluoroquinolone use has been linked to an increased risk of rupture, particularly in older populations taking concomitant oral steroids.4,6 Histologic examination confirms the presence of degenerative changes in > 75% of cases.1

Inflammation of the subcutaneous or retrocalcaneal bursae may mimic insertional AT. Extrinsic factors, such as high-heel or tight-fitting shoes with hard heel counters have been implicated in the development of calcaneal bursitis. In skeletally immature athletes, calcaneal apophysitis (Sever’s disease) is the most common cause of Achilles-related pain. Symptoms of Sever’s disease respond well to activity modification. Other soft tissue pathologies that could mimic achilles tendinopathy include posterior tibial tendinopathy or peroneal tendinopathy. Neurologic disorders that could mimic AT include S1 radiculopathy, as well as sural, tibial, or Baxter’s neuralgia.44 In the setting of bilateral AT, enthesitis from a seronegative spondyloarthropathy should be considered.

Essentials of Assessment

History

Patients with AT generally complain of a dull, burning pain along the tendon itself. The triad of pain, swelling and functional impairment are indicative of AT. It is important to evaluate for the intrinsic and extrinsic risk factors as outlined above.

A sudden “popping” sensation followed by pain and swelling during sudden pivoting movements or rapid acceleration, especially during eccentric loading/push off, should be suspicious for a tendon rupture.

Physical examination

Examination of the Achilles tendon begins with inspection of the tendon for any bruising or swelling. The tendon should be palpated along its length to assess for tenderness, thickness, or palpable gaps along the tendon. The ankle should be ranged in dorsiflexion and plantarflexion, which may reveal some crepitus. It is important to remember that an Achilles tendon rupture may be missed on exam due to inability to palpate a defect in the tendon, the patient’s inability to walk and plantarflex the ankle, or a painless tendon rupture.

The sensitivity of palpation to detect a tendon abnormality or partial tear remains about 0.73, with a specificity of 0.89.47 Other tests that can be used to assess tendon pathology include the Matles test, O’Brien’s test, the Copeland test, the Adams test, and the Thompson test. The Thompson test has the highest sensitivity at 0.96, and the Matles test, previously with the highest sensitivity (0.97), now is only about 88% sensitive.47

Functional assessment

As part of a thorough patient evaluation, it is important to assess for any gait and biomechanical abnormalities, leg length discrepancy, pes planus, or varus deformity of the foot.

Laboratory studies

If a systemic inflammatory process is suspected, a laboratory work-up may include complete blood count with differential, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, and anti-DNA antibody levels.

Imaging

Plain radiography has a low yield in detecting soft tissue pathology. However, it can be helpful for detecting bony pathology such as enthesopathy. Both ultrasound (US) and magnetic resonance imaging (MRI) provide the necessary anatomical detail for detecting AT pathology. Typical findings include a thickened paratenon, heterogeneity of tendon structure and increased vascularity of the ventral aspect of the tendon on color Doppler-augmented US and MRI. Early AT may present with increased fluid surrounding the tendon. Increased vascularity of the tendon’s dorsal side may indicate a partial tear, which may progress, unless managed appropriately.3

Hartgerink et al performed a study of 26 Achilles tendon tears using ultrasound and compared this to surgical findings. They found a sensitivity of 100%, specificity of 83% and positive predictive value of 83% in detecting partial from full thickness tears using ultrasound15. This and other studies show that US is helpful in detecting AT, however MRI remains the gold-standard imaging modality for establishing a definitive diagnosis.16

Although ultrasound can provide insight on the anatomical and morphologic features of AT, it lacks the full capability to assess the tendon’s mechanical properties that are altered due to extrinsic factors that lead to the tendinopathy.

New advances in ultrasound-based technologies, such as shear wave sonoelastography (SWE) and strain sonoelastography (SE), not only allow for the evaluation of both AT stiffness and elasticity, but ultimately can aid in an early diagnosis.33 Schneebeli et al 2021 study compared SE to SWE and found that SE used with a reference material was able to detect elasticity changes between the different contraction levels compared to the latter. Further studies are needed to evaluate the mechanical properties in pathological tendons.34

Supplemental assessment tools

Visual analog pain scale (VAS) and Victorian Institute of Sports Assessment – Achilles (VISA-A), an 8-question survey, have been validated for use in the AT population.17

Environmental

Training in inclement weather, excessive uphill or downhill running and physical deconditioning is associated with an increased risk of AT. Those at greater risk for Achilles tendon rupture tend to be older and less physically conditioned. Achilles tendinopathy is more common in men, and those with hypertension or rheumatologic disease. Individuals with flat feet, reduced ankle mobility, and decreased gluteal strength are also at higher risk. Lastly, steroid use increases the likelihood of AT.45

Social role and social support system

Since rehabilitation of AT may require significant changes to training/competition regimen, assistance of a sports psychologist may be necessary.

Professional issues

While good physical conditioning is protective against AT, those who rapidly increase exercise levels can be at risk. Each clinician should address any risk factors for rupture of the Achilles if the older patient returns to “weekend athletics” or if the high level athlete returns to the court or field. Treatment may vary for patients depending on their previous level of activity. For example, a high level athlete or individuals with physically demanding jobs will require more aggressive management. A full recovery is important to maintain their previous function. It is important for the clinician to determine the patient’s personal and professional needs in order to create a personalized treatment regimen. Physicians should also make patients aware that their rehabilitation management to full recovery may take time and weigh the patient’s personal desire to return to usual activity. As a general principle, their overall rehabilitation management should be closely monitored.

Rehabilitation Management and Treatments

Available or current treatment guidelines

According to the Orthopedic section of the American Physical Therapy Association 2018 practice guideline for midportion Achilles tendinopathy, the initial steps in conservative management of AT consisted of activity modification and an emphasis on mechanical loading in therapy (eccentric exercise), which was found to decrease pain and improve function. Meanwhile, bracing, orthoses, splinting, and elastic taping all were found to provide minimal or no benefit. Manual therapy including osteopathic manipulative treatments or other soft tissue mobilization techniques may be considered on a case by case basis.44 Rigid taping may be used to decrease strain on the Achilles tendon and/or alter foot posture in patients with midportion Achilles tendinopathy.35 In recalcitrant cases, surgery may be considered in those who fail conservative management.36

At different disease stages

New onset/acute

  • Activity modification
  • Cryotherapy to control pain and edema.
  • Non-steroidal anti-inflammatory drugs (NSAIDs) reduce pain and inflammation and facilitate physical therapy. Studies between oral NSAIDs and placebo show no overwhelming evidence of quicker return to activity, but they are reasonable medications for pain relief.
  • Intratendinous steroid injections are not recommended due to reported increased risk of Achilles tendon rupture, although no randomized study has shown that to be true. However, adverse events have been reported in 82% of corticosteroid trials while only providing short term pain improvement.4,5
  • Once healing has begun patients can begin a rehabilitation program. Many systematic reviews show benefit of eccentric strength training (EST) in non-insertional AT.4

Subacute

  • Includes secondary prevention and disease management strategies
  • Gastrocnemius/soleus stretching and EST are important in maintaining mobility and decreasing muscle tension.
  • Therapeutic ultrasound decreases pain and swelling in the acute inflammatory phase of tendon injuries, but there is lack of evidence to support its use in AT.4,5
  • The use of nitroglycerin transdermal patches may increase tendon blood flow and help with pain relief. One randomized control study showed improved pain and function with the use of nitroglycerin patches in tandem with eccentric training for mid portion AT, however these results have not been reproduced.44

Chronic/stable

  • Includes secondary prevention and disease management strategies and rehabilitation strategies that intend to optimize function.
  • Studies have shown eccentric strengthening can produce normalization of tendon tissue in non-insertional Achilles tendinopathy.2,20-22
  • Non-operative procedural interventions may include acupuncture, high-volume injectate (HVI), extracorporeal shockwave therapy (ESWT), prolotherapy, platelet rich plasma (PRP), other orthobiologic injections, corticosteroid injections, and percutaneous tenotomy. Current studies have shown that HVI or ESWT plus eccentric tendon loading PT programs may improve long term outcomes, and acupuncture has demonstrated good short and long term outcomes. However, more studies are needed to directly compare the various interventions.44
  • As stated above, intratendinous corticosteroid injections are not recommended because of the high risk of adverse events including Achilles tendon rupture.5,8,20
  • Percutaneous tenotomy is another treatment option. It can be performed two ways; either by needle fenestration of the diseased tendon with or without an associated injection, or as a minimally invasive phacoemulsification technique with debridement and aspiration by an ultrasonic vibrating needle attached to suction and irrigation system. Studies have shown a significant reduction in both short and long term pain in patients who underwent ultrasonic tenotomy.44
  • In chronic cases, a multidisciplinary team is helpful to optimize patient outcomes. Ideally, the physiatrist would lead a clinical team of physical therapists, orthotists, surgical consultants, nutritionist, and a sports psychologist.
  • For recalcitrant pain not improved with lifestyle modification, medications, and physical therapy, surgical management can be considered. Repair of an elongated or a partially torn tendon should be considered for patients with high functional demands. A physiatrist’s role should be to help establish the necessity of surgery in certain clinical scenarios and to ensure conservative options have been exhausted and risk factors, including biomechanics, are addressed.
  • Surgical treatments can include removal of the damaged peritendinous tissue, longitudinal incisions on the tendon to stimulate repair, or longitudinal incisions with damaged intratendinous excision.37 The incidence of postsurgical complications is 11%.4,5

Patient & family education

Patients should be counseled and educated regarding theories supporting the use of physical therapy and the role of mechanical loading; modifiable risk factors, including BMI and shoe wear; and typical time course for recovery from symptoms.35

Emerging/unique interventions

Given the current emphasis on healthcare metrics, patient reported outcome measures (PROM) help measure a patient’s perceived impact from Achilles tendinopathy. Both VAS and The Victorian Institute of Sports Assessment–Achilles tendinopathy questionnaire (VISA-A) can be used to assess patient’s pain and stiffness. Either the Foot and Ankle Ability Measure (FAAM) or the Lower Extremity Functional Scale (LEFS) can also be used to assess activity and participation in clinical settings.35

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Patient education should focus on preventive strategies, and validated outcomes measures (e.g., PROM) should be employed to document treatment progress. Training and exercise modification are very important. Analysis of gait and incorporation of strengthening other muscles besides the ankle/foot complex, such as the core and hip, would be ideal in decreasing the risk for further injury.

Cutting Edge/Emerging and Unique Concepts and Practice

Extracorporeal shock wave therapy (ESWT) is believed to initiate a reparative process that promotes tenocyte proliferation, collagen synthesis, neovascularization and pain relief.28 This process typically takes place as five weekly fifteen-minute sessions.

Although safe and well tolerated, the high diversity of application methodologies prevents ESWT effectiveness for Achilles tendinopathy from being fully recommended. The most effective doses and delivery methods remain unclear. Further multicenter, comparative randomized controlled studies are still needed.29   

Topical glyceryl trinitrate theoretically increases nitric oxide concentrations leading to improved fibroblast function and wound healing. One randomized, double blind, placebo-controlled study showed improvement in symptoms, while others found no difference.4,6

Several different injectable therapies are available, but high-quality research comparing the effectiveness of these interventions is lacking.

In 2015, Lynen et al compared three once weekly ESWT and two once weekly ultrasound guided hyaluronic acid peritendinous injections for AT. Statistically significant improvements in pain were reported with the hyaluronic acid injection group at one, three, and six months.8

Platelet-rich plasma (PRP) injections appear to show promise in recalcitrant mid-portion AT.9,10 PRP is believed to facilitate healing due to its high concentration of growth factors, which may promote tendon remodeling, especially when combined with percutaneous needle tenotomy. Krogh et al, in a randomized placebo controlled blinded study of 24 patients with non-insertional Achilles tendinopathy compared one single ultrasound guided PRP injection versus a saline injection over a 3 month period found no statistically significant improvement in VISA-A score.11 Limitations of this study included a poor follow up rate, questionable needle tenotomy technique, and an unstructured post-procedure rehabilitation protocol. Based on the available research, PRP therapy may be reserved for those patients who fail to improve with anti-inflammatory medications, activity modification, bracing, and physical therapy.10,11 In a recent randomized controlled trial, Kearney et al. did not support the use of PRP for the treatment of chronic midportion AT.30 Due to conflicting literature, a greater call for larger studies (and comparison to surgical techniques) is required for further clarification.5,9,18-21

Prolotherapy induces an inflammatory process, which initiate the body’s wound-healing cascade, and lead to cellular proliferation, collagen deposition, and eventually tissue repair, thereby leading to pain reduction and functional improvement.14–16 Dextrose, one of the most commonly used substances, is hypothesized to initiate a wound healing cascade of inflammation, granulation tissue formation, matrix formation, and remodeling.31 There is insufficient evidence to support the clinical benefits of dextrose prolotherapy. More high-quality randomized controlled trials are warranted to establish the benefits of prolotherapy. Other sclerosing agents, including polidocanol, which promote vessel thrombosis, may result in decreased tissue inflammation and neovascularity in patients with chronic AT.4,6 Ebbesen et al. performed a randomized controlled trial in 2018 and established polidocanol as a safe treatment, but the study only provided mid-term effects similar to the placebo group, and questioned its use in chronic AT.32 

Percutaneous needle tenotomy of the tendon is a minimally invasive option for patients’ refractory to conservative treatment. Of note, this treatment option is based on existing literature for treatment for other chronic tendinosis such as lateral epicondylosis.25,26 In a separate retrospective study of 26 patients by Ellis et al., 88.5% reported pain relief in up to an 18 month follow up period).21,22,27

Using similar principles found with needle tenotomy, percutaneous ultrasound tenotomy uses ultrasound energy and a high pressure delivery of saline to emulsify, debride, and remove pathologic tendon tissue. In doing so, healthy tendon edges can be brought closer together. Tenex is one example device that uses such technology. There appears to be positive results with animal studies, with possible benefit in humans.38,39

Intermittent pneumatic compression (IPC) was shown to improve the healing of Achilles tendon ruptures in rats, particularly when combined with cryotherapy. The increased local blood flow to the tendon caused by IPC may promote a healing effect in tendinopathy but has not yet been clinically investigated. 46

An emerging novel treatment is tendon scraping, which involves using a scalpel or needle to separate neovascularization between the affected tendon and the adjacent fat pad.40,41,43 Existing studies by Alfredson et al., which have used either a scalpel or percutaneous scraping with a needle under ultrasound and color doppler guidance for patients with midportion Achilles tendinopathy, appear to show similar decreases in pain, function, complication rate, and a quicker return to sport and tendon loading when compared to prolotherapy and polidocanol injections.41,42,43

Another percutaneous technique that has been studied is radiofrequency microtenotomy and coblation of the affected tendon. Here, a radiofrequency probe generating at a low temperature (40-70 degrees Celsius) is activated for 0.5 seconds while light axial pressure is applied to puncture the tendon perpendicularly over a number of areas.21,22 Approximately 20 points over the tendon are mapped prior to the procedure.21 Based on a 2012 review of 47 patients by Shibuya et al., their study reported that 14.7% of patients had to be re-operated on due to ineffective results, with 6.4% of patients having AT rupture (associated with higher BMI).22,23 Other smaller studies have reported more successful results (“90-95 % success rate”) lasting at least 6 months to 3 years.24 Due to the lack of level 1 studies with other studies using concurrent potentially confounding surgical techniques (e.g. arthroscopy, adhesiolysis) and variable results, this treatment option should not be recommended.

Minimally invasive stripping (MIS) of the para-tendinous tissue from the Achilles tendon is an understudied technique but with some promise. Maffulli et al treated a small group of active patients with MIS yielding an average return time to sports of 3 ½ months. Unfortunately, MIS came with a substantial risk of damage to the sural nerve, which was lessened by a subsequent technique modification. To this point however, there is not enough conclusive evidence to justify routine clinical use.46

Gaps in the Evidence-Based Knowledge

Although VAS is used as a subjective indicator of a patient’s symptoms and an indicator of a modality’s effectiveness, there is a lack of studies using objective testing to monitor the progression of AT or predict the risk of tendon rupture. Exercise therapy remains the most evidence based management option, with the fewest complications, while remaining cost effective. Future double-blinded randomized controlled studies are needed to clarify the best adjuvant option among the novel therapies and procedures available for pain reduction (e.g., PRP, prolotherapy, needle tenotomy, ESWT, MIS, and tendon scraping). High level comparison studies of function improvement in surgical and non-surgical candidates are needed as well.4,5,6,18-20,22 Orthobiologics involving tissue regeneration bring some degree of promise but remain still a way away from routine use.

References

  1. Alfredson H, Masci L, Ohberg L. Partial mid-portion Achilles tendon ruptures: new sonographic findings helpful for diagnosis. Br J Sports Med. 2011;45:429-32.
  2. Balius R, Alvarez G. A 3-Arm randomized trial for Achilles tendinopathy: eccentric training, eccentric training plus a dietary supplement containing mucopolysaccharides, or passive stretching plus a dietary supplement containing mucopolysaccharides. Current Therapeutic Research. 2016; 78: 1-7.
  3. Freedman B, Gordon J. The Achilles tendon: fundamental properties and mechanisms governing healing. Muscles, Ligaments, and Tendons Journal. 2014; 4(2): 245-255.
  4. Li HY, Hua YH. Achilles tendinopathy: current concepts about the basic sciences and clinical treatments. BioMed Research International. 2016; 2016: 1-9.
  5. Zwiers R, Wiegerinck JI, van Dijk N. Treatment of midportion Achilles tendinopathy: an evidence-based overview. Knee Surgery, Sports Traumatology, Arthroscopy. July 2016; 24(7):2103–2111.
  6. Maffulli N, Papalia R. Pharmacological interventions for the treatment of Achilles tendinopathy: a systematic review of randomized controlled trials. British Medical Bulletin. 2015; 113; 101-115.
  7. Maffulli N. The clinical diagnosis of subcutaneous tear of the Achilles tendon. The American Journal of Sports Medicine. 1998; 26(2): 266-270.
  8. Lynen N, De Vroey T, Spiegel I. Comparison of peritendinous hyaluronan injections versus extracorporeal shock wave therapy in the treatment of painful achilles’ tendinopathy: a randomized clinical efficacy and safety study. Archives of Physical Medicine and Rehabilitation. 2017; 98: 64-71.
  9. Di Matteo B, Filardo G, Kon E, Marcacci M. Platelet-rich plasma: evidence for the treatment of patellar and Achilles tendinopathy–a systematic review. Musculoskelet Surg. 2015;Apr 99(1):1-9.
  10. Guelfi M, et al. Long-term beneficial effects of platelet-rich plasma for non-insertional Achilles tendinopathy. Foot and Ankle Surgery. 2015;Sep 21(3):178-81.
  11. Krogh T, Ellingson T. Ultrasound-guided injection therapy of Achilles tendinopathy with platelet-rich plasma or saline. The American Journal of Sports Medicine. 2016; 44(8): 190-197.
  12. Calder J, Stephen J, Dijk N. Plantaris Excision Reduces Pin in Midportion Achilles Tendinopathy Even in the Absence of Plantaris Tendon. The Orthopaedic Journal of Sports Medicine. 2016; 4(12): 1-9
  13. Petrescu P, Izvernariu D. Evaluation of the normal and pathological Achilles tendon by real-time shear wave elastography. Rom J Morphol Embryol. 2016; 57(2): 785-790.
  14. Brukner P, Khan K. Clinical Sports Medicine 3rd Edition. Australia; McGraw-Hill Book Company; 2010: 40-54.
  15. Hartgerink P, Fessell DP. Full- versus partial-thickness Achilles tendon tears: sonographic accuracy and characterization in 26 cases with surgical correlation.Radiology. 2001; 220(2): 406-412.
  16. Kayser R, Mahlfeld K. Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging. Br J Sports Med. 2005;39(11):838.
  17. McCormack J, Underwood F. The minimum clinically importance difference VISA-A and LEFS for patients with insertional achilles tendinopathy. International Journal of Sports Physical Therapy. 2015 10(5): 639-644.
  18. Caudell GM. Insertional Achilles Tendinopathy. Clin Podiatr Med Surg.2017;34:195–205,
  19. Wiegerinck JI, et al. Treatment for insertional Achilles tendinopathy: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013;21:1345–1355.
  20. Roche AJ. Calder JDF. Achilles Tendinopathy: A Current Review of the Current Concepts of Treatment. Bone Joint J. 2013;95-B:1299–1307.
  21. Smith WB, Melton W, Davies J. Midsubstance Tendinopathy, Percutaneous Techniques (Platelet-Rich Plasma, Extracorporeal Shock Wave Therapy, Prolotherapy, Radiofrequency Ablation). Clin Podiatr Med Surg. 2017;34:161–174.
  22. Roche C. A review of the current concepts of treatment: Achilles tendinopathy. Bone Joint J 2013;95-B(10):1299–307.
  23. Shibuya N, Thorus J, Humphers J, et al. Is percutaneous radiofrequency coblation for treatment of Achilles tendinosis safe and effective? J Foot Ankle Surg. 2012;51:767–71.
  24. Tasto JP. The use of bipolar radiofrequency microtenotomy in the treatment of chronic tendinosis of the foot and ankle. Tech Foot Ankle Surg. 2006;5(2):110–6.
  25. Finnoff JT, Fowler SP, Lai JK, et al. Treatment of chronic tendinopathy with ultrasound-guided needle tenotomy and platelet-rich plasma injection. PMR. 2011 Oct;3(10):900-11.
  26. Barnes D, Beckley J, Smith J. Percutaneous ultrasonic tenotomy for chronic elbow tendinosis: a prospective study. J Shoulder Elbow Surg. 2015;24(1):67–73.
  27. Ellis M, Johnson K, Freed L, et al. Fasciotomy and surgical tenotomy for chronic Achilles insertional tendinopathy: a retrospective study using ultrasound-guided percutaneous tenotomy approach. J Am Podiatr Med Assoc. 2019. Jan;109(1):1-8
  28. Chao YH, Tsuang YH, Sun JS, Chen LT, Chiang YF, Wang CC, Chen MH. Effects of shock waves on tenocyte proliferation and extracellular matrix metabolism. Ultrasound Med Biol. 2008 May; 34(5):841-52.
  29. Stania M, Juras G, Chmielewska D, Polak A, Kucio C, Król P. Extracorporeal Shock Wave Therapy for Achilles Tendinopathy. Biomed Res Int. 2019;2019:3086910. Published 2019 Dec 26. Doi:10.1155/2019/3086910
  30. Kearney RS, Ji C, Warwick J, Parsons N, Brown J, Harrison P, Young J, Costa ML; ATM Trial Collaborators. Effect of Platelet-Rich Plasma Injection vs Sham Injection on Tendon Dysfunction in Patients With Chronic Midportion Achilles Tendinopathy: A Randomized Clinical Trial. JAMA. 2021 Jul 13;326(2):137-144.
  31. Yelland MJ, Sweeting KR, Lyftogt JA, et al. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. British Journal of Sports Medicine. 2011;45:421-428.
  32. Ebbesen BH, Mølgaard CM, Olesen JL, Gregersen HE, Simonsen O. No beneficial effect of Polidocanol treatment in Achilles tendinopathy: a randomised controlled trial. Knee Surg Sports Traumatol Arthrosc. 2018 Jul;26(7):2038-2044.
  33. Prado-Costa, R., Rebelo, J., Monteiro-Barroso, J. et al. Ultrasound elastography: compression elastography and shear-wave elastography in the assessment of tendon injury. Insights Imaging. 2018(9):791–814.
  34. Schneebeli A, Fiorina I, Bortolotto C, et al. Shear wave and strain sonoelastography for the evaluation of the Achilles tendon during isometric contractions. Insights Imaging. 2021;12(1):26.
  35. 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. J Orthop Sports Phys Ther. 2018 May;48(5):A1-A38.
  36. Fares MY, Khachfe HH, Salhab HA, et al. Achilles tendinopathy: Exploring injury characteristics and current treatment modalities. The Foot. 021(46):101715.
  37. Chung MW; Hsu CY, Chung WK, et al. Effects of dextrose prolotherapy on tendinopathy, fasciopathy, and ligament injuries, fact or myth? Medicine. November 13, 2020(99);46:e2320.
  38.  Kamineni S, Butterfield T, Sinai A. Percutaneous ultrasonic debridement of tendinopathy-a pilot Achilles rabbit model. J Orthop Surg Res. 2015;10:70.
  39. Langer PR. Two emerging technologies for Achilles tendinopathy and plantar fasciopathy. Clin Podiatr. Med Surg. 2015;32(2):183–93.
  40. Alfredson H. Low recurrence rate after mini surgery outside the tendon combined with short rehabilitation in patients with midportion Achilles tendinopathy. Open Access J Sports Med. 2016;7:51–
  41. Alfredson H. Ultrasound and Doppler-guided mini-surgery to treat midportion Achilles tendinosis: results of a large material and a randomised study comparing two scraping techniques. Br J Sports Med.2011;45(5):407–10.
  42. Alfredson H, Ohberg L, Zeisig E, Lorentzon R. Treatment of midportion Achilles tendinosis: similar clinical results with US and CD-guided surgery outside the tendon and sclerosing polidocanol injections. Knee Surg Sports Traumatol Arthrosc. 2007;15(12):1504–9.
  43. Schaaf S, Hogan MCV, Tenforde A. Achilles Tendinopathy. In: Onish K, Fredericson M, Dragoo JL. Tendinopathy: From Basic Science to Clinical Management. Springer;2021:259-260.
  44. von Rickenbach KJ, Borgstrom H, Tenforde A, Borg-Stein J, McInnis KC. Achilles Tendinopathy: Evaluation, Rehabilitation, and Prevention. Curr Sports Med Rep. 2021 Jun 1;20(6):327-33.
  45. Medina Pabón, M., Naqvi, U. Achilles Tendinopathy. NIH StatPearls. 2023 Aug 17.
  46. Ackerman, P., Phisitkul, P., Pearce, C. Treatment of Achilles tendinopathy: state of the art. Journal of ISAKOS. 2018 Nov. Vol 3, Iss 6, 367-76.
  47. Schwieterman, B., Haas, D., Columber, K., Knupp, D., Cook, C. Diagnostic Accuracy of Physical Examination Tests of the Ankle/Foot Complex: A Systematic Review. International Journal of Sports Physical Therapy. 2013 Aug 8 (4): 416-426.

Original Version of the Topic

Clark C. Smith, MD and Grigory Syrkin, MD. Achilles tendinopathy. 7/20/2012

Previous Revision(s) of the Topic

Richard G. Chang, MD, MPH, Brian Pekkerman, DO, Puneet Ralhan, DO. Achilles tendinopathy. 7/31/2017

Laurenie Louissaint, MD, MS, Richard G. Chang, MD, MPH. Achilles Tendinopathy. 11/8/2021

Author Disclosure

Richard G. Chang, MD, MPH
Nothing to Disclose

Marya Ghazzi, DO
Nothing to Disclose

Jacob Levine, MD
Nothing to Disclose