Achilles tendinopathy

What is Achilles tendinopathy?

The Achilles tendon connects the calf muscles to the heel bone. In tendinopathy it becomes painful and weakened because of repeated overload and reduced healing capacity. It is not usually caused by inflammation, but by gradual changes within the tendon structure.

The two types

• Mid-portion (non-insertional) tendinopathy. Pain 2 to 6 cm above the heel bone, more common in active people. The tendon may feel thickened or stiff. Pain often eases with gentle activity, then worsens later.
• Insertional tendinopathy. Pain where the tendon attaches to the heel bone, often linked with footwear pressure or a bony prominence (Haglund’s deformity). Worse walking uphill, on stairs or after rest, and stretching into deep ankle bend can aggravate it.

What causes it?

The tendon is loaded more than it can recover from, usually gradually:

1. Tight calf muscles (gastrocnemius and soleus), one of the most important contributors, increase tension in the tendon with every step.
2. A sudden change or increase in activity, such as returning after a break, new surfaces, or more distance or speed.
3. Repetitive loading without enough recovery, causing microscopic damage.
4. Footwear that is unsupportive or rubs the back of the heel.
5. Body weight, which increases the force through the tendon with each step.
6. Medical factors: diabetes, raised cholesterol, reduced circulation and some medicines, including certain cholesterol-lowering drugs.
7. Age, as tendons become less elastic and slower to repair.
8. Work and lifestyle: prolonged standing or walking, and the “weekend warrior” pattern.
9. Movement patterns and weakness elsewhere in the leg.

What are the symptoms?

• Pain and stiffness worst first thing in the morning or after rest, easing after warming up, then worse again later
• Pain during or after walking, running, stairs or hills
• Reduced push-off strength and endurance
• A thickened, tender tendon, or redness and irritation at the back of the heel from shoe pressure
• “Good days and bad days”

First-line treatment

Most people improve without surgery, though recovery can take several months.

• Activity modification. Reduce aggravating activities rather than stopping, and avoid sudden spikes.
• Exercise-based rehabilitation. Progressive or eccentric loading exercises have the strongest evidence, tailored to insertional or mid-portion disease.
• Calf flexibility and strength. Stretching is used carefully, especially in insertional disease.
• Footwear. Supportive shoes, temporary heel raises, and avoiding shoes that rub the back of the heel.

Second-line treatment

Used alongside, not instead of, ongoing loading exercises:

• Shockwave therapy (ESWT). Sound waves stimulate healing. Improvement builds over weeks to months. Good evidence for both types.
• PRP and high-volume injections. PRP uses growth factors from your own blood. High-volume injections aim to reduce pain from abnormal nerves and blood vessels around the tendon. Results vary and improvement is slow.

Surgery

Considered only when symptoms persist for at least 6 to 12 months despite well-structured non-surgical treatment.

Mid-portion tendinopathy

• Debridement of degenerate tendon tissue
• Paratenon release to free scarring around the tendon
• Longitudinal tenotomies or minimally invasive techniques to stimulate healing
• Gastrocnemius (calf) lengthening when calf tightness is a major factor

Endoscopic or minimally invasive techniques can reduce wound problems and speed early recovery.

Insertional tendinopathy

• Removal of damaged tendon tissue
• Excision of the bony prominence or heel spur
• Partial detachment and reattachment of the tendon with strong anchors, when needed
• Gastrocnemius lengthening
• Zadek’s osteotomy, removing a wedge of heel bone to move the prominence away from the tendon