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How do you manage Achilles Tendinopathy?


What is Achilles Tendinopathy?

Mid portion Achilles tendinopathy is a common and often frustrating condition experienced by patients. It is characterized by the combination of pain and swelling in the Achilles tendon and impaired performance.1 The degree of pain and stiffness is usually a good indicator of severity of the tendinopathy.2

Find out more about Achilles Tendinopathy

  • The most common clinical diagnosis of Achilles overuse injuries is paratendinopathy and/or tendinopathy (55-65%), followed by insertional problems like retrocalcaneal bursitis and insertional tendinopathy (20-25%).3,4,5,6
  • Non-insertional Achilles tendinopathy is characterized by pain which is worse at the beginning of & following sporting activity.7
  • As the tendinopathy progresses, pain can be present during exercise and even at rest. Pain and stiffness in the morning may also be experienced and the duration of these symptoms can assist in diagnosing the severity.
  • Pain experienced with mid portion tendinopathy is located 2-7cm above the calcaneus (often with fusiform thickenings.

Tendons transmit muscle forces to bone, allowing locomotion and enhancing joint stability. They respond to mechanical forces by changing their metabolism and their structural and mechanical properties. Inappropriate physical loading (either overuse or underuse) leads to tendon overuse injuries and tendinopathy.7 Although often attributed to over-use in sport, interestingly, in recent studies it was shown that 33% of patients with chronic Achilles tendinopathy are not physically active.8,9,10,11\

Clinical treatments focused on improving tendon structure or pathology are considered optimal interventions, but, as pain is often the clinical presentation, a case can be made for concentrating on reduction of pain as a valid outcome.19 Cook and Purdham’s continuum of tendon pathology provides a useful framework to tailor interventions dependent on the individual clinical presentation and pathology seen.19

Management of non-insertional Achilles tendinopathy is most commonly a conservative approach with loading protocols (predominantly eccentric exercises) being the first line treatment of choice. Systematic reviews have evaluated the results of eccentric loading of the injured tendon in tendinopathy,13-17 concluding although outcomes are promising, high-quality evidence is lacking.14

Shockwave Therapy for Achilles Tendinopathy

Shockwave therapy is another conservative approach that has been found to have similar efficacy to an eccentric exercise programme, and interestingly the combined use of shockwave therapy with eccentric exercises has been shown to produce greater improvement in pain and function compared with eccentric loading alone, or shockwave therapy alone.12

So how do you successfully combine both shockwave therapy and a loading protocol to treat Midportion Achilles Tendinopathy? Should the patient perform eccentric exercises before or after shockwave therapy? How long should you wait between treatments? How often should the exercise be performed and when should they be progressed?

How can DJO help?

DJO is your clinical education partner with a range of resources to help answer tough clinical questions, improve your clinical protocols, access expert opinion, and improve profitability.

  • Log on free of charge at DJOStore to watch our CPD webinars including Paul Hobrough discussing Clinical Protocols for Soft tissue conditions. In this webinar, Paul discusses loading protocols and shockwave therapy for achilles tendinopathy, as well as myofascial syndromes, trigger points, and more.
  • View the new DJO Video Library for arrange of short videos to help improve your knowledge and assist with product selection. Click here to access the Video Library
  • Receive a copy of our Literature Review: Common Allied Health Conditions filled with reviews of current literature and identifying changes in the treatment of common conditions. Request your copy here!


1 Maffulli N, Khan KM, Puddu G. (1998). Overuse tendon conditions: time to change confusing terminology. Arthroscopy, 14:840-43
2 Cook JL, Khan KM, Purdam C. (2002). Achilles Tendinopathy. Manual Therapy; 7:121–30
3 Jarvinen M. Epidemiology of tendon injuries in sports. (1992). Clinical Sports Med. 11:493-505
4 Jarvinen TA, Kannus P, Maffulli N, Khan KM. (2005). Achilles tendon disorders: etiology and epidemiology. Foot Ankle Clin. 10:255-66
5 Jarvinen TA, Kannus P, Paavola M, Jarvinen TL, Jozsa L, Jarvinen M. (2001). Achilles tendon injuries. Curr Opin Rheumatology. 13:150-55
6 Kvist M. (1994). Achilles Tendon injuries in athletes. Sports Med. 18:173-201
7 Calder J, Karlsson J, Maffulli N, Thermann H, Niek van Dijk C. (Eds). (2010). Achilles Tendinopathy: Current Concepts. Surrey, UK. DJO Publications.
8 Alfredson H. (2003). Chronic midportion Achilles tendinopathy: an update on research and treatment. Clin Sports Med; 22:727–41.
9 Astrom M. (1998). Partial rupture in chronic Achilles tendinopathy. A retrospective analysis of 342 cases. Acta Orthop Scand; 69:404–7.
10 Kader D, Saxena A, Movin T, et al. (2002) Achilles tendinopathy: some aspects of basic science and clinical management. Br J Sports Med; 36:239–49.
11 Luscombe KL, Sharma P, Maffulli N. (2003). Achilles tendinopathy. Trauma; 5:215–25.
12 Rompe JD, Furia J, Maffulli N. (2009). Eccentric loading versus eccentric loading plus shock-wave treatment for midportion Achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 37(3):463-470.
13 Kingma JJ, de Knikker R, Wittink HM, et al. (2007). Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review. Br J Sports Med.41:e3-5.
14 Rowe V, Hemmings S, Barton C, Malliaras P, Maffulli N, Morrissey D. (2012). Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning. Sports Med.42:941-67.
15 Woodley BL, Newsham-West RJ, Baxter GD. (2007). Chronic tendinopathy: effectiveness of eccentric exercise. Br J Sports Med. 41:188-98.
16 Meyer A, Tumilty S, Baxter GD. (2009). Eccentric exercise protocols for chronic non-insertional Achilles tendinopathy: how much is enough? Scand J Med Sci Sports.19:609-15.
17 Satyendra L, Byl N. (2006). Effectiveness of physical therapy for Achilles tendinopathy: an evidence-based review of eccentric exercises. Isokinet Exerc Sci.14:71-80
18 Habets B, van Cingel RE. (2015). Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review on different protocols. Scand J Med Sci Sports.25:3-15.
19 Cook JL, Purdam CR. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine. 43:409-416.
20 Alfredson H, Pietila T, Jonsson P, Lorentzon R. (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Medicine; 26: 360
21 Al-Abbad & Simon. (2013). The Effectiveness of Extracorporeal Shock Wave Therapy on Chronic Achilles Tendinopathy: A Systematic Review. Foot & Ankle Int. 34(1) 33 –41