22/10/2025
Achilles Tendinopathy (AT) Management Overview
▪️ The treatment of Achilles tendinopathy (AT) is centered on a biopsychosocial approach, with exercise, education, and activity modification forming the primary management strategy overseen by physiotherapists.
▪️ The management process generally involves screening and medical triage, followed by primary management, and, if necessary, secondary management or adjunct options.
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🎯 1. Management Philosophy and Goals
▪️ The overall management approach has shifted from a reductionist biomedical perspective toward a biopsychosocial view.
▪️ The primary goal is to empower the patient by fostering an understanding of their unique biopsychosocial contributors and building confidence for self-management through load modification and exercise.
▪️ Successful treatment relies on an effective alliance between the healthcare professional and the patient, facilitating shared decision-making regarding goals and treatment.
▪️ It is important to manage expectations, as while exercise interventions result in an average clinically meaningful improvement of 20 points in composite pain and disability over 12 weeks, further improvements may take up to 52 weeks.
▪️ Mild symptoms may persist for 60% of people at 5 years.
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💬 2. Education and Advice (Including Activity Modification)
▪️ Education (imparting knowledge) and advice (counseling on action) are critical for successful self-management.
📘 Key Educational Strategies
▪️ Addressing Beliefs and Fears: Clinicians should explore and address beliefs that pain signals tendon damage and fears of rupture. Education should communicate that the risk of rupture is minimal.
▪️ Normalizing Pain: Education should utilize pain science to explain that the pain experienced during exercise is generally safe and acceptable.
▪️ Managing Expectations: Patients should understand that recovery often takes 6 to 12 months.
▪️ Encouraging Continued Activity: Clinical guidelines recommend continued activity within acceptable pain limits rather than forced rest.
▪️ Low certainty evidence suggests that exercise with continued sport activity (if pain is acceptable) is preferable to forced cessation of sport activity.
🏃 Activity Modification
▪️ Activity modification is considered the most effective strategy for managing pain and is critical for success.
▪️ Initial Reduction: If load tolerance is severely compromised, it is often necessary to remove provocative, high-intensity stretch-shorten cycle activities (e.g., faster running or hills) and reduce volume by approximately 50% for 2 to 6 weeks.
▪️ Severe Cases: For patients with very high pain, ceasing provocative activity (100% reduction), possibly including wearing a boot if walking is provocative, may be necessary in the short term.
▪️ Monitoring: Patients with "activity avoidance" coping strategies benefit from gradual exposure and strategies to monitor pain and activity.
▪️ Objective data, such as running time, pace, or step count, should guide the gradual introduction of running or walking loads.
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🏋️ 3. Exercise Management: Graded Exposure
▪️ Exercise for AT is conceptualized as graded exposure, meaning the progression is based on both the perceived threat/apprehension (for those with kinesiophobia) and the patient's reported level of pain.
▪️ An acceptable pain intensity is generally rated up to 5 out of 10 on a Numerical Rating Scale.
▪️ Recommended exercise programs include the Modified Alfredson, Silbernagel, and Heavy Slow Resistance (HSR) programs.
▪️ These are performed between three times per week and daily, depending on the program.
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🔄 Phases of Graded Exposure
▪️ Phase 1 – Isometric Exercise
Start here if isotonic load is unacceptably painful.
Generally, a tolerable point in range can be found.
The exercise position is not critical unless the goal is range-specific strength gains.
▪️ Phase 2 – Isotonic Exercise (Strength)
Commence as soon as isotonic exercise is acceptable.
Generally performed slowly (e.g., 2–3 seconds for each phase, using a metronome) through the full range of motion to build confidence.
Progression involves increasing load (e.g., as done in HSR, progressing from 15 Repetition Maximum (RM) to 6RM over 12 weeks).
Inclusion of straight-knee and bent-knee options is advised to adequately focus on the gastrocnemius and the soleus, respectively.
▪️ Phase 3 – Stretch-Shorten Cycle (Power)
Acceptable pain during activities and adequate calf strength.
Involves the graded introduction of walking, running, plyometrics (landing, jumping, hopping), high-speed running, and sport-specific activities.
This phase carries a higher risk of pain flare-up and requires careful monitoring.
Adequate maximal strength, such as achieving or approaching 1.5 times body weight 6RM in seated calf raise (or 0.5 times body weight in standing), is desirable for recreational runners prior to commencing running and maximal plyometric progressions.
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💪 Addressing Specific Capacity Impairments
▪️ Despite improvements in pain, some patients retain persisting calf strength and power impairments.
▪️ Strength: Maximal strength is more impaired (16% to 44%) than endurance (8%) in patients with AT.
▪️ In the isotonic phase, maximal strength can be targeted by progression to higher intensity exercise (e.g., HSR).
▪️ Power: Power impairments are common. Reactive strength capabilities should be developed in the stretch-shorten cycle phase through progressive plyometrics (landing, jumping, and hopping).
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🧩 4. Adjunct Interventions
▪️ While not all adjuncts are evidence-based, some may be considered, particularly for pain management or if exercise is not tolerated.
⚙️ For Midportion Achilles Tendinopathy
▪️ Radial ESWT added to exercise: May improve pain/disability, pain, and global change at various time points, even compared to placebo.
▪️ Acupuncture vs. exercise: May be superior to exercise for pain/disability across time points.
▪️ Heel Wedges vs. exercise: May be beneficial over exercise for pain/disability, pain, and global change.
▪️ LLLT, Night Splint, Custom Orthotics, AirHeel brace, Needling, Pressure Massage added to exercise: Generally did not add benefit to exercise alone.
▪️ Accessible Adjuncts: Non-evidence-based options often helpful include ice/heat, rigid taping to reduce ankle range, heel wedges (0.8 to 1.2 cm), wearing shoes with a pitch of > 8 mm, and avoiding walking barefoot or with flat shoes.
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🦶 For Insertional Achilles Tendinopathy (IAT)
▪️ Exercise Modification: Management principles apply, but there is caution against increasing insertional tendon compression.
▪️ Traditional eccentric training (over a step into full dorsiflexion) may lead to poor outcomes.
▪️ Advice in the isotonic phase should be to limit ankle dorsiflexion if it is painful.
▪️ Graded introduction of dorsiflexion can be achieved using custom steps of increasing size (10 mm, 20 mm, 30 mm), progressing as tolerated.
▪️ Adjuncts:
- Adding instrumented manual therapy to exercise showed low certainty evidence for benefit in pain/disability at medium and longer terms.
- ESWT alone was found to be more effective than exercise, a finding that contrasts with midportion tendinopathy.
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🩺 5. Secondary Management
▪️ If there is a non-response to primary management (e.g., due to inadequate adherence or lack of effect), secondary management can be initiated.
▪️ This typically involves medical referral to a general practitioner or specialist care (such as a musculoskeletal or sports physician).
▪️ Specialist management may involve considering:
- Imaging
- Medication
- Injection
- GTN patches
- Surgery (in uncommon cases of continued impairments)
- A multidisciplinary team approach (e.g., dietetics for weight management or psychology for mood issues) based on biopsychosocial factors.
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⚠️Disclaimer: Sharing a study or a part of it is NOT an endorsement. Please read the original article and evaluate critically.⚠️
Link to Article 👇
