20/11/2025
Midportion vs. Insertional
Pathology Overview
Malliaras’ work builds on the tendon continuum model, emphasizing that Achilles tendinopathy is not an inflammatory condition but a load-related dysfunction with changes in tendon structure, pain sensitivity, and reduced load tolerance.
Midportion Tendinopathy
Occurs 2–6 cm above the calcaneal insertion.
Characterized by collagen disorganization, matrix degeneration, and neovascularisation.
Pain mainly under tensile load (running, hopping).
Insertional Tendinopathy
Located at the tendon–bone junction, often with bursitis.
Combines degenerative changes with compression of the tendon against the calcaneus.
Pain increases in end-range dorsiflexion.
Therapy & Training (key points from Malliaras)
1. Load Management
Reduce provocative loads temporarily, but avoid rest.
Malliaras: “Load is medicine” – correct dosing is the basis of recovery.
2. Midportion Tendinopathy Training
Heavy Slow Resistance (HSR)
Strong evidence: 3–4 sets × 6–8 reps, slow tempo.
Improves pain, function, and tendon adaptation.
Eccentric Training (Alfredson)
Effective, but HSR is equally or more effective and often better tolerated.
Later Phase: Plyometrics
Hops, jumps, running drills to restore tendon stiffness for sport.
3. Insertional Tendinopathy Training
Avoid Compression
No heel drops over the edge or deep dorsiflexion early on.
Progressive Strength in Neutral Position
Begin with calf raises with the foot neutral; progress slowly.
Isometrics for Pain Relief
30–45 sec holds × 5 reps can reduce pain and allow training progression.
4. Additional Considerations
Patient education, load planning, biomechanics, and footwear adjustments.
Shockwave or injections only as adjuncts when exercise alone is insufficient.
