Achilles Tendinopathy - Part III |
"Truth is ever to be found in simplicity, and not in the multiplicity and confusion of things."
~Isaac Newton
Today marks 10 years since my beloved Grandma Riederer passed away. While she was never one to overindulge (only one of those beers belonged to her), she used to say, "Certainly my doctors don't think I shouldn't enjoy myself every now and again!" Every year when February 2nd comes along, I'm reminded of how it really does feel like Groundhog Day. I sure do love and miss you, granny💖 Hope you're living the High Life!
A few years ago, in a two-part newsletter (Part I/Part I), I pulled back the curtain on my long, humbling detour with Achilles tendinopathy—and how my naivety about the depth of this injury quietly ballooned into the most difficult hurdle I’ve faced as a runner. If there’s one lesson my Achilles taught me, it’s that good intentions don’t guarantee good outcomes. For years, I turned a blind eye and a deaf ear to the signals my body had been sending for over a decade, until one day, the music stopped, and the party was over.
This month, I want to zoom out and connect those personal lessons to what the research actually supports when it comes to what we know about Achilles tendinopathy, which treatments are supported by current clinical guidelines, common risk factors, and to dispel some common myths still propped up by both athletes and, surprisingly, clinicians.
Current Procedural Guidelines: What the evidence actually supports (and what’s still murky)
Education + Progressive loading = the foundation of Achilles rehab
I could probably stop here and not do the literature a disservice. That said, there’s plenty more to unpack in the most up-to-date clinical guidelines, and it’s worth peeling back a few more layers of the onion.
First and foremost, education is critical. Athletes need education not only to successfully navigate their way through rehab, but also to help them make good choices when they’re fully back to sport. Having a firm understanding of the etiology of your injury and what will actually help you get past it, reduces anxiety and mitigates catastrophizing. Education around load management, realistic injury prognosis, and how to form clear expectations about pain is worth its weight in gold. In my opinion, the most meaningful takeaway from any patient/athlete encounter with me is education.
The second half of the equation, progressive loading, is almost universally accepted as a front-line treatment to improve function and decrease pain in those with Achilles tendinopathy. While there’s ongoing debate around contraction type, exercise frequency, and the nuances of what constitutes “adequate” loading, if athletes aren’t engaging in structured strengthening of the calf muscle complex, they’re missing the boat. Loading is critical to drive tendon adaptation, strength development, and to prepare athletes for high loads during activity.
Treatments with mixed, limited, or uncertain evidence:
Stretching: This can be useful early in rehab when ankle dorsiflexion is limited. However, for athletes with insertional Achilles tendinopathy, stretching may reproduce or exacerbate symptoms.
Manual Therapy: Mobilizing joints, muscles, and/or connective tissues. Again, for the athlete with range of motion deficits, this may be helpful. That said, the literature would suggest there are better uses of one's time.
Dry Needling: This may be useful for managing calf-related pain and stiffness, but evidence for tendon-specific benefit is limited and of low quality. Directly needling the tendon itself has NOT been shown to improve tendon structure.
Orthotics: These may reduce symptoms in the short term, but the evidence is mixed. As a result, they’re difficult to recommend as a standalone treatment.
Injections: Whether we’re talking about corticosteroid, PRP, prolotherapy, stem cell, hyaluronic acid, or other injections, the preponderance of evidence supporting injection-based therapies for Achilles tendinopathy is poor.
Risk factors
For athletes, understanding what may put them in harm's way is an important concept to understand. When we dig through the literature, what we find helps reframe Achilles tendinopathy as a load–capacity issue rather than a purely structural one. This helps to empower people instead of seeing themselves as “broken.”
- Previous Achilles pain or injury
- Rapid spike in training (intensity, hill running, volume)
- Reduced calf muscle strength
- Sudden change in footwear (more minimalist) and/or running surface (pavement to trails)
Unlikely risk factors
- Foot pronation - “bad mechanics” are not strong predictors of pain
- Flat feet
- Age - increased age can impact tolerance to high loads, but not a stand-alone cause
- BMI - in active populations, limited correlation exists
- Compression socks - I was more than surprised to read a research paper suggesting that socks subjected runners to a greater risk of Achilles tendinopathy
Facts vs Myths
Myth: Soft surfaces are better for a runner with acute Achilles pain.
Fact: Firm and consistent surfaces are preferred
Myth: If I just rest, this will get better.
Fact: Complete rest reduces tendon capacity further. Symptoms may settle in the short-term, but you’ve done nothing to address the root cause.
Myth: Pain means I’m doing (more) damage.
Fact: Tendons often improve before pain fully resolves. Some pain is expected and can be safe. Pain that settles within 24 hours after activity is likely okay.
Myth: If this doesn’t resolve in a few weeks, I don’t think rehab is the answer.
Fact: Tendon rehab is often slow. Depending on the chronicity of your situation, it can take upwards of 12-18 months. Quitting the rehabilitative process early is one of the most common reasons athletes don’t improve.
Easy adjuncts
- Heel lifts: Wearing 10–20 mm lifts in daily shoes can help athletes in the early stages of rehab, particularly when tendon irritability is high
- High-drop shoes: Shoes with an 8 mm or higher heel-to-toe drop are generally recommended. This is one scenario where it's advantageous to avoid minimalist footwear.
- Limit treadmill running: Running on a treadmill can increase forces on the Achilles tendon by 10–15% compared with overground running.
Keep moving forward!
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