Achilles Tendinitis vs. For specialized treatment, see our Achilles tendon treatment at Balance Foot & Ankle. Achilles Tendinopathy: Getting the Terminology Right

The term “Achilles tendinitis” implies active inflammation (“-itis” = inflammation), but research over the past two decades has demonstrated that most cases of Achilles pain—especially chronic cases—involve degenerative changes without significant inflammation. The more accurate term for these cases is “Achilles tendinopathy.” Understanding this distinction matters for treatment, because anti-inflammatory treatments (NSAIDs, cortisone) work well for acute tendinitis but are less effective—and potentially counterproductive—for chronic degenerative tendinopathy.

Acute Achilles tendinitis (inflammation from a sudden increase in activity, direct trauma, or fluoroquinolone antibiotic exposure) responds well to rest and anti-inflammatories. Chronic Achilles tendinopathy (pain persisting more than 6–12 weeks, with degenerative changes on imaging) requires a rehabilitation approach that stimulates tissue remodeling rather than just reducing inflammation.

Mid-Portion vs. Insertional Achilles Tendinopathy

Location matters for Achilles treatment. Mid-portion tendinopathy occurs 2–6 cm above the calcaneal insertion and is the most common form. Insertional tendinopathy occurs at the bone-tendon junction on the back of the heel and is associated with a Haglund’s deformity (bony prominence on the posterior heel) and retrocalcaneal bursitis in many patients.

The distinction matters because the eccentric exercise protocol—the most evidence-based treatment for mid-portion disease—is modified for insertional disease to avoid the end-range dorsiflexion that irritates the insertional site. Treatment protocols, prognosis, and sometimes surgical approaches differ between the two locations.

Evidence-Based Conservative Treatment

1. Eccentric Calf Exercises (Alfredson Protocol)

The Alfredson eccentric exercise protocol is the most evidence-supported treatment for mid-portion Achilles tendinopathy. Published in the American Journal of Sports Medicine in 1998, the original study showed 100% return to running in 15 patients with chronic mid-portion Achilles tendinopathy who had failed all other conservative treatments. Subsequent meta-analyses confirm eccentric exercise produces significantly better outcomes than concentric exercise alone.

Protocol: Standing on the edge of a step with just the forefoot. Rise onto both toes, then lower slowly on the affected foot alone over 3–5 seconds. Perform 3 sets of 15 repetitions, twice daily, 7 days a week, for 12 weeks. Both knee-straight (gastrocnemius focus) and knee-bent (soleus focus) variations are performed. The exercise is performed through pain—continuing despite tendon discomfort is part of the protocol and safe when done correctly. Stop if pain exceeds 5/10.

For insertional Achilles tendinopathy, the heel should not drop below neutral (flat) because this increases compression on the insertion. Modified eccentric exercises on a flat surface are used instead.

2. Load Management and Activity Modification

Complete rest worsens tendinopathy by allowing further degeneration and reducing the mechanical stimulus that drives collagen synthesis. Activity modification—not rest—is appropriate. Reduce high-impact activities (running, jumping) that acutely aggravate symptoms, but maintain eccentric loading and low-impact cross-training (cycling, swimming). A tendon that never receives load will not heal; a tendon that receives too much load will not have time to adapt. Finding the right load level is the therapeutic target.

3. Heel Lifts

A 10–12mm heel lift in both shoes reduces the stretch on the Achilles during gait, decreasing tensile load at the insertion. Heel lifts provide quick symptomatic relief (often within days) and are an excellent adjunct to eccentric exercise. They must be worn in both shoes to prevent leg-length discrepancy. Heel lifts are particularly helpful for insertional Achilles tendinopathy where dorsiflexion is the provocative movement.

4. Night Splints

For patients with significant morning pain and stiffness—who feel their Achilles is tight and painful with the first steps after rest—a night splint holding the foot at neutral or slight dorsiflexion prevents the Achilles from shortening overnight. This reduces the morning “starting pain” that commonly characterizes Achilles tendinopathy. Night splints improve compliance with the eccentric exercise protocol by making the morning exercises less painful to initiate.

5. Custom Orthotics

Overpronation increases Achilles tendon stress by rotating the calcaneus, placing the tendon under abnormal tension during stance. Custom orthotics with medial arch support and heel posting reduce this rotational stress. They’re most valuable in patients with documented overpronation contributing to symptoms. For insertional disease with a prominent Haglund’s deformity, orthotics with a heel cup that offloads the bony prominence are particularly helpful.

When Conservative Treatment Isn’t Enough

EPAT Shockwave Therapy

Extracorporeal Pulse Activation Technology (EPAT) is one of the most effective interventions for chronic Achilles tendinopathy that has failed eccentric exercise. A 2012 Cochrane review found ESWT superior to eccentric exercise alone for insertional Achilles tendinopathy at 12-month follow-up. The combination of ESWT plus eccentric exercise outperforms either treatment alone. EPAT stimulates fibroblast proliferation and collagen synthesis, restarting the healing process in chronically degenerated tendon tissue. A course of 3–5 treatments provides significant improvement in 70–80% of patients.

PRP Injection

Platelet-rich plasma injection delivers concentrated growth factors directly into the degenerated tendon tissue. Evidence for PRP in Achilles tendinopathy is generally positive, particularly when combined with an eccentric exercise program. PRP works best as an adjunct to rehabilitation—the growth factors stimulate biological repair while eccentric exercise provides the mechanical load needed to organize new collagen into functional architecture. PRP is a reasonable next step for patients who’ve completed 12 weeks of eccentric exercise with inadequate improvement.

Surgery

Surgery for Achilles tendinopathy is a last resort after exhausting conservative options (typically 6–12 months). Procedures include debridement of degenerative tendon tissue (tenoscopy or open), Haglund’s resection for insertional disease with bony impingement, and FHL tendon transfer augmentation for severe tendinopathy with significant tendon thinning. Surgical outcomes for Achilles tendinopathy are generally good but recovery is prolonged—6–12 months for full athletic return.

Frequently Asked Questions

Medical References & Sources

• American Orthopaedic Foot & Ankle Society — Achilles Tendinopathy
• PubMed Research — Eccentric Exercise Achilles Tendinopathy
• PubMed Research — Shockwave and PRP for Achilles

Dr. Tom Biernacki, DPM is a board-certified podiatric surgeon at Balance Foot & Ankle in Howell and Bloomfield Hills, Michigan. He treats Achilles tendinopathy with rehabilitation protocols, custom orthotics, EPAT shockwave therapy, PRP injection, and surgery when indicated.

Dr. Tom Biernacki, DPM

Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.