Achilles Tendinopathy: Current Concepts in Diagnosis and Evidence-Based Treatment

Abstract

Background: Achilles tendinopathy is a common load-related disorder affecting both physically active and sedentary individuals. Contemporary concepts have shifted from an inflammation-centered model toward a multifactorial disorder characterized by altered tendon structure, impaired load tolerance, pain, and functional deficits.

Objective: This mini-review summarizes current concepts regarding diagnosis and conservative management of midportion and insertional Achilles tendinopathy, with particular emphasis on progressive tendon loading, extracorporeal shockwave therapy (ESWT), and platelet-rich plasma (PRP).

Methods: Current clinical practice guidelines, systematic reviews, meta-analyses, and pivotal randomized controlled trials addressing diagnosis and treatment of Achilles tendinopathy were considered, with emphasis on contemporary evidence and clinically relevant outcomes.

Results: Diagnosis remains primarily clinical, while ultrasonography and magnetic resonance imaging should be reserved for diagnostic uncertainty, atypical presentations, suspected partial rupture, or refractory symptoms. Progressive tendon loading constitutes the cornerstone of treatment. Eccentric exercise is effective but has not demonstrated clear superiority over other appropriately dosed resistance-loading strategies, including heavy slow resistance training. ESWT may provide additional benefit in selected patients with persistent midportion tendinopathy, although evidence for insertional disease is less consistent. Despite a plausible biological rationale, high-quality randomized trials have failed to demonstrate a clinically relevant benefit of PRP over placebo or sham treatment in chronic midportion Achilles tendinopathy.

Conclusions: Management should focus on individualized load modification followed by progressive restoration of tendon capacity. Adjunctive interventions should not replace active rehabilitation. ESWT may be considered in refractory cases, whereas routine PRP injection cannot currently be recommended. Surgery should be reserved for persistent, functionally limiting symptoms after an adequately performed and sufficiently prolonged conservative treatment program.