45 Achilles Tendinopathy

Achilles Tendinopathy

Tendinopathy is the preferred term for persistent tendon pain and loss of function related to mechanical loading. Achilles tendinopathy is the preferred term for persistent Achilles tendon pain and loss of function related to mechanical loading, this injury is commonly categorized into two types:

  • Insertional (affects 20–25%)
  • Non-insertional (affects 75–80%)


The presentation of pain in a tendon, does not always mean that the tendon is the primary contributor to pain. The multifactorial model of tendinopathy suggests that an impaired motor system, local tendon pathology, and changes in the pain/nociceptive system contributes to the complex clinical picture of tendon pain (Eckenrode et al., 2019).


A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient Specific Functional Scale
  • Brief Pain Inventory (BPI)
  • Visual Analog Scale (VAS)
  • Lower Extremity Functional Scale (LEFS)
  • Foot and Ankle Ability Measure
  • Foot and Ankle Disability Index

Physical Examination

Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.

  • Thompson’s Test
  • Tinel’s Sign
  • Royal London Hospital Test
  • Arc Test



Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. There may be times that focal irritability (i.e., nerve irritation, trigger points, nervous system sensitization) co-exists with Achilles tendinopathy. Structures to keep in mind while assessing and treating patients suffering from Achilles tendon pain may include neurovascular structures and investing fascia of:

  • Plantar Fascia
  • Lumbricals
  • Adductor Hallucis
  • Flexor Hallucis Brevis
  • Metatarsals & Interossei
  • Peroneals (peroneus longus, peroneus brevis)
  • Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)
  • Anterior Compartment of the Leg (tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius)
  • Superficial Posterior Compartment of the Leg (gastrocnemius, soleus, plantaris)
  • Deep Posterior Compartment of the Leg (flexor hallucis longus, flexor digitorum longus, tibialis posterior, popliteus)
  • Ankle Joint (the talocrural joint, subtalar joint and the inferior tibiofibular joint)

Self-Management Strategies

Massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for patients with Achilles pain including manual therapy, simple home-care recommendations and remedial exercise, such as slow eccentric heel-drops. Remedial loading programs such as eccentric heel drops do-as-tolerated repetition and specific Alfredson Achilles tendinopathy rehabilitation protocol have both been shown to be useful for Achilles tendon pain (Head et al., 2019).


Multimodality options self-care techniques such as exercise therapy, relative rest, activity modifications should be considered as the first line treatment of tendon pain (van der Vlist et al., 2020). Clinicians should be thoughtful and skilled in managing the load on the tendons and supporting structures through several rehabilitation considerations including, but are not limited to manual therapy, education on psychosocial factors such as fear avoidance, and remedial loading programs.

Manual joint mobilization and soft tissue techniques for the calf muscles may modify a contributing factor in the experience of pain. In cases that involve nerve entrapment, a massage therapist may use a specialized technique called neural mobilization. The goal of neural mobilization is to free the entrapped nerve by mobilization of the nerve itself or muscles that surround the nerve. There research to support the use of neural mobilization. A 2017 meta-analysis published in the Journal of Orthopaedic & Sports Physical Therapy showed that nerve mobilizations are an effective treatment approach for patients with back, neck and foot pain (Basson et al., 2017).

PhysioTutors: Alfredson Achilles Tendinopathy Rehab Protocol

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for Achilles tendon pain based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

Albin, S. R., Koppenhaver, S. L., Bailey, B., Blommel, H., Fenter, B., Lowrimore, C., … McPoil, T. G. (2019). The effect of manual therapy on gastrocnemius muscle stiffness in healthy individuals. Foot (Edinburgh, Scotland), 38, 70–75. doi:10.1016/j.foot.2019.01.006

Basson, A., Olivier, B., Ellis, R., Coppieters, M., Stewart, A., & Mudzi, W. (2017). The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis. The Journal of orthopaedic and sports physical therapy, 47(9), 593–615. doi:10.2519/jospt.2017.7117

Challoumas, D., Clifford, C., Kirwan, P., & Millar, N. L. (2019). How does surgery compare to sham surgery or physiotherapy as a treatment for tendinopathy? A systematic review of randomised trials. BMJ open sport & exercise medicine, 5(1), e000528. doi:10.1136/bmjsem-2019-000528

Chimenti, R. L., Cychosz, C. C., Hall, M. M., & Phisitkul, P. (2017). Current Concepts Review Update: Insertional Achilles Tendinopathy. Foot & ankle international, 38(10), 1160–1169. doi:10.1177/1071100717723127

Cook, J. L. (2018). Ten treatments to avoid in patients with lower limb tendon pain. British journal of sports medicine, 52(14), 882. doi:10.1136/bjsports-2018-099045

Coppieters, M. W., Crooke, J. L., Lawrenson, P. R., Khoo, S. J., Skulstad, T., & Bet-Or, Y. (2015). A modified straight leg raise test to differentiate between sural nerve pathology and Achilles tendinopathy. A cross-sectional cadaver study. Manual therapy, 20(4), 587–591. doi:10.1016/j.math.2015.01.013

Dilger, C. P., & Chimenti, R. L. (2019). Nonsurgical Treatment Options for Insertional Achilles Tendinopathy. Foot and ankle clinics, 24(3), 505–513. doi:10.1016/j.fcl.2019.04.004

Docking, S. I., & Cook, J. (2019). How do tendons adapt? Going beyond tissue responses to understand positive adaptation and pathology development: A narrative review. Journal of musculoskeletal & neuronal interactions, 19(3), 300–310.

Eckenrode, B. J., Kietrys, D. M., & Stackhouse, S. K. (2019). Pain Sensitivity in Chronic Achilles Tendinopathy. International journal of sports physical therapy, 14(6), 945–956.

Head, J., Mallows, A., Debenham, J., Travers, M. J., & Allen, L. (2019). The efficacy of loading programmes for improving patient-reported outcomes in chronic midportion Achilles tendinopathy: A systematic review. Musculoskeletal care, 17(4), 283–299. https://doi.org/10.1002/msc.1428

Jayaseelan, D. J., Weber, M. J., & Jonely, H. (2019). Potential Nervous System Sensitization in Patients With Persistent Lower Extremity Tendinopathies: 3 Case Reports. The Journal of orthopaedic and sports physical therapy, 49(4), 272–279. doi:10.2519/jospt.2019.8600

Magnusson, S. P., & Kjaer, M. (2019). The impact of loading, unloading, ageing and injury on the human tendon. The Journal of physiology, 597(5), 1283–1298. doi:10.1113/JP275450

Martin, R. L., Chimenti, R., Cuddeford, T., Houck, J., Matheson, J. W., McDonough, C. M., … Carcia, C. R. (2018). Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. The Journal of orthopaedic and sports physical therapy, 48(5), A1–A38. doi:10.2519/jospt.2018.0302

Reiman, M., Burgi, C., Strube, E., Prue, K., Ray, K., Elliott, A., & Goode, A. (2014). The utility of clinical measures for the diagnosis of achilles tendon injuries: a systematic review with meta-analysis. Journal of athletic training, 49(6), 820–829. doi:10.4085/1062-6050-49.3.36

Scott, A., Squier, K., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., … Zwerver, J. (2020). ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology. British journal of sports medicine, 54(5), 260–262. https://doi.org/10.1136/bjsports-2019-100885

Silbernagel, K. G., Hanlon, S., & Sprague, A. (2020). Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. Journal of athletic training, 55(5), 438–447. https://doi.org/10.4085/1062-6050-356-19

Stefansson, S. H., Brandsson, S., Langberg, H., & Arnason, A. (2019). Using Pressure Massage for Achilles Tendinopathy: A Single-Blind, Randomized Controlled Trial Comparing a Novel Treatment Versus an Eccentric Exercise Protocol. Orthopaedic journal of sports medicine, 7(3), 2325967119834284. doi:10.1177/2325967119834284

van der Vlist, A. C., Breda, S. J., Oei, E., Verhaar, J., & de Vos, R. J. (2019). Clinical risk factors for Achilles tendinopathy: a systematic review. British journal of sports medicine, 53(21), 1352–1361. doi:10.1136/bjsports-2018-099991

van der Vlist, A. C., Winters, M., Weir, A., Ardern, C. L., Welton, N. J., Caldwell, D. M., Verhaar, J., & de Vos, R. J. (2020). Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials. British journal of sports medicine, bjsports-2019-101872. Advance online publication. https://doi.org/10.1136/bjsports-2019-101872


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Evidence-Based Massage Therapy by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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