Nonoperative Management of Achilles Tendinopathy

  • Justin Paoloni
  • George A.C. Murrell


The soleus and gastrocnemius muscles combine in the calf to form the Achilles tendon, which inserts onto the posterior process of the calcaneus. The Achilles musculotendinous unit is the primary ankle plantar flexor. The Achilles tendon is the largest and strongest tendon in the body, and is able to accept weight-bearing forces of ten times body weight.1

The Achilles tendon has a spiral configuration, internally rotating prior to inserting inferiorly onto the posterior calcaneus. The retrocalcaneal bursa lies anterior to the Achilles tendon, is located between the tendon and the calcaneus immediately proximal to its insertion, and provides lubrication for the tendon passing over the bone. The retro-Achilles bursa is posterior to the Achilles tendon at its insertion and functions to lubricate motion between the Achilles tendon and the overlying skin. In insertional Achilles tendinopathy, both the retrocalcaneal bursa and calcaneal tuberosity, and also the retro-Achilles bursa,...


Achilles Tendon Eccentric Exercise Tendon Healing Achilles Tendinopathy Ankle Plantar Flexor 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Clain M, Baxter D.E. 1992 Achilles tendinitis.Foot Ankle Int ;13: (8)482–7.Google Scholar
  2. Merkel K, Hess H, Kunz M. 1982; Insertional tendinopathy in athletes: a light microscope, histochemical and electron microscope examination. Pathol Res Pract 173:303–9.PubMedGoogle Scholar
  3. Clement D, Taunton JE, Smart GW. 1981; A survey of overuse running injuries. Physician Sports Med 9:(5)47–58.Google Scholar
  4. Brukner P, Khan K. 2005.Clinical Sports Medicine, 3rd ed. Blackwell Scientific, Sydney:Google Scholar
  5. Krissoff W, Ferris WD. 1979; Runner's injuries. Physician Sports Med 7:(12)55–64.Google Scholar
  6. Burdett R. 1982; Forces predicted at the ankle during running. Med Sci Sports 14:308–16.Google Scholar
  7. Scott S, Winter DA. 1990; Internal forces at chronic running injury sites. Med Sci Sports Exerc 22:(3)357–69.PubMedGoogle Scholar
  8. Khan K, Cook JL, Bonar F,. et al. 1999; Histopathology of common tendinopathies. Sports Med 27:(6)393–408.PubMedCrossRefGoogle Scholar
  9. Astrom M, Rausing A. 1995; Chronic Achilles tendinopathy: a survey of surgical and histopathological findings. Clin Orthop 316:151–64.PubMedGoogle Scholar
  10. Alfredson,R. Lorentzon,H. 2000; Chronic Achilles tendinosis. Recommendations for treatment and prevention. Sports Med 29:(2)135–46.PubMedCrossRefGoogle Scholar
  11. Renstrom AFH. 1994:An introduction to chronic overuse injuries. In: Harris M, Williams C, Stanish.,WD eds., et al. Oxford Textbook of Sports Medicine. Oxford University Press, New York: 531–45.Google Scholar
  12. Kvist M, Jozsa L, Jarvinen M. 1987; Chronic Achilles paratenonitis in athletes: a histological and histochemical study. Pathology 19:1–11.PubMedCrossRefGoogle Scholar
  13. Arnoczky S, Tian T, Lavagnino M,. et al. 2002; Activation of stress-activated protein kinases (SAPK) in tendon cells following cyclic strain: the effects of strain frequency, strain magnitude, and cytosolic calcium. J Orthop Res 20:947–52.PubMedCrossRefGoogle Scholar
  14. Puddu G, Ippolito E, Postacchini F. 1976; A classification of Achilles tendon disease. Am J Sports Med 4:145–50.PubMedCrossRefGoogle Scholar
  15. Murrell G, Jang D, Deng XH,. et al. 1998; Effects of exercise on Achilles tendon healing in a rat model. Foot Ankle Int 19:(9)598–603.PubMedGoogle Scholar
  16. Vailas A, Tipton CM, Laughlin HL,. et al. 1978; Physical activity and hypophysectomy on the aerobic capacity of ligaments and tendons. J Appl Physiol 44:(4)542–6.PubMedGoogle Scholar
  17. Lagergen C. 1958; Vascular distribution in Achilles tendon—an angiographic and microangiographic study. Acta Chir Scand 116:491–5.Google Scholar
  18. Harris CA, Peduto AJ. 2006; Achilles tendon imaging. Aust Radiol 50:(6)513–25.CrossRefGoogle Scholar
  19. Cook JL, Khan KM, Purdam C. 2002; Achilles tendinopathy. Manual Ther 7:(3)121–30.CrossRefGoogle Scholar
  20. Kainberger F, Mittermaier F, Seidl G,. et al. 1997; Imaging of tendons-adaptation, degeneration, rupture. Eur J Radiol 25:(3)209–22.PubMedCrossRefGoogle Scholar
  21. Werd MB. 2007; Achilles tendon sports injuries: a review of classification and treatment. J Am Podiatr Med Assoc 97:(1)37–48.PubMedGoogle Scholar
  22. McLauchlan GJ, Handoll HH. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Data System Rev 2001;2.Google Scholar
  23. DeGara C, Taylor M, Hedges A. 1982; Assessment of analgesic drugs in soft tissue injuries presenting to an accident and emergency department—a comparison of antrafenine, paracetamol, and placebo. Postgrad Med J 58:489–92.CrossRefGoogle Scholar
  24. Paoloni JA, Orchard J. 2005; The use of therapeutic medications in soft tissue injuries. Med J Aust 183:(7)384–8.PubMedGoogle Scholar
  25. McLauchlan G, Handoll HHG. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Data System Rev 2004;4.Google Scholar
  26. Astrom M, Westlin N. 1992; No effect of piroxicam on Achilles tendinopathy. A randomized study of 70 patients. Acta Orthop Scand 63:(6)631–4.PubMedGoogle Scholar
  27. Auclair J, Georges M, Grapton X,. et al. 1989; A double-blind controlled multicenter study of percutaneous niflumic acid gel and placebo in the treatment of Achilles heel tendinitis. Curr Ther Res Clin Exp 46:(4)782–8.Google Scholar
  28. Akizuki KH, Gartman EJ, Nisonson B,. et al. 2001; The relative stress on the Achilles tendon during ambulation in an ankle immobiliser: implications for rehabilitation after Achilles tendon repair. Br J Sports Med 35:(5)329–33.PubMedCrossRefGoogle Scholar
  29. Wilson JJ, Best TM. 2005; Common overuse tendon problems: a review and recommendations for treatment. Am Fam Phys 72:(5)811–8.Google Scholar
  30. Wallace RG, Traynor IE, Kernohan WG,. et al. 2004; Combined conservative and orthotic management of acute ruptures of the Achilles tendon. J Bone Joint Surg [Am] 86–A:(6)1198–202.Google Scholar
  31. Mazzone MF, McCue T. 2002; Common conditions of the Achilles tendon. Am Fam Phys 65:(9)1805–10.Google Scholar
  32. Sobel E, Levitz SJ, Caselli MA. 1999; Orthoses in the treatment of rear foot problems. J Am Podiatr Med Assoc 89:(5)220–33.PubMedGoogle Scholar
  33. Iwuagwu F, McGrouther DA. 1998; Early cellular response in tendon injury: the effect of loading. Plast Recon Surg 102:(6)2064–71.CrossRefGoogle Scholar
  34. Kvist M, Jarvinen M. 1982; Clinical, histochemical and biomechanical features in repair of muscle and tendon injuries. Int J Sports Med 3:12–14.PubMedCrossRefGoogle Scholar
  35. Alfredson H, Pietila T, Jonsson P,. et al. 1998; Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 26:(3)360–6.PubMedGoogle Scholar
  36. Niesen-Vertommen S, Taunton JE, Clement DB. 1992; The effect of eccentric versus concentric exercise in the management of Achilles tendonitis. Clin J Sports Med 2:109–13.CrossRefGoogle Scholar
  37. Fahlstrom M, Jonsson P, Lorentzon R,. et al. 2003; Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arth 11:(5)327–33.CrossRefGoogle Scholar
  38. Krishna Sayana M, Maffulli N. 2005; Insertional Achilles tendinopathy. Foot Ankle Clin 10:(2)309–20.PubMedCrossRefGoogle Scholar
  39. DaCruz, DJ, Geeson, M, AllenMJ, et al. 1988; Achilles paratendonitis: an evaluation of steroid injection. Br J Sports Med 22:(2)64–5.PubMedCrossRefGoogle Scholar
  40. Kennedy J, Willis RB. 1976; The effects of local steroid injections on tendons: a biomechanical and microscopic correlative study. Am J Sports Med 4:11–21.PubMedCrossRefGoogle Scholar
  41. Hayes DW Jr, Gilbertson EK, Mandracchia VJ,. et al. 2000; Tendon pathology in the foot. The use of corticosteroid injection therapy. Clin Podiatr Med Surg 17:(4)723–35.PubMedGoogle Scholar
  42. Shrier I, Matheson GO, Kohl HW 1996;:Achilles tendonitis: are corticosteroid injections useful or harmful? Clin J Sport Med 6(4)245–50.3rd.CrossRefGoogle Scholar
  43. Speed CA. 2001; Fortnightly review: corticosteroid injections in tendon lesions. Br Med J 323:(7309)382–6.CrossRefGoogle Scholar
  44. Furia JP. 2006; High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles tendinopathy. Am J Sports Med 34:(5)733–40.PubMedCrossRefGoogle Scholar
  45. Rompe JD, Nafe B, Furia JP,. et al. 2007; Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med 35:(3)374–83.PubMedCrossRefGoogle Scholar
  46. Paoloni JA, Appleyard RC, Nelson J,et al. 2004; Topical glyceryl trinitrate application in the treatment of non-insertional Achilles tendinopathy: a randomized, double-blind, placebo controlled clinical trial. J Bone Joint Surg 86A–(5):916–22.Google Scholar
  47. Paoloni J and Murrell GAC. Three-year prospective comparison study of topical glyceryl trinitrate treatment in chronic noninsertional Achilles tendinopathy. Foot Ankle Int 2007;28:1064–8. .PubMedCrossRefGoogle Scholar
  48. Capasso G, Maffulli N, Testa V. 1993; Preliminary results with peritendinous protease inhibitor injections in the management of Achilles tendinitis. J Sports Traumatol Rel Res 15:37–40.Google Scholar
  49. Brown R, Orchard J, Kinchington M,. et al. 2006; Aprotinin in the management of Achilles tendinopathy: a randomised controlled trial. Br J Sports Med 40:(3)275–9.PubMedCrossRefGoogle Scholar
  50. Alfredson H, Ohberg L. 2005; Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: a double-blind randomised controlled trial. Knee Surg Sports Traumatol Arth 13:(4)338–44.CrossRefGoogle Scholar
  51. Alfredson H, Lorentzon R. 2007; Sclerosing polidocanol injections of small vessels to treat the chronic painful tendon. Cardio Hematol Agents Med Chem 5:(2)97–100.CrossRefGoogle Scholar
  52. Lind B, Ohberg L, Alfredson H. 2006; Sclerosing polidocanol injections in mid-portion Achilles tendinosis: remaining good clinical results and decreased tendon thickness at 2–year follow-up. Knee Surg Sports Traumatol Arth 14:(12)1327–32.CrossRefGoogle Scholar
  53. Rabago D, Best TM, Beamsley M,. et al. 2005; A systematic review of prolotherapy for chronic musculoskeletal pain. Clin J Sport Med 15:(5)376–80.PubMedCrossRefGoogle Scholar
  54. Paavola M, Kannus P, Paakkala T,. et al. 2000; Long-term prognosis of patients with Achilles tendinopathy: an observational 8-year follow-up study. Am J Sports Med 28:(5)634–42.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Justin Paoloni
    • 1
  • George A.C. Murrell
  1. 1.Orthopaedic Research Institute, Research and Education CenterUniversity of New South WalesNew South WalesAustralia

Personalised recommendations