Overview
Achilles tendinopathy is a degenerative condition of the Achilles tendon causing pain,
stiffness, and localised swelling at the mid-portion (2–7 cm above the heel) or at
the insertional site on the calcaneus. It is the most common lower-limb tendinopathy
in runners but increasingly seen in sedentary individuals with metabolic risk
factors. Distinguishing mid-tendon from insertional tendinopathy is critical as
treatment approaches differ significantly.
Symptoms & Causes
Common Symptoms
- Morning stiffness and pain at the back of the heel or just above it
- Pain with the first steps after rest — improves with gentle activity
- Localised tendon thickening and tenderness (mid-portion: 2–7 cm above
heel; insertional: at heel bone)
- Pain with calf raises and jumping
- Visible swelling along the tendon or at insertion
- Crepitus on palpation of the tendon
- Painful arc sign (tender nodule moves with ankle plantarflexion in
mid-tendon type)
Common Causes
- Sudden increase in running mileage or training intensity
- Stiff-soled footwear or inadequate heel drop
- Tight gastrocnemius-soleus complex
- Diabetes, hypertension, obesity — metabolic tendinopathy
- Fluoroquinolone antibiotic use (ciprofloxacin, levofloxacin)
- Haglund's deformity — bony prominence causing insertional irritation
- Pronated foot biomechanics
Conservative & First-Line Treatment
- Eccentric calf strengthening programme (Alfredson protocol for mid-tendon;
modified for insertional)
- Heel lift inserts to reduce tendon load
- Activity load management
- NSAIDs (short-term for pain control)
- Extracorporeal Shockwave Therapy (ESWT) — strong evidence for mid-tendon type
How Vedant Pain Management Clinic Can Help
Our interventional pain specialists offer the following evidence-based procedures, all
performed with real-time ultrasound guidance for precision and safety:
- Ultrasound-guided PRP injection into the pathological zone of the Achilles
tendon — promotes collagen regeneration, avoids fat pad / tendon rupture risk of
corticosteroids
- Ultrasound-guided high-volume injection (HVI) — saline + adrenaline to strip
pathological neovascularity (advanced treatment for chronic cases)
- Ultrasound-guided dry needling / tenotomy of tendon lesions
- Diagnostic ultrasound to grade tendinopathy, measure tendon thickness, identify
partial tears, and assess neovascularity with Power Doppler
- Retrocalcaneal bursa injection for insertional type with co-existing bursitis
- IMPORTANT: Corticosteroid injections are avoided into the Achilles tendon due to
risk of rupture — PRP and HVI are the preferred options at Vedant Pain Clinic
Newer Diagnostic Concepts & Advances
The 'continuum model' of tendinopathy (reactive → dysrepair → degenerative) guides
treatment selection at Vedant Pain Clinic. Power Doppler ultrasound identifying
neovascularisation (abnormal blood vessel ingrowth) correlates with severity and
pain. High-Volume Injection (HVI) targeting this neovascularisation is now a
well-established interventional technique for chronic refractory Achilles
tendinopathy.
