Mid-portion Achilles Tendinopathy

Where is Mid-portion Achilles Tendinopathy painful? (Body Chart)

Mid-portion Achilles Tendinopathy

What are the classical features of Mid-portion Achilles Tendinopathy?

65% of Achilles tendinopathy (AT) is mid-portion 

Age: Can be anyone, the younger population likely to have reactive presentations, older populations more like to be degenerative (reactive on degenerative)

Gender: No difference between genders

Sport: increased prevalence in sports with high tendon load including basketball, volleyball, netball, high jump, soccer, football

Where is Mid-portion Achilles Tendinopathy painful?

– Pain will always stay local, if diffuse consider a differential diagnosis

– 2-6cm above the calcaneus is the accepted region for pathology 

– If within 2cm or reports symptoms on the calcaneus consider insertional

Characteristics of symptoms for Mid-portion Achilles Tendinopathy

– Very localised

– Stiffness type pain

– Can be sharp whilst performing activity 

– Dull aching normal especially in the morning or after provocative activity

– Can have a warm-up effect //start symptomatic and improves throughout  

– Can have a latent effect // symptoms after activity 

– Typically intermittent and varying dependant on mechanical factors 

Typical activity capability/restriction for clients with Mid-portion Achilles Tendinopathy

– Progressive restriction with activities that require high spring loads of the lower limb

– Limitations in running, jumping, hopping, change of direction and acceleration are common 

– Inhibit or reduced performance in sport // especially if requiring explosive movements ie jumping in basketball 

– If mild then can maintain high function 

– Unlikely to impact activities of daily living 

– If serve will stop from running and can be painful with walking 

– Can respond well to activity modification like reducing speed and cadence

Behaviour of symptoms for Mid-portion Achilles Tendinopathy


– Running, jumping, hopping, stairs, stretching, sprinting, agility, cutting, landing 


– Heat, warm-up, heel lift, flat surface, reduced cadence, reduced speed

24-hour pattern:

– AM stiffness

– activity dependant the rest of the day 

Typical history of a client with Mid-portion Achilles Tendinopathy

– Best described as an overuse injury 

– Acute increase in loading common // look at training diary if available 

– Typical ‘tendon signs’ (morning stiffness, warm-up phenomenon, cool down effect)

– Onset with high energy-storing loads

– Can be insidious or acute 

– Check for history of tendon pathology locally and other areas of the body

– Common to have been carrying the symptoms for a long period of time // need through a history of loading 

Pathobiological mechanisms behind Mid-portion Achilles Tendinopathy

– Nociceptive with acute presentation (more commonly a reactive tendon)

– The more degenerative the presentation the increased likelihood of nociplastic pain influences

– Also be mindful of the presence of nociplastic symptoms if long term rehabilitation is indicated which is common in degenerative presentations

Proposed pathology underlying Mid-portion Achilles Tendinopathy

– Excessive tensile forces through the tendon // not as worried about compressive force, if present then consider insertional tendinopathy AT

– Thought to be an imbalance between the capacity of the tendon and the load that is being placed through it. An example of this is the Cook and Purdham paradigm

Reactive Tendinopathy 

– Sudden increase in relative tendon load 

– Leads to high levels of pain and functional decline

– Relative microtraumas to the tendon

– Not enough time for tendon synthesis to restore greater than the degeneration 

– Commonly younger individuals

Degenerative/disrepair Tendinopathy

– Sustained period of poor tendon

– Collagen matrix disruption 

– Has mechanical changes with reduced stiffness and strength

– Can be both symptomatic and asymptomatic

Reactive on degenerative is the most common 

Physical impairments & associated structure/tissue sources (ie P/E findings)


– Tenderness on palpation of the AT // 2-6 cm from the calcaneus 

– Thomas test to exclude rupture 

– Platerflexors wastage

– Thickened AT

– Local swelling

– Deduced dorsiflexion range of motion 

– Reduced plantar flexor strength 

– Stiffness at TCJ and STJ with passive accessory movements 


– Reduced dorsiflexion with gait 

– Compensations to avoid dorsiflexion ie circumduction 

– Reduced shock absorption capability 

– Reduced vertical jump

– Reduced maximal and 3 x maximal hop distance 


Validated questionnaires for monitoring mid-portion AT

– Visa-a 

– Sport pain and function (SPaF)

Typical contributing factors to Mid-portion Achilles Tendinopathy

– Genetics 

– Maladaptive biomechanics 

– Weight


– Reduced PF strength 

– Footwear

– Diabetes 

– Participation in high-risk activities 

– Steroid use 

– Asthma 

– Immunocompromised

Relevant precautions/ contraindications to P/E and treatment

– Severity and irritability

– Stage of tendon injury (reactive vs degenerative)

– Absolute rest is contraindicated

Relevant diagnostic imaging for Mid-portion Achilles Tendinopathy

– Ultrasound: is adequate to make the diagnosis (will give detail on size, collagen formation and integrity)  // more cost-effective 

– MRI: gold standard, will give superior detail when considering tendon health picture

Typical prognosis for Mid-portion Achilles Tendinopathy

– The earlier treatment is started the more positive the prognosis

– 10-86% return to sport in 12 weeks

– 55-90% return to sport in 52 weeks 

– Should progressively improve with rehabilitation 

– Needs to be guided individually to establish a return to sport criteria that are tailored to the patient’s demands

Management/treatment selection for Mid-portion Achilles Tendinopathy

within Relative load reduction (High-level evidence)

– Can be done in numerous ways (training, gametime, or adjustment of high peak force activities

– Attempt to optimise energy storage of tendon in this process

Isometric exercises (high-level evidence) 

– Evidence to suggest helpful with pain reduction and improves motor drive (5 x 45″ holds with 2 min in between @ 70% MVC)

Heavy eccentric calf loading (high-level evidence)

– improvement greater than natural history and/or conventional physiotherapy 

– lacks evidence to suggest that it is superior to other exercise interventions 

Strengthening (high-level evidence) 

– Place high emphasis on plantarflexion 

– Be progressive and control variables such as weight, reps and range 

– Isometrics to isotonic to plyometrics 

– Ensure overloading tendon to get sufficient synthesis however need an adequate rest period 

Energy storage

– Emphasis on later stage rehab

– Try to make it as sport-specific as possible

– Introduce gradually and ensure ample rest period

Pain and exercise

– Evidence shows exercising with low-level pain is not detrimental to tendon health.

– Implement a traffic light system when considering pain (0-3 green 3-5 yellow 6-10 red) 

– Symptoms should return to baseline30 minutes of finishing the exercise

– Shouldn’t have any pain the next day 

Remove compressive elements and optimise mechanics (orthotics and/or heel lifts) 

Joint mobilisation (low-level evidence)

– Soft tissue PF compartment 

– Joint mobilisation TCJ and STJ 

Shockwave therapy // evidence is conflicting at this point in time 

Low-level evidence for CSI // likely short term pain relief but detrimental long term tendon health

Differential diagnosis for Mid-portion Achilles Tendinopathy

– Insertional achilles tendinopathy //compressive pattern 

– Platerfasiopathy // windlass 

– Tibial nerve // SLR + DF + EV

– Sural nerve // SLR + DF + EV

– Retrocalcaneal bursitis // inflammatory signs, lack contractile element in all ranges 

– Calcaneal stress fracture // history and squeeze test 

– Sever’s disease // age, history, palpation 

– Posterior impingement // prone DF

– Tendon rupture // trauma and relative contractile deficit 

– Strain // palpation, history 

– Calcaneal fat pad // palpation


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Murphy, M.C., Travers, M.J., Chivers, P., Debenham, J.R., Docking, S.I., Rio, E.K. and Gibson, W., 2019. Efficacy of heavy eccentric calf training for treating mid-portion Achilles tendinopathy: a systematic review and meta-analysis. British journal of sports medicine, 53(17), pp.1070-1077.