Stop Overcomplicating the Achilles: The 2024 Midportion Tendinopathy Revision
The 2024 JOSPT revision for Achilles Midportion Tendinopathy is out, and it’s a masterclass in clinical practicality. The "Big Three" findings? Diagnosis is about the 2-6cm "sweet spot," morning stiffness, and palpable pain. But we can’t stop at tissue. We have to assess power—not just "can they do a heel raise," but what is their total endurance and torque?
Loading remains the undisputed king. Whether you prefer Eccentrics or Heavy Slow Resistance (HSR), the evidence is clear: Grade A. Pick the one the patient will actually do. Education is equally vital—teach them the "Pain Rule" (0-4/10 is safe) and settle in for a 12-week minimum haul. Stop the injections (Grade F!) and only use manual therapy to clear DF restrictions so they can load better. Treat the mindset, load the tendon, and get better outcomes.
Achilles Revision
Pain, Stiffness, and Muscle Power Deficits: The New Standards for Midportion Tendinopathy.
Clinical Diagnosis
Localization is key. 2-6cm proximal to insertion. Pain with morning loading and tendon palpation.
Power Deficits
It's not just "strength." Assess heel raise endurance and plantar flexion torque vs. norms.
Psychological Factors
Fear-avoidance and catastrophizing are Grade B associations. Address the mindset, not just the tissue.
The Golden Standards
Mechanical Loading Strong Evidence
Eccentric exercises OR Heavy Slow Resistance (HSR) are equally effective. Don't overcomplicate it—just pick the one they'll actually stick with. Load it heavy, load it slow.
Patient Education Strong Evidence
Mandatory. Explain the "Pain Rule" (0-4/10 is okay). Address that structural changes don't equal pain. Set a 12-week minimum timeframe for results.
Adjunct Treatments
- Grade B Shockwave (ESWT)
Consider for those who aren't responding to loading alone within 6-12 weeks.
- Grade C Night Splints & Orthoses
Optional. Only if symptoms > 6 months. Orthoses are for short-term strain reduction, not a primary fix.
- Grade D Iontophoresis / Manual Therapy
Weak evidence. Manual therapy should ONLY be used to improve ankle DF as a prerequisite for loading.
- Grade F Injections
Strong recommendation against CSIs for midportion. They increase risk of rupture and have poor long-term outcomes.
Risk Factors: Why did this happen?
Age
30 - 50 years old
Metabolic
Obesity, Diabetes
Load
Rapid training spikes
Drugs
Fluoroquinolones
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