Back Pain Doctor
Achilles Tendinopathy
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
Achilles tendinopathy is an overuse-related condition of the Achilles tendon, causing pain, stiffness and reduced tolerance for loading activities such as running and jumping. It can affect the mid-portion of the tendon or its attachment at the heel.
The foundation of treatment is a progressive loading (strengthening) program, which has the strongest evidence for Achilles tendinopathy. This is combined with managing overall load so the tendon is challenged but not overwhelmed. Recovery is typically measured in months.
Where symptoms persist despite a well-executed loading program, additional options such as shockwave therapy may be considered, particularly for mid-portion tendinopathy. Assessment confirms the type and location of the problem and leads to a realistic plan.
Common symptoms
- Pain and stiffness in the Achilles tendon, often worse in the morning
- Pain at the start of activity that may warm up, then return afterwards
- Tenderness or thickening of the tendon
- Reduced tolerance for running, jumping or hills
Commonly seen in
Evidence for twelve treatment options in achilles tendinopathy
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation: diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Core care
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan, with weight management where that is clinically relevant.
What the evidence shows
Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).
Pairing reviewed 2026-09-02.
Where it fits
This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. Dry needling added nothing to rehab
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with a very dilute local anaesthetic (0.02-0.08%) is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling (the same technique with nothing injected) is not offered here.
What the evidence shows
Searched 7 November 2026 (PubMed: trigger point, dry needling, wet needling, trigger point injection, myofascial or intramuscular stimulation with Achilles or calcaneal tendon, 74 records, most of them animal, healthy-volunteer or other-condition studies; and a randomised-trial and systematic-review pass across the tendon conditions). No study has injected a calf-muscle trigger point in Achilles tendinopathy, with glucose or anything else. The nearest evidence is dry needling, the same needle with nothing injected, which is not offered here, and it is negative: in a 52-person trial of persistent midportion Achilles tendinopathy, adding calf needling to a 12-week loading program was no better than sham needling or the program alone (VISA-A 76 with needling, 76 with sham and 82 with rehab alone at 12 weeks; no difference at 6 or 12 months) (Solomons, PLoS One 2020). A 22-person feasibility trial of dry needling of calf and tibialis posterior trigger points added to manual therapy and exercise found no between-group difference at four weeks or three months, with 68% lost to follow-up (Koszalinski, J Man Manip Ther 2020). In a 60-person single-blind trial, dry needling of gastrocnemius trigger points did less well than percutaneous electrolysis of the tendon (Delgado Álvarez, Cureus 2026; between-group figures not given in the abstract).
Pairing reviewed 2026-11-07.
Where it fits
The loading program treats the tendon. A trigger point injection would be considered only where examination finds a tender calf-muscle band adding to the pain, and you would be told that the closest trials found no added benefit.
Ultrasound-guided injections Guidance means the needle can be seen reaching the target. What goes into the needle depends on the diagnosis. Not into the tendon
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis, and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
Corticosteroid is not injected into or around the Achilles tendon here. A systematic review of 41 randomised trials and 2,672 participants found the short-term pain benefit of corticosteroid in tendinopathy reversed at intermediate and long term, and recorded one serious adverse event among the 991 participants who received corticosteroid, a tendon rupture (Coombes, Lancet 2010). Reviewing the two recent trials that added corticosteroid to exercise in Achilles tendinopathy and plantar fasciopathy, a 2024 appraisal weighed the higher recurrence and rupture risk and recommended against corticosteroid injection for tendinopathy (Visser, J Orthop Sports Phys Ther 2024). Ultrasound guidance improves needle accuracy but only improves outcomes where the target is small or deep (Aly, Br J Sports Med 2014; Fan, Arthroscopy 2021), and it does not make the tendon a safe target. The largest trial of a steroid-containing injection beside this tendon, 192 people given 50 mL of fluid with 25 mg of hydrocortisone, a steroid-free version or a sham alongside exercise, found the steroid injection ahead of the sham at six weeks, no different at 12 months, and behind the steroid-free injection at 26 weeks; the authors advise against routine use (Malliaras, BMJ 2026).
Pairing reviewed 2026-11-06.
Where it fits
Not offered for the tendon itself. A separate inflammatory target, such as a retrocalcaneal bursa or a tendon sheath, is a different question and is assessed on its own merits, with the number of injections kept low and the loading programme continuing alongside it.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Plausible: no studies
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.
Pairing reviewed 2026-08-30.
Where it fits
A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. Mid-portion only; trials unblinded
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue, including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
Radial shockwave is the form most Achilles trials used, and the answer depends on where the tendon hurts. For MID-PORTION pain, three low-energy sessions did better than waiting, 52% against 24% recovered or much improved at four months, and about as well as eccentric loading in 75 people (Rompe, Am J Sports Med 2007). Added to loading in 68 people, 82% against 56% were recovered or much improved at four months, with no difference left at a year (Rompe, Am J Sports Med 2009). In 46 runners, three sessions added to exercise gave a larger gain in the Achilles score at three months, 33 points against 18 (Tenforde, BMJ Open Sport Exerc Med 2025). A review pooling three mid-portion trials put the benefit over a loading program alone at about 9 points out of 100, at moderate certainty, and classes the early trials as radial (Paantjens, Sports Med Open 2022). The three trials named above were not blinded. One double-blind trial of 50 people did favour shockwave over a sham, but reviews disagree about whether its device was radial or focused (Abdelkader, Foot Ankle Int 2021), and the blinded trial with a clearly radial device found the recommended dose no better than a minimal dose in 57 people (Wheeler, Foot Ankle Int 2025). For INSERTIONAL pain, where the tendon meets the heel bone, three trials against a sham found no benefit, the largest in 119 people with scores of 63.2 and 62.3 out of 100 at 24 weeks (Mansur, J Bone Joint Surg Am 2021; Alsulaimani, Clin Rehabil 2024; Pinitkwamdee, Foot Ankle Int 2020). An earlier unblinded trial of 50 had favoured it over eccentric loading (Rompe, J Bone Joint Surg Am 2008). The most recent pooled analysis, of nine trials against sham or no treatment, found no clinically meaningful benefit at either site and advises against routine use, while noting very low-certainty evidence of a meaningful effect for the radial form (Korakakis, J Orthop Sports Phys Ther 2026).
Pairing reviewed 2026-10-09.
Where it fits
An adjunct that can be discussed for mid-portion Achilles pain alongside a loading program, not instead of one, with the position that the supportive trials were mostly unblinded and the blinded trial of a clearly radial device was not supportive. For insertional pain the sham-controlled trials found no benefit, so patients are told so and the effort goes into loading.
Focused shockwave (ESWT) A true shock wave converging at depth: for tendon, joint, ligament and bone. Focused sham trials null
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form used for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
The Achilles shockwave evidence has to be split by device, because most of the positive trials used the radial form on the row below. For the FOCUSED form, the two trials with a clearly focused device and a sham comparison found no benefit: 49 people with chronic Achilles pain had no more pain relief than with sham, and two people aged 62 and 65 had tendon ruptures after treatment (Costa, Clin Orthop Relat Res 2005); and in 66 people doing the same physiotherapy, point- and line-focused treatment improved the Achilles score by 23 and 18 points against 15 with sham, a difference that was not significant at 24 weeks (Gatz, Sports Health 2021). A 43-person sham trial using focused and radial pulses together found small differences at 16 weeks but no difference in the change over time (Vahdatpour, J Res Med Sci 2018), and a 2026 trial of 41 people adding focused treatment to twelve weeks of resistance training reported tendon changes on imaging but no clinical difference from training alone (Katolický, J Sci Med Sport 2026). Two positive double-blind trials are classed as focused by some reviews and as radial by others: 50 people with mid-portion pain had large gains over sham that lasted to 16 months (Abdelkader, Foot Ankle Int 2021), and 48 people had a better ankle score than sham at 8 and 12 weeks (Rasmussen, Acta Orthop 2008). For INSERTIONAL pain, the one focused trial did worse than a laser treatment (Notarnicola, Lasers Med Sci 2014), and the studies that favoured high-energy treatment were not randomised (Furia, Am J Sports Med 2006 and 2008). The most recent pooled analysis, of nine trials against sham or no treatment, found no clear advantage for either device, no clinically meaningful benefit at the insertion, and reported the two ruptures after focused treatment (Korakakis, J Orthop Sports Phys Ther 2026). The earlier review this row rested on placed its mid-portion trials in the radial group by its own account (Paantjens, Sports Med Open 2022).
Pairing reviewed 2026-10-24.
Where it fits
Can be discussed as an adjunct for mid-portion Achilles pain that has not settled with a good loading program, with the position that the trials of a clearly focused device were no better than sham. For insertional pain the evidence does not support it, and the effort goes into loading. Used with care over the age of 60 because of the rupture reports.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Usually painless, no contact. Plausible: no studies
What it involves
You sit with the applicator positioned over the area for a short session. It is usually painless and needs no gel or skin contact. It is usually given as a course, commonly alongside shockwave.
What the evidence shows
There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).
Pairing reviewed 2026-08-30.
Where it fits
Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. No better than sham in largest trial
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
Tested against a dummy injection in four randomised trials, and three found no benefit. The largest, across 24 UK hospitals, gave 240 people with mid-portion Achilles tendinopathy one PRP injection into the tendon or a sham needle. At six months the Achilles scores were 54.4 and 53.4 out of 100, a difference that was not significant (adjusted difference -2.7, 95% CI -8.8 to 3.3), and its authors concluded the findings do not support the treatment (Kearney, JAMA 2021). Two earlier double-blind trials against saline found the same in 54 and in 24 people (de Vos, JAMA 2010; Krogh, Am J Sports Med 2016). The exception used a course of four injections a fortnight apart with eccentric training in 60 men, and found a larger gain than a sham at 24 weeks, 20 points against 9, while a high-volume cortisone injection did better still in the first twelve weeks (Boesen, Am J Sports Med 2017). Pooling six randomised trials and 422 people, PRP did not improve the Achilles score over placebo at three months, six months or a year (0.5 points at six months, 95% CI -8.5 to 9.3), and the authors advise against its use until better trials show a benefit (Barreto, Clin Orthop Relat Res 2024). Soreness at the injection site was more common than after the sham, 97 against 73 people in the largest trial. None of these trials studied the insertional form, where the tendon meets the heel bone.
Pairing reviewed 2026-10-09.
Where it fits
Not a routine treatment for Achilles tendon pain. A progressive loading program is the core, and the best trial of a single PRP injection found it no better than a sham. It can still be discussed for stubborn mid-portion pain that has not responded to months of properly dosed loading, with that evidence, the cost and the fact that the one positive trial used a course of four injections all stated beforehand.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Worth discussing
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
Only one randomised trial of prolotherapy in Achilles tendinosis was identified in a systematic review of 20 trials, and it found combined prolotherapy plus eccentric loading improved symptoms more rapidly than prolotherapy alone (Capotosto, Orthop J Sports Med 2024).
Pairing reviewed 2026-08-30.
Where it fits
Considered only alongside a loading programme, never instead of one. The evidence base here is a single trial.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Not used for tendons
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
Not offered here. A meta-analysis of 19 randomised trials of hyaluronic acid in soft-tissue problems, 1,629 patients in all, reported less pain than the comparison treatments overall, but it contained only one Achilles tendinopathy trial, so that result has not been repeated (Khan, Sports Health 2022). These are injections around a tendon, which is a different procedure from the joint injection in this row.
Pairing reviewed 2026-10-05.
Where it fits
Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and this is a tendon problem.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve, not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Only if relevant
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
No trial has tested perineural injection for Achilles tendinopathy itself, and the treatment targets nerves rather than tendon. Its relevance here is diagnostic: one detailed case report describes sural nerve dysfunction that mimicked Achilles tendinopathy, with the nerve two-and-a-half times its normal size on ultrasound and pain settling from 8 to 2 out of 10 after dextrose hydrodissection, sustained at two years (Yoon, Diagnostics 2025).
Pairing reviewed 2026-09-05.
Where it fits
Not part of treating a tendinopathy. It becomes relevant only if the pain turns out not to be tendon pain at all. Burning, numbness or a nerve that is tender and enlarged on ultrasound point to a different diagnosis, which is then treated on its own terms.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Tested — no benefit over sham
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
Searched 6 November 2026 (PubMed: Achilles with high-volume injection, hydrodissection, hydrorelease, brisement, paratenon or Kager's fat pad, 47 records, plus randomised-trial and systematic-review passes; every abstract read). At this tendon the nearest procedure to this row is the high-volume injection, in which a large volume of fluid is injected under ultrasound between the tendon and the fat pad in front of it to strip the tissues apart. It has been tested against a sham injection, and the result is evidence of absence rather than absence of evidence. Without corticosteroid it did no better than a sham in three randomised trials: 80 people at 24 weeks, an adjusted difference of 0.5 points on the 100-point VISA-A score (van der Vlist, BMJ 2020); 62 servicemen with Achilles or patellar tendinopathy at six months (Barker-Davies, Orthop J Sports Med 2022); and 192 people at 12 months (Malliaras, BMJ 2026). With 25 mg of hydrocortisone added it helped more than the sham at six weeks (by 9.2 points), was no different at 12 months, and did worse than the same injection without corticosteroid at 26 weeks (Malliaras 2026). An earlier trial of 60 men found a steroid-containing high-volume injection ahead of a placebo to 24 weeks (Boesen, Am J Sports Med 2017); the larger, later trial did not confirm a lasting benefit. No serious adverse events were recorded in the 2026 trial. Every trial added the injection to an exercise program, and every group, sham included, improved.
Pairing reviewed 2026-11-06.
Where it fits
Not offered as a treatment for the tendon itself: the loading program does the work, and adding fluid around the tendon has not added to it in trials. Where burning, numbness or an enlarged, tender sural nerve on ultrasound suggests the pain is coming from the nerve beside the tendon rather than the tendon, nerve hydrodissection is a separate question, and that rests on one case report (Yoon, Diagnostics 2025).
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target. The method behind the ratings, and the treatments not offered, are set out on the evidence page.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So treatment plans are not built around it. Where an injection is the right call, the specific diagnosis and target are reviewed, what is being injected and why is discussed, the number is kept low, and it is paired with the loading work that changes the longer-term course.
When it might still be considered
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal: a trip, a procedure, a return to work
- Diagnostic use, where the response shows where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other foot, ankle & lower leg conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Related articles
Shorter articles that answer the questions patients ask most often about this.
Frequently asked questions
What is the most important treatment for Achilles tendinopathy?
Should I stop activity completely?
When are other treatments considered?
Ready for a clearer plan for your back or musculoskeletal pain?
Book an assessment with Dr Joshua Hatch.
Your assessment focuses on understanding the likely source of your pain and the most appropriate non-surgical options for your diagnosis, with the aim of reducing pain and improving function.
You must have your own regular GP before booking. This service works alongside your GP for focused care. Booking requirements.
Book an appointment