What is a mid-portion Achilles tendinopathy?

Achilles tendinopathy is a common problem that affects both athletes and those who are more sedentary.

It has been discovered that it affects 7.4% of all marathon runners and 1.4 percent of the UK military population (Baker-Davies et al, 2017).

According to Longo et al. (2009), a mid-portion Achilles tendinopathy is directly responsible for 6-17 percent of all running injuries.

Achilles tendinopathy is a debilitating ailment that can be difficult to treat, with up to 50% of patients still suffering from pain after a year. As a result, it’s critical to receive a precise diagnosis and treatment plan as soon as feasible.

There are two types of Achilles tendon problems: insertional and mid-portion abnormalities (see image below).

The lower section of the Achilles tendon, where it joins to the heel bone (green circle), is affected by insertional Achilles pain (known as the calcaneum). A structure termed the retrocalcaneal bursa may possibly be involved.

  • section in the middle Achilles tendon pain (blue circle) affects only the main section of the tendon.

Pain in the mid section of the Achilles tendon (blue circle) and insertional Achilles tendon (red circle) (green circle).

The Achilles tendon can become irritated and inflamed as a result of repeated or unusual activities. The tendon swells and becomes painful as a result of this. Tendinitis is the inflammation of a tendon. Extreme tenderness while touching or squeezing the tendon is a telltale indication.

The healing process can be hampered if the tendon is not given enough time to recuperate before being subjected to more exercise, resulting in a thicker, weaker, and painful tendon. Tendonopathy is caused by a cycle of acute inflammation and inadequate tendon repair (Almekinders et al, 2007).

What are the symptoms of mid-portion Achilles tendinopathy?
Pain is the most prevalent sign of mid-Achilles tendonopathy. Pain is commonly felt at the start and finish of exercise, whether it’s a stroll or a run, with symptoms subsiding as the exercise is completed. Many people claim to be able to ‘exercise through’ their discomfort, but that their problems return once they finish their walk or run.

This reduction in discomfort during activity diminishes when a mid-portion Achilles tendinopathy develops, resulting in a persistently sore tendon. If this is allowed to continue, the discomfort from a mid-portion Achilles tendinopathy might become unbearable and interfere with daily activities. In extreme cases, activities like walking or ascending and descending stairs are frequently reported as painful.

A swollen, thicker tendon that is uncomfortable to touch is described by many persons. 2-3 inches above the calcaneus (heel bone) is the most usual site (Almekinders et al, 2007).

The following are some of the most common symptoms of mid-portion Achilles tendon tendinopathy:

The tendon is inflamed and painful.

2. Extreme soreness while contacting the tendon can be pinpointed.

3. Exercising, such as running, skipping, and leaping, causes pain.

4. Pain and stiffness are worst first thing in the morning or after sitting for long periods of time.

5. Gentle movement helps to relieve pain.

6. Pain worsens after an exercise, such as a run, for a few hours or the next day.

We believe that obtaining a more specific diagnosis is critical, thus we perform a diagnostic ultrasound scan.

To adopt the most effective treatment strategy for your specific problem, you’ll need to learn more about which section of the tendon is afflicted and the severity of the condition

Diagnostic ultrasound is the gold standard imaging method for examining tendon structure in different parts of the body, including the shoulder (Stenroth et al, 2019). For this disease and many tendon symptoms, it is preferable than MRI.

These crucial questions will be answered by a diagnostic ultrasound scan:

1. What portion of the tendon has been injured?

A tendonopathy is diagnosed when the tendon becomes swollen and irritated. Paratendinitis occurs when the thin layer of tissue surrounding the tendon (known as the paratenon) becomes swollen and inflamed. Because these two disorders are treated differently, it’s critical to learn more about them.

2. Is there a tear in your tendon?

This cannot be determined just through clinical examination and necessitates the use of a scan. A scan will reveal not only whether or not there is a tear, but also its size and location. This, too, may have an impact on the best treatment plan for your Achilles tendon.

3. Are there any other structures that need to be considered?

A diagnostic ultrasound scan will also reveal whether or not there are any other structures implicated in your issue. For example:

  • a nerve (the sural nerve) that runs along the outside of the tendon
  • a tiny tendon (the plantaris) that runs along the interior of the tendon
  • or a bursa (the retrocalcaneal bursa) that runs down the heel bone

4. What is the severity of your tendon inflammation?

A scan will reveal the extent of the tendon inflammation as well as the injury’s stage. The ultrasonography features a power Doppler mode that can determine how many new blood vessels have grown as a result of the tendon structure alteration (more later). One of the injection procedures can use these new blood vessels as a target (more later).

An ultrasound scan provides us with crucial information that allows us to optimise your recuperation.

What is the treatment of mid-portion Achilles tendinopathy?

The majority of people do well with conservative treatment for mid-portion Achilles tendinopathy. This usually entails a set of at-home workouts aimed at strengthening your Achilles and calf muscles. With a specialised, individualised workout regimen, around 50-60% of customers will improve.

A physiotherapist should prescribe and monitor your exercise programme.

If you’re a runner, here are a few pointers that can be useful:

  • Reduce your exposure to activities that irritate or aggravate your discomfort.
  • Consider lowering your training load by 50% for two weeks if you have pain when jogging.
  • Will trainers, how old are you? It’s time to replace your trainers if they’ve been worn for more than six months or if you’ve run more than 500 kilometres in them.
  • A small bag of frozen peas wrapped in a tea towel applied to your Achilles for 10 minutes will help relieve discomfort. Make sure you don’t get an ice burn.
  • Exercises that strengthen your Achilles tendon and calf muscle include eccentric heel raises. Try doing this exercise 3 sets x 15 reps every day for 4 weeks to see if it helps. If this exercise does not relieve your pain after a month or makes it worse, we recommend that you see one of our experienced clinicians.
  • However, consult your pharmacist before using a topical anti-inflammatory gel like Voltarol.

What if physiotherapy doesn’t seem to be helping yourAchilles tendon pain?

Conservative treatment may not be enough to alleviate your discomfort in some circumstances. There are two basic therapy choices if this is the case.


Extracorporeal Shockwave Therapy (ESWT) 

Shockwave therapy is a proven therapeutic option with a vast body of evidence to back it up. Shockwave therapy can help with approximately 70% of Achilles problems (Korakakis et al, 2017). It is a safe and efficient treatment for Achilles tendonitis.

Shockwave therapy uses intense soundwave pulses to deliver a small amount of controlled microtrauma to the Achilles tendon. The body’s natural healing process is stimulated, allowing the tendon to mend. These pulses desensitise local nerve endings surrounding the injured tendon, resulting in even more pain relief.

Recent evidence suggests that using 3-5 shockwave sessions in conjunction with a progressive loading exercise regimen for the treatment of all lower limb tendinopathies can yield positive effects.

Shockwave therapy is taught to all Joint Injections clinicians. Please contact us if you would like more information on shockwave therapy.

Injections guided by ultrasound

For the treatment of mid-portion Achilles tendinopathy, a few injectable methods are available. These are only used in circumstances where exercise-based physiotherapy isn’t helping.

These injections are meant to be used in conjunction with your rehabilitation exercises. Injections are not a treatment in and of themselves.

Furthermore, injections into the tendon are not recommended. The injections we utilise target the tissues around the tendon, which have been found to be the source of discomfort in Achilles tendon problems in the mid-portion.

1. ‘Stripping’ or ‘high volume’ technique

Joint Injections has been employing this innovative injection process for many years. It accounts for roughly 80% of the injections we provide for mid-portion Achilles problems.

It entails injecting a significant amount of saline (sterile water) mixed with local anaesthesia, with or without steroid, into the Achilles to’strip’ the surrounding fat and arteries away from the Achilles (known as neovascularisation). This operation, which must be done under ultrasound guidance, can be an effective treatment.

The interior structure of a tendon is altered when it becomes tendinopathic. The tendon thickens, and a process known as neovascularization takes place. Neovascularisation is the formation of new blood vessels as a result of a tendon injury. Small nerves, which have been found to be one of the causes of discomfort in Achilles tendon disorders, are carried by these new veins.

High-volume ultrasound-guided injections are used to interrupt neovascularization and relieve discomfort, allowing you to recover faster (Barker-Davies et al, 2017).

When combined with a gradual exercise loading regimen, ultrasound guided high-volume injection for Achilles tendinopathy can considerably reduce discomfort and improve function (Walkley et al, 2019 and Maffulli et al, 2012).

The decision to inject steroid or not is based on a number of criteria that will be addressed with you at your consultation once a scan has been performed. Steroid, commonly known as corticosteroid, is a powerful anti-inflammatory that works quickly to relieve pain. However, there have been reports of tendon rupture following corticosteroid injection around load-bearing tendons, so this must be carefully examined (the Achilles tendon is a primary load-bearing tendon).

Only one occurrence of tendon rupture was observed in the 991 individuals, according to a comprehensive evaluation of randomised control trials published by Coombes et al (2010).

2. Plantaris-related discomfort

If you have discomfort on the inside of your Achilles tendon and an ultrasound examination reveals that it is caused by the plantaris tendon, the plantaris tendon can rub against the Achilles tendon, causing pain.

We’d then aim to use the high-volume injection strategy described above, but with a few tweaks to target Plantaris. The goal of the injection procedure is to detach the plantaris tendon from the Achilles tendon.

Joint Injection’s experts are dual-trained, highly specialised physiotherapists and musculoskeletal sonographers with extensive experience diagnosing all foot and ankle. We provide a ‘one-stop’ clinic, which means you’ll get an examination, a diagnostic ultrasound, and, if necessary, an ultrasound-guided injection.