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Treatment of Achilles tendinopathy: state of the art
  1. Paul W Ackermann1,2,
  2. Phinit Phisitkul3,
  3. Christopher J Pearce4
  1. 1 Integrative Orthopedic Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
  2. 2 Department of Orthopedics and Sports Medicine, Karolinska University Hospital, Stockholm, Sweden
  3. 3 Tristate Specialists, Orthopedics, Siox City, Iowa, USA
  4. 4 Department of Orthopaedic Surgery, National University Health System, Singapore, Singapore
  1. Correspondence to Dr Paul W Ackermann, Department of Orthopedics and Sports Medicine, Karolinska University Hospital, Stockholm 171 76, Sweden; paul.ackermann{at}


Achilles tendinopathy (AT) is a continued enigma for clinicians from all parts around the world. The increasing prevalence is related to physical activities, but additionally also to metabolic factors unrelated to activities that load the Achilles tendon. AT can comprise two different diagnosis: insertional AT and non-insertional AT (NIAT). This review will deal predominantly with the treatment of NIAT. The exact aetiology and pathophysiology of NIAT are not fully known, but seem to be a partly degenerative condition. This gap of knowledge is accountable for the highly variable principles of treatment. The diagnosis of NIAT can usually be made clinically but MRI scans may be used and ultrasound may be useful, with power Doppler to assess the level of neovascularisation, or to guide injection therapies. Current treatments of NIAT with highest evidence entail non-surgical methods to promote tendon healing with focused eccentric exercises and biophysical procedures. Injection therapies (cortisone, sclerosing agents, blood products including platelet-rich plasma) may have short-term effects, but have no proven long-term treatment effects. Targeted minimally invasive surgical procedures should be considered in specific recalcitrant cases to initiate healing and alleviate pain by removing pathological tissue or abnormal neoinnervation. Other surgical options including open debridement, gastrocnemius recession and plantaris tendon excision have been described. Overall, more high-quality level 1 studies are needed to define the optimal treatment protocols. Future therapies should target the differential underlying pathologies of NIAT using combined non-surgical and minimal-invasive including biological approaches.

  • ankle
  • endoscopy
  • tendon
  • outcome studies
  • rehabilition/physical therapy
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  • Contributors All authors participated in the design of the work, drafting and revising of the work and read and approved the final manuscript. PWA focused on conception and design of the manuscript and the first draft of non-surgical treatments, CJP focused on drafting the chapter of diagnostics and performed substantial revision of the non-surgical treatments chapter and PP focused on drafting the chapter on minimally invasive and surgical treatments. All authors agreed to be accountable for all aspects of the work.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

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