Physical therapy for achilles tendinopathy

NewsBot · Nov 15, 2024

Optimising physiotherapist delivery fidelity of exercise and physical activity advice for Achilles tendinopathy: a prospective repeated-measures observational study
Rebecca Phillips et al
Physical Therapy in Sport; 14 November 2024

Highlights
•Assessing physiotherapist delivery fidelity can provide opportunity for improving delivery of rehabilitation as intended.
•Physiotherapist delivery fidelity can be optimised with feedback and boost-training.
•Boost-training consisted of clarifications, cross-permeation, and collaboration.
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Objectives
To assess physiotherapist delivery fidelity and identify factors optimising delivery fidelity of an intervention based on recommended guidelines for Achilles tendinopathy.
Design
A prospective repeated-measures observational study of physiotherapist delivery fidelity with carefully defined exercise and physical activity advice.
Setting
An inter-disciplinary clinic in X, embedded in a randomised controlled trial.
Participants
Two physiotherapists delivering the intervention to five participants each, at three timepoints.
Intervention
All participants were expected to receive the same intervention. Feedback at timepoint one, guided boost-training to optimise delivery fidelity.
Main outcome measures
Proportion of exercise and physical activity advice components delivered as intended (high ≥80%; moderate 51 to 79%; low≤50%), with relationships between variables analysed using chi-square tests.
Results
Physiotherapist delivery fidelity improved significantly between timepoint one and two (χ2 = 83.3, p < 0.001), then sustained at timepoint three. At timepoint one, seven (70%) of intervention components were delivered with high fidelity, one (10%) with moderate fidelity and two (20%) with low fidelity. At timepoint two, after boost-training, nine (90%) were delivered with high fidelity and one (10%) with moderate fidelity. At timepoint three, all intervention components (100%) were delivered with high fidelity by both physiotherapists.
Conclusion
Physiotherapist delivery fidelity can be optimised with feedback, collaboration and boost-training.
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NewsBot · Nov 26, 2024

The Fragility of Statistically Significant Binary Outcomes for Treating Achilles Tendinopathy: A Systematic Review of Randomized Trials
Omkar S Anaspure et al
Foot Ankle Orthop. 2024 Nov 20;9(4):24730114241300160

Background: Randomized controlled trials (RCTs) are the gold standard for treatment efficacy, but foot and ankle RCTs are often small or inconsistent. The Fragility Index (FI) evaluates the stability of significant findings. This study assessed the fragility of RCT outcomes for Achilles tendon pathology (ATP) interventions.

Methods: This systematic review queried PubMed up to May 14, 2024, for RCTs on ATP interventions. RCTs with significant binary outcomes were included. Two reviewers assessed eligibility, extracted data, calculated FIs, and evaluated risk of bias. Frequency-weighted means were used for narrative synthesis.

Results: Eleven RCTs with 4506 patients (mean cohort size: 409.64 ± 160.54) and a mean age of 36.97 ± 13.51 years (n = 4356; 96.67%) were included, covering 24 binary outcomes. The median FI across all outcomes was 3 (interquartile range 1-4; mean 3.92), indicating that changing the outcome of just a few patients could shift a study's results from statistically significant to nonsignificant. Trials having an FI ≤3 comprised 58.33%. Three outcomes (12.5%) had an FI of zero after recalculating P values using the two-sided Fisher exact test. Half of the outcomes were robust. No RCT reported FIs or adjusted significance for multiple testing. Most studies (81.82%) performed 2 or more statistical tests, with an average of 30.81 ± 41.28 P values reported per study. The overall risk of bias was low in 1 study (9.09%) and moderate in 7 (63.64%). Most studies had low risk of bias in randomization (72.73%) and missing outcome data (90.91%).

Conclusion: The FI assesses the fragility of statistically significant binary results, revealing that many ATP RCTs have fragile outcomes due to small sample sizes. A median FI of 3 means that changing the outcome of 3 patients could shift a study's results from statistically significant to nonsignificant.
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NewsBot · Feb 18, 2025

Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision – 2024
Journal of Orthopaedic & Sports Physical Therapy

Midportion tendinopathy is a common overuse lower extremity injury, with a prevalence of 4% to 7%. Achilles tendinopathy especially affects people who participate in activities that load the Achilles tendon, such as running. The Victorian Institute of Sport Assessment—Achilles (VISA-A) questionnaire has been the go-to patient-reported outcome measure of the perceived impact of Achilles tendinopathy. Recently, new instruments have been developed to try and overcome concerns about the validity of the VISA-A. The revised CPG summarized current evidence, and updated recommendations to support evidence-based practice, including tailored clinical decision-making, about managing Achilles tendinopathy. The CPG excluded interventions that were outside the typical scope of physical therapy practice (eg, pharmacological interventions and surgery) and extracorporeal shock wave therapy.
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NewsBot · May 28, 2025

Diagnostic domains, differential diagnosis and conditions requiring further medical attention that are considered important in the assessment for Achilles tendinopathy: a Delphi consensus study
Peter Malliaras et al
Source

The absence of agreed methods to diagnose Achilles tendinopathy impedes research and clinical practice. This gap results in heterogeneous and/or poorly described study samples, making it challenging to apply findings in clinical practice. The aim of this Delphi study was to define consensus on (1) diagnostic domains; (2) differential diagnoses; and (3) conditions requiring further medical attention, when assessing for Achilles tendinopathy.

We conducted a sequential three-stage process which included: (1) identifying diagnostic domains, differential diagnoses and conditions requiring further medical attention based on existing scoping reviews and clinical practice guidelines; (2) developing Delphi survey questions; and (3) administering a five-round Delphi online survey. Consensus was defined as ≥70% agreement.

52 participants completed the surveys. Four diagnostic domains were deemed essential and reached consensus (pain location (93%); pain during activity (97%); tests that provoke pain (87%); palpation to assess pain (83%)). 15 differential diagnoses reached consensus: 2 for both midportion and insertional (partial tear (80%); posterior ankle impingement (78%)), 6 for midportion (plantaris tendinopathy (84%); tibialis posterior or flexor hallucis longus tendinopathy/tenosynovitis (72%); flexor digitorum longus tendinopathy (77%); accessory soleus muscle (74%); paratendinopathy (86%); sural nerve neuropathy (81%)) and 7 for insertional (superficial (88%) and retrocalcaneal bursitis (86%); Haglund’s/calcaneal exostosis (80%), intratendinous calcifications (73%); Sever’s disease (78%); calcaneal stress reaction/fracture (80%); subtalar/ankle pain (71%)). Six conditions requiring further medical attention reached consensus: (Achilles tendon rupture (83%); systemic inflammatory joint disease (86%); metabolic syndrome (75%); familial hypercholesterolaemia (77%); endocrine and hormonal disorders (80%); drug reactions (77%)).

This consensus identified essential diagnostic domains, differential diagnoses and conditions requiring further medical attention that should be considered when assessing for Achilles tendinopathy.
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NewsBot · Jun 13, 2025

Do Anxiety, Depression, Fear of Movement and Fear of Achilles Rupture Correlate with Achilles Tendinopathy Pain, Symptoms or Physical Function?
George White et al
J. Clin. Med. 2025, 14(2), 473; https://doi.org/10.3390/jcm14020473

Objectives: To determine if psychological factors, such as anxiety, depression, fear of movement and fear of rupture are associated with increased tendon-related disability, quantified by the Tendinopathy Severity Assessment-Achilles (TENDINS-A). Design: Cross-sectional. Setting: Online Qualtrics survey. Participants: Sixty-eight participants (54% female) with Achilles tendinopathy and a mean (standard deviation) age of 40.1 (12.6) years. Main Outcome Measures: The TENDINS-A (including subscales of pain; symptoms such as stiffness; physical function), Patient Health Questionnaire-9, General Anxiety Disorder-7, Tampa Scale for Kinesiophobia and fear of tendon rupture. Associations were evaluated using generalised linear models (adjusting for age and sex), with significance accepted when p < 0.05. Results: Anxiety symptoms were positively associated with Achilles pain (p = 0.035), symptoms (p = 0.045) and physical function (p = 0.019). Depressive symptoms were negatively associated with symptoms (p = 0.045) but not pain (p = 0.078) or physical function (p = 0.429). Fear of movement was not associated with pain (p = 0.479), symptoms (p = 0.915) or physical function (p = 0.064). Fear of rupture was associated with pain (p = 0.042), but not symptoms (p = 0.797) or physical function (p = 0.509). Conclusions: Our research demonstrated anxiety symptoms and fear of rupture, not fear of movement or depressive symptoms, are positively associated with the severity of tendon-related disability. Therefore, clinicians should include an assessment anxiety symptoms and fear of rupture in their practice.
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NewsBot · Jun 30, 2025

Comparison of Isolated Eccentric Exercise and Eccentric Exercise Combined with Shock Wave Therapy in Non-insertional Achilles Tendinopathy
Gokhan Pehlivanoglu et al
Source

This study aimed to compare the effectiveness of eccentric exercise (EE) alone versus combined treatment with EE and extracorporeal shock wave therapy (ESWT) for treating noninsertional Achilles tendinopathy. Seventy-eight patients who underwent treatment with EE alone or combined with ESWT were retrospectively evaluated. Results were compared between the two groups before and after treatment, at the third-month, and after an average follow-up period of 6.3 years. The VAS and Likert scale scores were significantly better after treatment and at the third-month follow-up for those who underwent combined treatment (p < 0.05). Both groups showed statistically significant improvements in VISA-A and VAS scores compared to baseline levels after treatment, in the third-month, and at the final follow-up (p < 0.05). The final follow-up results revealed no significant differences between the VISA-A, VAS, and Likert scores of both groups. Fifty-six out of 78 patients (71.8%) who rated themselves as Likert 1 (fully healed) or 2 (much better) on the 6-point Likert scale were deemed successful. While both treatment groups reached minimal clinically important difference (MCID) in VAS scores, the intergroup MCID was not clinically significant. This study underscores the efficacy of EE in noninsertional Achilles tendinopathy, and the clinical effect of ESWT remains controversial. However, ESWT+EE combination therapy may be a viable option for specific patient groups requiring rapid recovery, such as athletes.
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NewsBot · Jul 6, 2025

No short-term changes in tendon structure following temporary replacement of running with low-impact exercises in service members with midportion Achilles tendinopathy: a prospective cohort study
M A Paantjens et al
Source

Introduction Midportion Achilles tendinopathy (mid-AT) is associated with tendon degeneration that may worsen due to mechanical loading. Contrastingly, load can also improve tendon structure. We aimed to evaluate short-term changes in midportion tendon structure and their associations with symptoms, following temporary replacement of running with low-impact exercises on a stair climber or cross-trainer, in service members with mid-AT.

Methods We recruited 40 service members (40 symptomatic tendons) for this study. Ultrasound tissue characterisation (UTC) was used to quantify aligned fibrillar structure (echo-type I+II) and disorganised structure (echo-type III+IV), in the tendon midportion (2–7 cm) and in the area of maximum degeneration (AoMD) within the midportion. Symptoms were evaluated with the modified Victorian Institute of Sports Assessment – Achilles (VISA-A) questionnaire. All measurements were performed at baseline and after 8 weeks. The Wilcoxon signed-rank test was used to evaluate differences in UTC and VISA-A. Spearman’s rho was used to calculate the correlations between UTC and VISA-A change scores.

Results Tendon structure did neither change significantly in the midportion: echo-type I+II from median 64.7% (IQR 19.4) to 68.6% (IQR 25.1) (p=0.793); echo-type III+IV from median 35.3% (IQR 19.4) to 31.5% (IQR 25.1) (p=0.775) nor in the AoMD: echo-type I+II from median 56.3% (IQR 18.0) to 57.9% (IQR 32.0) (p=0.677); echo-type III+IV from median 43.8% (IQR 18.0) to 42.3% (IQR 32.1) (p=0.572).

On the other hand, VISA-A improved significantly (p=0.000) from baseline (median 46.5, IQR 16.0) to follow-up (median 56.0, IQR 9.0). Correlations between UTC and VISA-A change scores were consistently graded as low (range: 0.309–0.338).

Conclusions Although the replacement of running with low-impact exercises improved symptoms, no changes in tendon structure were observed after 8 weeks. Changes in midportion structure and symptoms were poorly associated. These findings can support loading advice in patients with mid-AT when aiming to prevent progressive degeneration or tendon rupture.
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NewsBot · Jul 20, 2025

Mechanisms influencing adult adherence to physiotherapist-delivered rehabilitation for Achilles tendinopathy: a longitudinal qualitative study
Rebecca Phillips et al
Source

Purpose

Achilles tendinopathy rehabilitation can be complex to deliver. Outcomes are variable, with low adherence a likely contributory factor. We aimed to identify the mechanisms influencing adult adherence behaviour to physiotherapist-delivered rehabilitation for Achilles tendinopathy.
Method

We applied interpretative descriptive design, utilising semi-structured interviews of 30 adults with Achilles tendinopathy who were interviewed at six-timepoints across 52-weeks. Data were analysed using Framework Analysis.
Results

We identified twelve mechanisms influencing adherence behaviour and grouped these into four themes: Tendinopathy paradigm consisted of “meaning-making of load and pain”, “comprehension of new knowledge” and “operationalising knowledge.” Self-management skills consisted of “internal self-management capability”, “external life-rhythm management” and “managing physical capability.” Therapeutic relationship consisted of “pre-scheduled regular check-ins”, “personal and professional connection”, and “coaching support.” Focus on outcome consisted of “motivation to maintain functional ability with progressing age”, “framing success” and, “it’s a trial.”

Three delivery profiles were identified guiding clinicians in the application of the mechanisms to optimise adherence.
Conclusion

Identification of mechanisms influencing adult adherence behaviour to physiotherapist-delivered rehabilitation for Achilles tendinopathy and delivery profiles to support implementation may optimise adherence, with the potential to improve outcomes.
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NewsBot · Aug 8, 2025

The Effect of an Aquatic Neuromuscular Exercise
Program on Pain Alleviation and Functional
Performance in Cases of Chronic Achilles
Tendinopathy Among Overweight Middle-Aged
Women
Sawani Aphale , Sandeep Shinde , Harshal Y. Kale , Manoj P. Ambali
Source

Background: Chronic Achilles tendinopathy is characterized by persistent pain, swelling, and functional
limitations, particularly in overweight middle-aged women. This demographic is predisposed to tendon
degeneration due to biomechanical overload and hormonal fluctuations.
Objective: This study aimed to compare the effectiveness of an aquatic neuromuscular exercise program vs.
a conventional land-based exercise program in overweight middle-aged women with chronic Achilles
tendinopathy, using pain intensity (visual analogue scale), ankle dorsiflexion range of motion (weight-
bearing lunge test, WBLT), and functional performance (patient-specific functional scale, PSFS).
Methods: A randomized controlled study was conducted on 102 overweight women aged 40-50 years (body
mass index 25-29.9 kg/m²), clinically diagnosed with chronic Achilles tendinopathy. Participants were
randomly assigned to Group A (aquatic neuromuscular program) or Group B (conventional exercise therapy).
Both groups underwent supervised exercise sessions four times weekly for four weeks, with progressive
intensity. Outcome measures included the visual analog scale for pain, the WBLT for ankle dorsiflexion, and
the PSFS. Data were analyzed using paired and unpaired t-tests. Mean differences, standard deviations, p
values, and effect sizes were reported.
Results: Group A showed superior improvements across all outcome measures. Pain during activity reduced
from 5.96±1.26 to 1.36±0.88 (effect size: 4.23), dorsiflexion improved from 15.24±1.47° to 27.34±1.77° (effect
size: 7.44), and PSFS scores improved from 15.21±2.86 to 28.65±2.74 (effect size: 4.80). Group B showed
statistically significant but comparatively smaller gains. Statistical significance (p<0.0001) was observed in
all outcomes.
Conclusion: This four-week aquatic neuromuscular exercise program proved superior to conventional
exercises in reducing pain, improving ankle dorsiflexion, and enhancing functional performance in
overweight middle-aged women with chronic Achilles tendinopathy. These findings support the use of
aquatic-based neuromuscular rehabilitation as a clinically beneficial and low-impact intervention for this
population.
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NewsBot · Aug 23, 2025

Efficacy of Heel Lifts for Managing Mid-Portion Achilles Tendinopathy (the LIFT Trial): A Participant- and Outcome Assessor-Blinded, Randomized Controlled Trial
Journal of Orthopaedic & Sports Physical Therapy

OBJECTIVE: To evaluate the efficacy of heel lifts in people with mid-portion Achilles tendinopathy.
DESIGN: This was a parallel-group randomized, sham-controlled, participant- and assessor-blinded trial conducted at a single center (Victoria University, Institute for Health and Sport, Melbourne, Australia).

METHODS: One hundred and eight participants (38 females and 70 males, mean age 48 years, SD 10 years) with clinically- and ultrasound-diagnosed mid-portion Achilles tendinopathy, were randomly allocated to either a heel lift (n=54) or sham intervention (n=54) group. The primary outcome was pain intensity (11-point numerical rating scale) at 12 weeks. Differences between groups were analyzed using intention-to-treat with analysis of covariance.

RESULTS: There was 100% follow-up of participants at 12 weeks. Pain intensity reduced by a mean of 3.7 points in the heel lifts group and 2.5 points in the sham intervention group. On average, there was a significant between-group difference in favor of heel lifts for reducing pain intensity (adjusted mean difference −0.9, 95% CI −1.7 to −0.2, p=0.02), which approximated, but did not meet the predetermined minimum important difference of 1.5 points. The primary analysis was not robust to sensitivity analysis when controlling for expectation (adjusted mean difference −0.7, 95% CI −1.5 to 0.0, p=0.06).

CONCLUSION: In adults with mid-portion Achilles tendinopathy, heel lifts demonstrated greater efficacy than a sham intervention for reducing pain intensity at 12 weeks, but this benefit was small and may not be clinically-meaningful. These results do not support the use of heel lifts for the primary management of Achilles tendinopathy.
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NewsBot · Aug 30, 2025

Exercise parameters to consider for Achilles tendinopathy: a modified Delphi study with international experts
Yoann Demangeot et al
Source

To assess the level of agreement among experts on the heel raise exercise parameters that influence midportion and insertional Achilles tendinopathy (AT) rehabilitation outcomes.

An international expert panel in AT rehabilitation was invited to complete a three-round Delphi survey. In the first two rounds, experts were asked to review a pregenerated list of exercise parameters (based on the heel raise exercise) and rate their perceived influence on rehabilitation outcome, using a 5-point Likert scale. For each parameter, consensus criteria for major influence on rehabilitation were (a) median≥4, (b) ≥75% of scoring 4 or 5 and (c) IQR≤1. The third round aimed to rank the exercise parameters according to importance (from most to least important) during rehabilitation.

17 experts participated in the entire Delphi process. A total of 16 exercise parameters were assessed, of which 4 (intensity of contraction, total time under tension, number of repetitions and sets, type of contraction) reached consensus as having a major influence on rehabilitation for midportion AT and 3 reached consensus for insertional AT (range of ankle dorsiflexion during the exercise, intensity of contraction, number of repetitions and sets). The rankings of parameters that reached consensus showed that contraction intensity was perceived as the most important variable for midportion AT rehabilitation, while range of ankle dorsiflexion was deemed the most important variable for insertional AT rehabilitation.

This study identified key exercise parameters for mid-portion and insertional AT rehabilitation based on expert opinion. This information should assist practitioners in optimising their approach to deliver more effective, patient-specific exercises for AT rehabilitation.
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NewsBot · Dec 2, 2025

Exercise, radial pressure waves, and photobiomodulation for management of non-insertional Achilles tendinopathy in runners: a three-arm non-blinded randomised control trial
Source

Objectives Non-insertional Achilles tendinopathy (AT) is a common running injury. Exercise loading programme (EXER) is the primary treatment. Other options include radial pressure wave (RPW, commonly referred to as shockwave) and photobiomodulation therapy (PBMT). We hypothesised that EXER+RPW and EXER+RPW+PBMT would result in greater reduction in symptoms measured using the eight-item Victorian Institute of Sports Assessment-Achilles (VISA-A) and greater improvement in functional outcomes compared with EXER. A secondary aim was to explore outcomes using elective treatment for three additional months.

Methods Runners with AT and symptoms exceeding 3 months were randomised to EXER, EXER+RPW or EXER+RPW+ PBMT. RPW was delivered once weekly for three treatments. Those assigned to receive PBMT additionally received treatment two times a week for 3 weeks. VISA-A, University of Wisconsin Running Injury and Recovery Index and Patient-Reported Outcomes Measurement Information System 29-item were obtained at baseline and intervals over 3 months. Afterwards, runners could elect to receive a different treatment for three additional months.

Results Forty-six runners enrolled (24 males, 22 females; average age±SD:40±12 years). Runners assigned EXER+RPW had a greater improvement than EXER at 3 months in VISA-A (mean 33 vs 18 points, p=0.023; 95% CI 28.4 to 2.4), and no differences were detected between EXER+RPW+ PBMT and EXER (25 vs 18 points, p=0.12; 95% CI 25.9 to –10.8). There were greater improvements in running index measures, pain interference and social roles in EXER+RPW compared with EXER. VISA-A increased over 3 month crossover to EXER+RPW and EXER+RPW+PBMT (11 points, both p<0.05 compared with EXER).

Discussion Combined EXER and RPW had the largest measured reduction in symptoms at 3 months. However, all groups met clinical improvement, highlighting the importance of EXER. Larger studies in other physically active populations may clarify clinical benefits of each treatment.
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NewsBot · Dec 4, 2025

Relationships Among Patient-reported Outcome Measures, Functional Performances, and Tendon Properties in Patients with Mid-portion Achilles Tendinopathy: A Cross-Sectional Study
Yuantai Li et al
Foot and Ankle Surgery 3 December 2025

Background
Achilles tendinopathy is a common overuse-related musculoskeletal disorder. The relationships among patient-reported symptoms, functional performance, and structural tendon changes remain poorly understood. This study aimed to clarify the relationships among these in patients with Achilles tendinopathy.
Methods
46 patients with mid-portion Achilles tendinopathy were included in the study. Evaluations included patient-reported outcome measures, functional performances, and tendon properties. Pearson correlation analysis and multiple linear regression were used to explore the relationships between outcomes.
Results
Only Victorian Institute of Sport Assessment-Achilles was found to have a significant association with Achilles tendon thickness (p = 0.038, β = 0.368), and tendon stiffness was found to have a significant association with maximal voluntary isometric contractions of ankle plantarflexion (p < 0.001, β = 0.598).
Conclusion
The relationships among PROMs, tendon properties, and functional performances are weak. Combining these outcomes is suggested for a comprehensive evaluation of patients with Achilles tendinopathy.
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Physical therapy for achilles tendinopathy

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Physical therapy for achilles tendinopathy

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Treating plantar fasciitis; American Physical Therapy Association guidelines

Effectiveness of physical therapy treatment in addition to usual podiatry management of plantar heel

Physical Therapy May Not Help with Ankle sprains

Severs disease: orthotics vs physical therapy vs 'wait and see'

Predictors of Response to Physical Therapy Intervention for Plantar Heel Pain

Physical Therapy - Cold Therapy what do you use?

Electrophysical therapy for managing diabetic foot ulcers

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