A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation

Article summarized by: Evan Peterson PT, DPT

Achilles injuries, more specifically tendinopathies, are one of the most common injuries seen by physical therapists. Achilles Tendinopathy is an overuse injury which typically causes pain at the insertion of the tendon near the heel or at the mid portion of the tendon. This injury has a propensity to last for several years without proper rehabilitation. Typically, the injury is brought on by excessive utilization of the tendon or increasing intensity of training to rapidly. Unfortunately, reoccurrence or re-injury of the tendon is high with too little time in between rehabilitation and returning to usual activities. This specific article being reviewed had the goal of creating a return to sport program for those with mid portion Achilles tendinopathy injuries.

What Is Achilles Tendinopathy?

As described above, Achilles tendinopathy is an overuse injury which has hallmark signs such as swelling, pain, and impaired performance of function. The diagnosis of insertional versus mid portion is based on the distance from the calcaneus (heel). Mid portion is typically located 2-6 cm above the calcaneus whereas insertion is located at the bottom of the heel. Mid portion tends to be the more common of the two at 55-65% of all cases of Achilles tendinopathy. Both are categorized by pain, stiffness in the morning, tenderness to palpation or a thickening of the tendon, and gradual onset of pain and symptoms.

How Do We Treat It?

The treatment of Achilles tendinopathy has been extensively researched and has several systematic reviews investigating numerous interventions. Exercise time and again has shown significant benefits for Achilles rehabilitation, more specifically eccentric exercises. Many other interventions have shown benefits such as orthoses, shockwave therapy, and low-level laser but none as effective as exercise when used in isolation. There has been some evidence that the use of low-level laser or shockwave therapy alongside exercise can help to speed recovery.

What Exercise is Specifically Used?

At the present moment, exercise for Achilles tendinopathy revolves around eccentric heel raise activities with knee both bent and straight. It is suggested each exercise be performed 2x daily for 15 repetitions of 3 sets. This is a model that has been shown effective in the athletic population but has had mixed results in the general population. Therefore, it has been suggested that a more fine-tuned approach is important, considering age, sex, and activity level, in order to properly dose the intervention. More often it is suggested to utilize a numeric pain rating scale (NPRS) to establish the correct loading during exercise.

When Can the Patient Return to Sport?

When attempting to return to participation in sport, it is important to have gradual progression and loading of the tendon with adequate recovery in order to prevent re-injury after return to sport. Re-injury rate in soccer players was shown to be 27% to 44% when returning to sport to soon or with inadequate recovery. The clinician should be aware of symptoms the following day after sport activities that include stiffness, pain, and swelling. These are good indicators of readiness for returning to full activity. Some research advocates for no running or jumping until symptoms have subsided; however, others believe this is not always necessary. Instead there are numerous factors that must be considered when implementing a return to sport program. The level of pain with physical activity should be considered as well as the healing time of the tendon, the strength, range of motion, and functionality of the Achilles, and the physical demands of the specific sport.

Major Principles

The most important aspect of return to sport for Achilles tendinopathy is to progressively load the tendon while considering the intensity, duration, and frequency of the forces placed on the tendon. Before a patient begins jumping and running the patient should have a maximum of 2/10 pain while performing activities of daily living. Rehabilitation should be performed daily, despite having performed plyometric tasks during that day. One of the most important steps in returning an athlete to their sport, is to educate the patient on healing times and instilling a routine to increase adherence as they move closer to participating in sport again. The athlete must also understand the differences between light, medium, and heavy activities. These can be classified by pain during and after the activity performed. These activities are fluid and can change based on the patient’s response to pain.

Physical Therapy First

At Physical Therapy First, the therapists are trained to work with athletes or recreational athletes to implement plans of care that allow a person to return to their sport of choice. We utilize the aspects discussed in this article to minimize reoccurrence of injury when the patient feels they are ready to begin participation again. If you are someone who has experienced Achilles pain in the past or are currently experiencing Achilles pain, we here at Physical Therapy First are here to assist you.


A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation | Journal of Orthopaedic & Sports Physical Therapy (jospt.org)