Achilles tendinopathy: understanding the key concepts to improve clinical management

Introduction: Achilles tendinopathy is commonly encountered in clinical practice yet can be quite difficult to successfully treat. Relative overload is the precursor to most presentations, while systemic conditions can decrease the amount of load that triggers overload. While there is evidence for the use of eccentric exercise, it is not recommended in isolation for most presentations of Achilles tendinopathy as it fails to address strength and kinetic chain deficits, which can leave the individual vulnerable to recurrence. Insertional tendinopathy requires a tailored management that avoids dorsiflexion, as this position compresses the tendon onto the calcaneus. Purpose: This masterclass summarises the tendinopathy continuum and articulates the authors clinical reasoning and hands-on experience managingAchilles tendinopathy. We outline graded loading concepts while emphasising that relying on recipes is likely to fail. We also provide a perspective on the role of central pain processing and peripheral input from nociceptive fibres in the context of tendinopathy. Implications: Rehabilitation should be tailored to address identified impairments (muscle bulk asymmetries, kinetic chain dysfunction, tolerance of energy storage and release in the Achilles tendon), and progressively work toward movements and activities relevant for the individual s sport or daily activities. Within the three-stage rehabilitation sequence, stage I aims to reduce pain and increase calf muscle bulk; stage 2 focuses on improving power within the whole kinetic chain, and movement control during jumping and landing; and stage 3 begins to retrain sport specific load, and carefully introduces movements that require energy storage and release within the tendon.