30 Seconds Of Therapy: Treating Mid-Portion Achilles Tendinopathy: Evidence-Based Interventions for Lasting Recovery

START

1. Applying slow, heavy resistance training beyond just eccentric loading

   1. Progression: Bilateral heel raises → single-leg → eccentric off-step. Include variations with knees straight (gastrocnemius) and bent (soleus)

   2. Frequency: 2x per week

   3. Intensity: Load within ≤5/10 pain tolerance. Start with body weight, then add resistance (e.g., dumbbells) once 15+ reps are tolerated. Progress to 6–12 reps with added load to promote tendon remodeling.

      
      

2. Use Pain Monitoring Model to guide load and pacing

   1. What to monitor: Mild Pain is Not Harmful. It's helpful. 

      1. Pain during activity: ≤5/10

      2. Pain immediately after: ≤5/10

      3. Pain the next morning: ≤5/10

   2. Reaction to

      1. Escalating Pain Increased From Previous Week.

      2. Reduce load or intensity, Increase rest days between sessions, Modify exercises to lower-impact variations.

      3. Pain should return to baseline next day.

         
         

3. Differentiating acute vs. non-acute tendinopathy for Intervention

   1. Effective treatment depends on proper stage identification and irritability level.

      1. Acute/Irritable: Duration < 3 months, visible swelling, pain ≥ 4/10 with low-load tasks (e.g., walking, standing, light activity)

      2. Non-Acute: Duration > 3 months, tendon thickening, pain triggered by high-load tasks (e.g., running, jumping, heavy resistance exercises)

STOP

1. Stop using night splints and elastic taping

   1. Night splints: minimal to no benefit.

   2. Elastic taping: no meaningful change in function or pain.

   3. Wastes time and distracts from high-impact interventions like loading with no physiological effect on tendon remodeling.

      
      

2. Stop relying solely on eccentric protocols

   1. Eccentric ONLY: Avoid performing eccentric loading only, rather Include slow concentric-eccentric exercises

      1. Adjust based on load response= Progress the exercise based on how the tendon tolerates the load (pain ≤ 5/10), not just because a protocol says to. Tolerated: increase resistance. Symptoms Worsen: , reduce or pause.

   2. Match rehab to tendon loading thresholds: Start: Cycling ≈ 1x Body Weight (BW) , Progress: Walking ≈ 3.5x BW,  Progress: Jumping ≈ 5x BW, Progress: Running ≈ 12x BW

      
      

3. Stop discharging when pain is gone but function remains impaired

   1. What to verify before return to sport:

      1. Heel raises endurance: > 25 single-leg heel raises ( good form and no pain) (compare bilaterally).

      2. Jump/hop control: Hop in place on one leg for 30 seconds; forward and multidirectional hops without pain, loss of balance, or compensation.

      3. ROM and strength symmetry: Ankle dorsiflexion and plantarflexion ROM and calf strength should be within 90–95% of the uninvolved side.

      4. Sport-specific tolerance: Patients should complete drills or activities mimicking sport demands (e.g., running, cutting, jumping) without increased pain or stiffness during, after, or the next morning. 

WHY

1.  Effective Achilles tendinopathy treatment relies on progressive loading not passive modalities. While PRP, steroids, or splints may ease pain briefly, they don’t restore tendon function. Unloading may relieve symptoms, but without load, the tendon won’t remodel, leaving it weak and prone to re-injury.

   
   

2. Clinicians need to shift both their mindset and patient expectations using the Pain Monitoring Model. This approach allows for controlled, tolerable discomfort that’s essential for tendon remodeling because loading is what stimulates collagen repair and strengthens the tendon. It also helps reduce kinesiophobia, which can limit progress. Educating patients to expect and accept some pain during rehab is often the difference between recurrence and resolution.