Current concept review of Achilles tendinopathy

Abstract

Achilles tendinopathy is a common overuse injury affecting the ankle and foot. It manifests as a clinical condition that includes pain, edema, and decreased functionality. This condition can be broadly categorized into two main types based on anatomical location: insertional and noninsertional tendinopathy. The development of Achilles tendinopathy involves various factors, both internal and external. Patients with Achilles tendinopathy often experience stiffness worsened by prolonged rest, and pain exacerbated by physical activity. These symptoms can limit work activity and sports participation, with many patients facing discomfort while wearing shoes due to heel sensitivity. Diagnosis is primarily clinical, although MRI and ultrasound imaging can aid in differential diagnosis. Identifying risk factors and understanding the patient's biomechanics assist in accurate diagnosis and subsequent management. Management of Achilles tendinopathy involves a range of conservative and surgical options. However, due to varying results in clinical studies, a definitive gold standard treatment has not emerged. Eccentric exercises are a valuable tool in managing the condition. The recommend treatments such as shock wave therapy or nitric oxide patches are sought if symptoms do not improve. Peritendinous injections could be options if physical therapy proves ineffective. Surgical intervention is required after six months of conservative treatment. Recent research on Achilles tendinopathy emphasizes the need for individualized treatment plans that address its multifaceted nature. Combining biomechanical analysis, advanced imaging, and patient-specific factors is key to achieving optimal outcomes. Additionally, preventive strategies focusing on proper training techniques, load management, and addressing modifiable risk factors play a critical role in reducing the incidence of this condition. In conclusion, this article provides a current overview of Achilles tendinopathy. It highlights the importance of a comprehensive approach to understanding its causes, pathophysiology, diagnosis, and management strategies.

1. Introduction

Achilles tendinopathy (AT) is a commonly observed disorder in the lower limb.¹ The main symptoms of AT are persistent pain and swelling in the tendon, as well as a decrease in performance due to excessive mechanical strain (overuse) on the Achilles tendon, which is often encountered in both sports and daily activities.2, 3, 4 The overall incidence of AT is estimated to be 1.85 cases per 1000 patients, with a higher rate of 2.35 cases per 1000 in the 21-60-year-old population. Among athletes, individuals engaged in running and jumping sports are particularly prone to developing AT.⁵ While the sensation of stiffness in the calf muscles has been identified as a risk factor for AT, the condition is influenced by multiple factors.¹ Several treatment approaches are available for Achilles tendinopathy and have shown satisfactory outcomes. Nonetheless, AT remains a relevant clinical concern, prompting further exploration of potential new therapies. The purpose of this review is to provide clinicians with a comprehensive overview of the diagnostic and therapeutic modalities currently employed for the management of Achilles tendinopathy.

2. Anatomy of Achilles Tendon

2.1. The muscle

The Achilles tendon is the body's thickest, largest and robust tendon.⁶ It is a composite tendon formed by the confluence of the tendons of the gastrocnemius & soleus muscles and sometimes plantaris, known as triceps surae, which are located in the posterior aspect of the leg. The triceps surae, along with Achilles tendon, plantarflexes ankle joint.^7,8 The gastrocnemius's medial head contributes more posterior fibers, and the anterior fibers are contributed by lateral head. The fibers to the central and medial regions are contributed by soleus muscle, offering an additional contribution to the tendon.⁹ The AT and the muscles that form it receive their neurovascular supply from the posterior tibial & peroneal arteries, tibial nerve, and their branches.¹⁰

2.2. The tendon

The Achilles tendon is around 15 cm in length, with a range 11–26 cm. It originates as the conjoint tendon of triceps surae muscle in the calf. At its origin, the tendon averages 6.8 cm (range, 4.5–8.6 cm), gradually tapering down to 1.8 cm (range, 1.2–2.6 cm) in the midsection. It then takes on a more rounded shape until about 4 cm above the calcaneum, where it expands. It inserts as a wide, crescent-shaped structure with extensions both medially (up to 9.1 mm) and laterally (up to 5.5 mm), around 2 cm distal to the posterosuperior calcaneal prominence, where its average width is 3.4 cm (range 2.0–4.8 cm) at midpoint.11, 12, 13 This has significant consequences for surgical interventions in this location, as the undamaged section of tendon must be preserved. At the tendon insertion bursae are present, located above and below the tendon. The most common is retrocalcaneal bursa, which is located between calcaneum and the tendon. Also a bursae is located superficial to the Achilles tendon, known as an adventitious bursa, which may become inflamed due to friction caused by footwear rubbing against the bursa.¹⁰ A thin paratenon, which consists of loose areolar tissue and acts as a gliding membrane, surrounds the tendon. Its main purpose is to allow smooth movements of tendon against the neighboring tissues. The fibers of the Achilles tendon do not align strictly in a vertical manner and exhibit varying degrees of spiraling or winding, with up to 90 degrees of rotation occurring after the formation of the tendon. Thus area of increased strain is created as a result, which is most noticeable 2 cm to 5 cms above the calcaneal insertion. Due to its inadequate blood supply, this area is prone to tendinopathy and rupture..¹⁰

2.3. Neurovascular supply

Within the posterior compartment of the leg, the posterior tibial artery (PTA) runs medially, while the peroneal artery (PA) runs laterally. The proximal portion of tendon is supplied by PTA, midsection by PA and distal by PTA. It is worth noting that the anterior surface of tendon seems to have better vascularity than the posterior surface. The twisting or torsion of the Achilles tendon fibers leads to rotation of the blood vessels, creating areas of heightened stress and diminished blood flow within the tendon.¹⁴ The skin covering the Achilles tendon has three vascular zones: a) medial - with the most abundant blood supply, b) posterior - with limited blood supply, c) lateral - better than posterior but not as good as medial (Fig. 1). Considering these vascular zones, a carefully planned incision in the medial and lateral zones will help to enhance wound healing following surgery.¹⁵ The Achilles tendon is primarily innervated by nerve fibers that originate from the sural nerve (SN). Approximately 8–10 cm proximal to upper border of calcaneum and around 3.5 cm distal to the musculotendinous junction, the SN traverses the Achilles tendon's lateral border.¹⁶ Consequently, SN is at a high chance of inadvertent injury during surgeries involving the Achilles tendon. Sensory impairments may develop from injury to this nerve, and it is crucial to be aware of its presence during Achilles tendon procedures in order to avoid subsequent paresthesia.^17,18

Fig. 1.

Vascular zones of skin overlying Achilles Tendon for planning skin incision- (a) medial zone with abundunt supply provided by three or four small branches arising from the posterior tibial artery (b) central hypovascular zone along the posterior skin covering the tendon (c) lateral zone provided by three or four small branches arising from the peroneal artery or its recurrent branch, not as good as in the medial zone but better than in the posterior zone.

3. Epidemiology

AT is a frequent disorder in foot and ankle caused by overuse. It is commonly seen in people who engage in running or jumping. The prevalence and incidence of AT in different groups is still uncertain, however there are different studies which provides some light on the epidemiology of AT. Lysholm et all observed that 9% of recreational runners may be affected by AT, while professional athletes can experience it in about 5% of cases.¹⁹ A study by Waldecker, which examined 1394 feet, found that Achilles tendinopathy was present in 5.6% of the participants. Of these cases, 4% had insertional tendinopathy, 3.6% had noninsertional tendinopathy, & 1.9% had both insertional as well as noninsertional.²⁰ A study by Kvist revealed, among Achilles tendinopathy patients, approximately 20%–25% suffered from insertional tendinopathy, 66% suffered from noninsertional tendinopathy, and 23% suffered either from insertional tendinopathy or retrocalcaneal bursitis.²¹ Chronic tendinopathy is common in middle aged individuals (30–55 years old) compared to younger ones. In a study by Kvist's, only 25% of the 470 patients with AT were young athletes.⁹ Furthermore, noninsertional tendinopathy more commonly occur in older, sedentary, and obese individuals whereas active individuals tend to develop insertional tendinopathy.²²

4. Etiology

The fundamental cause of Achilles tendinopathy is known to be complex, involving multiple factors. It may be triggered by internal or external stimuli, in isolation or in combination. External factors tend to be more prominent in acute trauma, whereas injuries by excessive use typically have a complex origin. These two categories of variables tend to coexist in chronic conditions..²³ Intrinsic factors include lower extremity anomalies such as disparity in leg length, hyperpronation of foot, cavus or varus foot, decreased motion of the subtalar joint, etc.²² The conditions, such as increasing age,²⁴ inflammatory joint diseases, corticosteroids, overweight, and gout,²⁵ are also considered intrinsic factors. External factors may encompass increased mechanical stress and mistakes in training, such as engaging in intense interval training, sudden modification in training routines, increased uphill or downhill workouts, workouts on rigid or inclined surfaces, running excessively long distances or at high intensities. Poor surroundings, such as wintertime temperatures, concrete surfaces, and wet or a frozen terrain, have also been linked to AT.^22,23,25

5. Pathophysiology

Achilles tendinopathy, as defined by Maffulli et al. refers to a clinical condition with three characteristics: pain, swelling, and functional impairment. These symptoms align with the histological pattern of “tendinosis,” & signifies a non-inflammatory degenerative process involving an irregular structure of collagen.²⁶ Various terms such as tendinitis, tendinosis, and paratenonitis have been used to describe these disorders. However, recent histopathological studies have revealed that these conditions are the result of an inadequate healing response, concomitant neovascularization, leading to degenerative changes in the tendon. Consequently, the term “tendinitis” should not be used because it implies inflammation, which might or might not exist in the damaged tendon. and cannot be reliably assessed clinically.^4,27 Additionally, in cases of insertional Achilles tendinopathy, numerous additional disorders, such as calcifications within the tendon, an inflamed retrocalcaneal bursa, and tendinosis frequently coexist with it, & also bony overgrowth known as Haglund's deformity.²⁸

6. Clinical features

The primary means of diagnosing AT relies on the medical history and a physical clinical evaluation. AT is categorized based on its location: insertional, which occurs at junction of the Achilles tendon and the calcaneum, and noninsertional, which is situated 2–6 cm above this insertion point.²¹ Patients often experience pain in the tendon when initiating movement after a period of rest or in the morning, but the pain tends to decrease with continued activity. In athletes or during exercise, discomfort usually begins as the session starts and also when the session ends, with intervals of lesser discomfort. As the problem gets more severe, and becomes chronic, the pain may persist even after minor exertion, potentially hindering daily activities and necessitating a reduction or cessation of physical activity. Patients typically exhibit tenderness when pressure is applied within the 2 cm of tendon insertion. Inspection often reveals fullness and redness at back of the heel. Palpation may reveal tenderness, thickening, nodularity, or a grating sensation in the affected area. Assessing the range of motion in ankle dorsiflexion (including the Silversköld test to evaluate isolated gastrocnemius contracture) & checking for weakness in plantarflexors are useful. Painful movement may be detected, characterized by the nodule's movement within the paratenon during ankle movement. Additionally, examining hindfoot malalignment, previous scarring, deformity, asymmetry of the tendons, Haglund deformity.

7. Imaging

Imaging has a crucial part in diagnosing AT and formulating an appropriate treatment plan. Three imaging techniques commonly used for AT are radiographs, ultrasound (US), and Magnetic Resonance Imaging (MRI). In symptomatic cases of more than 6 weeks' duration, a lateral view radiograph of the heel is typically the initial investigation. This helps identify any associated bony abnormalities, cavus, posterior calcification, haglund, or intratendinous calcification (Fig. 2). The presence of posterior calcification in the calcaneum is a diagnostic indicator of insertional.²⁹ MRI and ultrasound are valuable tools in obtaining more detailed information about tendon morphology, the extent of degeneration, preoperative planning, and differentiating between peritendinitis and tendinosis. Though operator-dependent, ultrasound can be reliable in diagnosing and monitoring Achilles tendinopathy, as it allows visualization of tendon structure and the use of color Doppler to detect neovascularity.^28,29 A recently introduced method called Ultrasound Tissue Characterization (UTC) enables quantitative evaluation of structure of tendon along with differentiation between symptomatic and asymptomatic tendons.³⁰ MRI yields extensive details about tendon structure, helping distinguish between healthy and diseased tendons and assess surrounding bone and soft tissue. It is particularly useful in differentiating paratendinopathy from tendinopathy (Fig. 3). Additionally, it is useful for preoperative planning since it aids in assessing the amount of unhealthy tissue present.²⁹ When it comes to detecting incomplete tendon tears, MRI outperforms ultrasound.³⁰ However, due to the substantial amount of information provided by MRI, the results should be carefully interpreted, and clinical correlation of patient's complaints is essential prior to making any decisions.

Fig. 2.

Xray both heel lateral showing extensive posterior calcification involving tendon with Haglund.

Fig. 3.

MRI showing tendon degeneraion, edema and insertional tendinopathy.

8. Management

There are several treatment options available for AT. Initially, conservative treatment is recommended for most cases. This approach involves identifying potential causes and addressing them, along with managing the symptoms. Conservative treatment may include rest and modifying activities, medications, orthotic treatment such as using heel raises and appropriate footwear to correct malalignments, as well as incorporating stretching and strengthening exercises. Additionally, extracorporeal shock wave therapy and injections are also potential treatment options. If non-surgical treatments are not successful, then surgical treatment can be considered. However, it's generally recommended to continue conservative management for at least three to six months before contemplating surgery. During this period, about 75% of patients may experience resolution of their AT.²⁹

8.1. Conservative management

8.1.1. General

During the early phase of treatment for AT, the primary objectives are to manage inflammation and address any underlying causes. A comprehensive approach is taken, which involves rest and the use of cryotherapy to reduce inflammation. While it's important to minimize or eliminate activities that triggered the symptoms, it's also advisable to maintain normal activity levels. Orthotics play a crucial role in this phase, as they can modify the foot and ankle's biomechanics, thereby alleviating heel pain. If there is an abnormal foot alignment, orthoses can help position the hindfoot in a neutral position, which in turn reduces stress on the tendon. As part of the treatment, a heel raise of approximately 12–15 mm is commonly recommended to help de-tension the tendon.^29,31 The night splint might be helpful in certain patients of AT where passive dorsiflexion may be helpful, resulting in a reduction of strain on the tendon..^34,36,37 RCT conducted by Vos et al. reported that a night splint did not provide additional benefits when used alongside eccentric exercises for AT.³⁸

8.1.2. Pharmacological

For the pharmacologic management of AT, nonsteroidal anti-inflammatory medications (NSAIDs) are usually advised, due to their analgesic and anti-inflammatory properties. NSAIDs, however, may prevent migration of tendon cell, proliferation, and repair, according to a few studies. Despite these concerns, short-term use of NSAIDs can be beneficial in managing pain and inflammation to aid rehabilitation.^29,31,32

Nutraceutical supplements have shown potential in influencing various aspects of AT, such as promoting the production of collagen, reducing inflammation, improving mechanical qualities, maturing collagen bundles, reducing edema, and relieving pain. However, their full effectiveness is yet to be confirmed by clinical studies, making it difficult to draw definitive recommendations on their use for treating AT.³³

A randomized control trial reported significant benefits in treating tendons with topical glyceryl trinitrate patches. 28 out of 32 tendons became asymptomatic after six months of continued treatment with the patches applied to the tendon, which required daily replacement for six months. At 12 and 24 weeks, treatment group experienced less activity-related pain in comparison to the control group, and these advantages lasted for up to 3 years. A more recent study, however, has cast doubt on the clinical utility of topical glyceryl trinitrate patches..^29,35

8.1.3. Eccentric exercise

Eccentric exercises are considered primary approach for conservative management of AT, yielding positive short-term and long-term clinical outcomes. Alfredson's 12-week eccentric training model is the most commonly used protocol. It involves two types of eccentric exercises, one with extended knee and the other with bent knee. To activate the soleus muscle, the muscle in the calf is eccentrically stretched first with the knee extended and subsequently with the knee bent. (Fig. 4).

Fig. 4.

Patients are guided through a series of eccentric exercises, which begins with a heel lift (a). Following this, they proceede to perform eccentric drops using the injured leg with knee extended (b) and then knee flexed (c). Informed consent was obtained for the publication of this figure.

Patients are advised to undergo these eccentric exercises twice daily, seven days a week, for 12 weeks, with 15 repetitions in 3 sets, totaling 180 repetitions per day. The protocol emphasizes the importance of continuing the exercises even if there is some pain in the tendon. If patients do not have tendon discomfort while participating in the program, the intensity should be adjusted till the exercises cause pain. It is normal for patients to experience muscle soreness during the initial 1–2 weeks of training.³⁶

The exact mechanism of action for eccentric exercise in AT treatment is not entirely comprehended, but it is postulated to be related to its ability to disrupt neovascularization between the paratenon-fascial tendon layers. Notably, Alfredson's model involves no concentric loading. In almost 90% of cases with noninsertional pathology, 12-week eccentric exercise regimen helps where other traditional treatments have fallen short. The response is less favorable for insertional tendinopathy, and only about 30% of tendons show promising clinical outcomes..³⁷

8.1.4. Intralesional injections-

• a)Corticosteroid injections are frequently employed for treatment of AT, however, their usage is still debatable. The limited number of randomized controlled studies investigating injection of local steroid have yielded variable outcomes in AT. In the short term, a few studies have demonstrated an overall decrease in tendon thickness as determined by ultrasonography and a decrease in walking discomfort. However, it is imperative to be aware about possible hazards related to corticosteroid injections. The corticosteroid injection, either intratendinous or peritendinous, has been linked to spontaneous rupture of the Achilles tendon. Due to this risk, local corticosteroid injections are not indicated as a first-line therapy option for Achilles tendinopathy..^31,37
• b)Platelet-rich plasma (PRP) is being more widely used to treat tendinopathy. By providing cytokines and growth factors that are involved in tissue repair processes, it is thought to improve tendon recovery. However, the results from studies using PRP have shown variability, and there is no evidence of a clinically significant difference between PRP and saline solution treatments when used alone..^31,34,39 Nevertheless, another aspect to consider is the potential benefit of concurrent treatment, such as combining PRP with physical therapy, particularly based on eccentric exercises. This combination aims to promote biological stimulation of tendon healing and potentially lead to a better overall outcome. Current evidence therefore suggests that combining both methods could be successful in treating difficult cases of complicated tendinopathies.³⁹
• c)An indirect cause of tendon pain in AT is believed to be neovascularization.^4,27 This has been studied using Ultrasound-guided injection of a vascular sclerosant called Polidocanol, which is both a sclerosing and anesthetic agent. The injection is administered anterior to the tendon in the region of neovascularization, resulting in pain relief and improved patient satisfaction.³⁷ An injection of Polidocanol, a sclerosing agent, was found to be more effective than injections of lidocaine and epinephrine, a non-sclerosing agent, in a double-blind RCT..³⁷ Similar to this, high quantities of ultrasound-guided saline injections work to stop neovascularization by mechanically disrupting new blood vessels and the nerve supply.³¹ These therapies may have advantages, but they have not received general acceptance. This may be because noninvasive methods, such as eccentric exercise sessions, have also demonstrated ability to reduce neovascularization and relieve pain in patients.^31,36,37

8.1.5. Extracorporeal shock wave therapy

Extracorporeal Shock Wave Therapy (ESWT) is used in patients who have not experienced satisfactory results with other conservative management or have failed conservative treatments altogether. ESWT is supposed to function by producing alterations in the dorsal root ganglia and sensory nerve fibers, potentially leading to decreased pain sensation. Additionally, it might encourage catabolic and proinflammatory activities, assisting in the elimination of disrupted matrix components, as well as stimulate tenocyte proliferation and collagen synthesis. These effects typically start to manifest after 3–4 sessions of therapy.^31,34,37,40 Low-energy ESWT has shown positive outcomes in treating chronic AT. Studies have shown reduced pain and improved functional results for at least three months, making ESWT a viable option to consider before resorting to surgery if other conservative management approaches have not been successful.^37,40 The recommended dosage to achieve positive effects typically ranges between 1500 and 2500 impulses per session, administered at a flux density of 0.1–0.5 mJ/mm2. Usually, a minimum of 3 sessions with a one-week interval between sessions can be expected to improve pain and function. Increasing the number of sessions does not appear to provide any further benefit in terms of results. The most common reported risk of ESWT is transitory skin reddening, which has been observed in most studies..⁴⁰

8.2. Surgical management

Surgery is typically considered when all conservative measures have been explored and patient's symptoms persist, significantly impairing their daily activities and quality of life. Approximately 24%–45% of patients with AT do not respond well to conservative treatments, leading to the recommendation for surgery after trying conservative approaches for at least 6 months.^29,31 For AT, various surgical procedures are described with different goals. Some methods are intended to cause minor damage to the deteriorated tendon, triggering a healing process. Others focus on removing the degenerated portion of the tendon, calcifications, haglund deformity & the retrocalcaneal bursa. The choice of the specific surgical approach is determined by the individual patient's condition, the severity of the tendon damage, and the surgeon's expertise.^29,31

8.2.1. Percutaneous tenotomy and debridement

Tenotomy and debridement is an extensively researched and validated surgical procedure for noninsertional AT. Percutaneous longitudinal tenotomy is a specific procedure in which several percutaneous incisions are performed in the affected region of the Achilles tendon under the guidance of ultrasound. It is suitable for mild-to-moderate cases and those at risk for wound complications. Percutaneous longitudinal tenotomy has shown successful outcomes in 67%–97% of cases, particularly in athletic individuals, while in cases with more severe tendinopathy and paratendinopathy may experience less favorable outcomes.^31,34 Comparing different patient groups, better outcomes and fewer postoperative complications have been reported in athletic patients compared to nonathletic individuals. Additionally, better outcomes have been observed in male patients in comparison to females.³⁴ These differences in outcomes may be altered by different parameters, like the extent of tendon damage, activity levels, and individual healing responses.

8.2.2. Open debridement and decompression

In patients with moderate to severe noninsertional Achilles tendinopathy, an open procedure may be necessary, especially when adhesions are difficult to remove with simple percutaneous techniques. It is also indicated for patients with insertional tendinopathy who have a prominent calcaneal tuberosity and posterior calcification that does not respond to conservative management.^29,31,34,41 The primary purpose of the open surgery is to excise the diseased tendon and restore the function and strength of the Achilles tendon. In cases of noninsertional tendinopathy, the diseased tendon is removed, and the tendon is thoroughly assessed for the degree of involvement of tendon. Fibrotic adhesions and intratendinous lesions are identified and resected, while the remaining healthy tendinous tissue is repaired.^31,34 For insertional tendinopathy, there are various approaches described in the literature, but insufficient evidence exists to support one approach over another. The main aim is to minimize soft tissue and wound healing complications, which could be problematic. A preferred approach involves a vertical incision positioned on the medial or lateral side of the tendon. This approach provides good visualization, minimal disruption of the neurovascular supply, access to the flexor hallucis longus (FHL) if augmentation is required, and slightly reduced possibility of injury to sural nerve. It is crucial to ensure haglund resection along with resection of posterior calcification, excision of retrocalcaneal bursa, and removal of adhesions and diseased paratenon for favorable outcomes.^29,41 The acceptable extent of detachment for debridement of the Achilles insertion can vary but it is generally considered safe to detach up to half of the tendinous insertion. If the detachment exceeds 50 percent, a double-row fixation using anchors for reinsertion is required and recommended over single-row anchors.⁴¹ When the Achilles tendon is severely degenerated, the transfer of FHL reinforces the repair, particularly in adults over the age of 50. Also described is the method of endoscopic debridement, which may have benefits including a quicker recovery time and fewer surgical problems. However, a drawback of the endoscopic method is that, particularly in situations with full-thickness intratendinous calcifications, it may not entirely remove bone spurs or all the damaged tissue.^29,41 Rehabilitation plays a crucial role after surgery and focuses on early motion while avoiding excessive strain on the tendon when it's still in a reparative process. Patients often go through a period of crutch walking and splinting to let the discomfort and swelling go down. After 3 weeks, they are made to walk and engage in daily activities using a removable walker boot, along with passive ankle movement exercises and light resistive exercises. More intense conditioning workouts are started 6–8 weeks after surgery, gradually transitioning to plyometrics, jumping, and running..^29,31,41 The rehabilitation process is carefully tailored to each individual's progress and response to treatment.

8.2.3. Gastrocnemius recession

Tightness of the gastrocnemius muscle is associated with the development of AT, and to address this issue, recession of the gastrocnemius has been utilized. This procedure can be done as standalone or combined with other surgery.^29,31,41 Patients who are not very active tend to get better results and have faster recovery from just having the medial head of the gastrocnemius lengthened than from having open debridement. However, recession surgery may decrease calf muscle strength and circumference because the muscle is being lengthened. However, most patients are still able to perform the same functional activities they did before surgery. Therefore, it is not advisable for the athletic population.^34,41 Gastrocnemius recession surgery was found to be more effective for people without spurs than for people with spurs.⁴¹

9. Conclusion

Achilles tendinopathy has been a subject of extensive research, but its clinical diagnosis and management can still pose challenges even in the hands of experienced surgeons. It is important for the patient to know that symptoms may come back even after they have been treated. For nonoperative treatment, eccentric exercises remain the first-choice option due to their proven effectiveness. However, if eccentric training alone does not provide sufficient relief, PRP injections and ESWT can be considered as second-line treatments, particularly for patients who wish to avoid surgery. Surgery is considered the last resort and may not always guarantee complete resolution of symptoms. While surgical intervention can be beneficial in certain cases, it is crucial for patients to understand that the outcome may differ based on individual factors and the extent of tendon damage. Each patient's treatment plan should be tailored to their specific condition and goals, and a comprehensive approach involving both the patient and surgeon is essential to achieve the best possible outcomes in managing Achilles tendinopathy.

Funding

No specific grant for this research was provided by funding organizations in the public, private, or nonprofit sectors.

CRediT authorship contribution statement

Pradeep Moonot: Conceptualization, Methodology, Writing, Editing. Shubham Dakhode: Writing, review of literature.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.