Achilles Tendinopathy: Evidence-Based Treatment & Ultrasound-Guided Injection

The Achilles tendon links your calf muscles to your heel and takes enormous loads every time you walk, run or jump. When it becomes painful and its structure changes, we call it Achilles tendinopathy (a better term than "tendonitis", because long-standing Achilles problems aren't simply inflammation). It can make walking, stairs, running, even those first steps out of bed, uncomfortable, and the tendon can visibly thicken. Reassuringly, most cases settle with the right rehabilitation. This page explains how I assess it and what the evidence really supports, including a treatment I'm often asked about, the high-volume injection, where recent research has genuinely changed the picture.

What is Achilles tendinopathy, and which type?

Tendinopathy develops when the load on the tendon outstrips its current capacity to cope. Common symptoms are pain during or after activity, morning stiffness, pain on the first steps after resting, tenderness when you squeeze the tendon, thickening or swelling, and reduced calf strength. Crucially, it isn't one single condition, and the two main types are treated slightly differently:

• Midportion, pain about 2–6 cm above the heel, often with a thickened area you can feel. This is the type most of the research (and most injections) relates to.
• Insertional, pain right where the tendon attaches to the heel bone. It can come with calcification, a bony "Haglund" prominence or a retrocalcaneal bursa, and it's aggravated by compression of the tendon against the bone. That's why the rehab is adjusted, a 2025 trial showed that reducing tendon compression (rather than dropping the heel into full stretch) gives better results here (Pringels et al., 2025).

What causes it?

Usually there's no single cause, it often follows a mismatch between load and capacity: a jump in running volume or speed, hill running, more jumping, a change of sport, returning after time off, or not enough recovery. But it isn't only an athlete's problem: age, body weight, metabolic health, diabetes, inflammatory conditions, lower-limb mechanics, previous tendon injury, and certain medications (particularly fluoroquinolone antibiotics) can all play a part. That's exactly why treatment has to be about more than just "what looks abnormal on the scan".

How I diagnose it, and what ultrasound shows

Diagnosis is mainly clinical: where the pain is, how long it's been there, morning stiffness, your training history, calf strength and single-leg heel-rise, tendon tenderness and thickness, and how your ankle and leg move. I also check for the things that can mimic it, a partial tear, a bursa, plantaris pain, posterior ankle impingement, inflammatory enthesitis or nerve-related pain.

Ultrasound is especially good for the Achilles because I can examine the whole tendon in real time, looking for thickening, loss of the normal fibre pattern, increased blood flow (neovascularity) on Doppler, partial tears, calcification or a bursa, and tell midportion from insertional problems. One important caveat: a scan that looks abnormal isn't always the source of pain. So I base treatment on the whole picture, your story, the examination and the imaging together, not the scan alone.

Treatment: loading comes first

The single most important principle is that tendons need the right loading, not prolonged rest.

Progressive tendon loading

Exercise rehabilitation is the first-line treatment for most people. A 2023 review of randomised trials confirmed that loading exercise works, while finding no single protocol is universally best (Maetz et al., 2023). The old "eccentric heel-drops only" approach isn't required; heavy slow resistance, concentric-eccentric calf raises and progressive resistance all work. What matters is progressive load, enough resistance, and consistency. Tendons adapt slowly, so a programme usually runs for at least 12 weeks, with improvement often continuing over months.

Evidence: strong, the foundation of treatment

For insertional tendinopathy I usually start heel raises from a more neutral ankle position (rather than dropping into deep stretch, which compresses the sore insertion) and add depth gradually as symptoms allow (Pringels et al., 2025). And rather than complete rest, it's usually better to temporarily ease off the biggest tendon loads, sprinting, hills, jumping, high mileage, while keeping lower-load fitness going. The goal isn't just to be pain-free walking about; it's to rebuild enough capacity for the activities you actually want to do.

Shockwave therapy

Shockwave (ESWT) has been popular for chronic Achilles pain, and earlier trials were encouraging when it was added to rehab. But the picture has shifted: a 2025 placebo-controlled trial in insertional tendinopathy found radial shockwave added no benefit over sham, and a 2026 meta-analysis concluded there's no clinically meaningful overall benefit for either type, though the certainty of the evidence is low (Alsulaimani et al., 2025; Korakakis et al., 2026). So I no longer treat shockwave as an essential step. It's a reasonable option in selected chronic cases, but progressive loading matters more, and you don't have to "fail shockwave" before considering anything else.

Evidence: weaker than once thought, especially for insertional

High-volume & peritendinous injection, the honest story

This is the treatment I'm asked about most, and it's worth explaining properly because the evidence has genuinely changed.

A high-volume image-guided injection (HVIGI) uses ultrasound to place a relatively large volume of fluid in front of the Achilles (between the tendon and the tissue ahead of it), deliberately not into the tendon itself. The original idea was that the volume disrupts the small blood vessels and nerves that grow around a chronically painful tendon. Early results looked impressive, but there was a catch: those early injections usually also contained a small dose of corticosteroid. So the key question became: is it the volume that helps, or the steroid?

A high-quality 2020 BMJ trial answered it. High-volume injection without steroid did reduce the abnormal blood flow on Doppler, but that didn't translate into less pain, and the authors concluded it wasn't worth recommending on its own (van der Vlist et al., 2020). In other words, washing out the vessels doesn't wash out the pain.

High volume alone (no steroid): no convincing benefit

What does help is a carefully placed steroid. A 2022 placebo-controlled trial (JAMA Network Open) gave 100 people with chronic midportion tendinopathy structured heavy-slow-resistance rehab plus either an ultrasound-guided corticosteroid injection placed in front of the tendon (not into it) or a placebo. At six months the steroid group improved markedly more on the standard pain-and-function score, with no rise in serious problems, and outcomes held up at two years (Johannsen et al., 2022). The message: as an adjunct to rehabilitation, a peritendinous steroid injection can meaningfully reduce pain, but it's not a cure on its own, and it was tested in a carefully selected group who also did their exercises and avoided running/jumping for the first three months.

Peritendinous corticosteroid + rehab: moderate, a useful adjunct in selected midportion cases

Is a steroid injection dangerous around the Achilles?

It's a fair concern, tendon ruptures have been reported historically. The critical distinction is into the tendon versus carefully placed around it. I would never inject steroid into the Achilles. In the 2022 trial the steroid was placed in front of the tendon under ultrasound, and there was no increase in serious adverse events over two years (Johannsen et al., 2022). That's much stronger reassurance than old case reports, provided the studied, ultrasound-guided technique is used.

When I'd consider it, and when I'd be cautious

I'd mainly consider an ultrasound-guided peritendinous injection for chronic midportion tendinopathy when symptoms have persisted for months, the diagnosis is clear on examination and scan, you've already given a proper loading programme a real go, pain is blocking rehab progress, there's significant thickening and/or Doppler vascularity, and there's no significant tear. I'm more cautious with insertional disease, significant partial tears, previous rupture or tendon surgery, inflammatory disease, uncontrolled diabetes, recent fluoroquinolone-related symptoms, or an uncertain diagnosis. And I'm always clear that high-volume saline alone isn't an effective treatment, the aim is to reduce pain enough to let rehabilitation continue, not to "regenerate" the tendon.

What the procedure involves

It's done under continuous ultrasound. I first assess the tendon structure, thickness, Doppler flow, any partial tearing and the surrounding tissues. After cleaning the skin and using local anaesthetic, the needle is guided to sit in front of the tendon, and the fluid (and any agreed medication) is placed there, never into the tendon fibres. It takes a few minutes. And the injection isn't the end: progressive calf and tendon strengthening remains the core of your recovery.

PRP & hyaluronic acid

PRP is heavily marketed as "regenerative", and the lab rationale is appealing, but the clinical trials don't back it up here. The largest modern trial (JAMA 2021, 240 patients) found a single PRP injection was no better than sham at six months, and a 2024 meta-analysis found no significant improvement over control (Kearney et al., 2021; Ling et al., 2024). So I wouldn't routinely recommend PRP for chronic midportion Achilles tendinopathy.

PRP: no convincing benefit over placebo

Hyaluronic acid has been studied across soft-tissue problems with some promising but very mixed results, not enough robust placebo-controlled evidence to put it ahead of rehabilitation or the better-studied options. I'd treat it as a selected/emerging option, not standard care. The same goes for dry needling / tendon fenestration, usually combined with other treatments, with less convincing Achilles-specific evidence than loading.

Hyaluronic acid / fenestration: limited evidence

If rehab and injections don't work

Surgery is rarely the first option, it's generally reserved for symptoms that persist after several months of well-run non-operative treatment. For midportion disease it may involve debriding abnormal tendon or surrounding tissue; for insertional disease it can include removing degenerative tendon, calcific deposits or a symptomatic bony prominence, and reattaching the tendon. Reviews suggest surgery can help carefully selected, stubborn insertional cases, though the evidence is still mostly observational (systematic reviews, 2024–25). So it stays a last-line, not early, treatment, and where prolonged conservative care fails, I'll help arrange the right foot and ankle surgical opinion.

My approach

1. Early or moderate symptoms, education, load modification and progressive tendon strengthening. This is the foundation for everyone.
2. Persistent midportion tendinopathy, first reassess the diagnosis and the loading strategy; then consider a selected adjunct, shockwave in the right circumstances, or an ultrasound-guided peritendinous corticosteroid injection alongside continued rehab. I generally wouldn't prioritise PRP.
3. Persistent insertional tendinopathy, focus on reducing compression plus progressive loading, and assess for calcification, Haglund shape, a bursa or significant tearing. Shockwave looks less convincing here.
4. If prolonged conservative care fails, referral to a foot and ankle surgeon.

Frequently asked questions

References