Achilles & Heel
Non-Insertional Achilles Tendinopathy
About Your Condition
Non-insertional Achilles tendinopathy is degeneration within the body of the tendon, typically 2–6cm above its attachment to the heel bone. This region has a relatively poor blood supply, which is part of why it can be slow to heal and prone to becoming a persistent, nagging problem.
Symptoms include pain and thickening in the mid-portion of the tendon, stiffness with the first steps in the morning, and aggravation with running, hill work, and other higher-load activity.
Non-Operative Management
Non-operative management centres on eccentric tendon loading — the strongest evidence-based treatment for this condition.
Eccentric Loading (Alfredson Protocol)
- Heel drops performed off the edge of a step, with both a straight-knee and bent-knee variation, typically 3 sets of 15 repetitions twice daily for around 12 weeks.
- This is the mainstay of treatment and should be introduced and progressed under physiotherapy guidance — some discomfort during loading is expected, but pain that persists well beyond the exercise session suggests the load should be reduced.
Footwear and Activity Modification
- A heel lift can ease symptoms during a flare by reducing tendon strain.
- Reducing running and hill-work load during a symptomatic period allows the tendon to settle before resuming a graduated return.
Injections
- Cortisone injections are not recommended for Achilles tendinopathy — they can weaken the tendon and increase the risk of rupture, and are generally avoided in Dr Hogan's practice.
When to Consider Surgery
Surgery is considered when symptoms significantly limit your daily activities despite an adequate trial of non-operative treatment, typically over six months of dedicated eccentric loading.
The standard operation is Achilles tendon debridement — removal of the diseased portion of tendon. Where degeneration is more extensive, this is combined with a myotendinous FHL transfer, bringing healthy, well-vascularised tissue to the area to support healing.