Treatment of Achilles Tendinopathy When Eccentric Exercise Has Not Worked

This protocol addresses Achilles tendinopathy that has persisted after a completed first-line eccentric calf-muscle programme without achieving the expected therapeutic targets, and specifies the structured approach for further management.

First-line treatment — targets not achieved

The prior treatment was eccentric calf muscle training (Alfredson protocol), combined with rest or modified activity, orthotic measures, stretching, and night splint over 12 weeks.

Escalation applies when these targets were not reached at 12 weeks:

Resolution of Achilles tendon pain during loading activity
Decreased Achilles tendon volume on MRI
Decreased Achilles tendon signal intensity on MRI

Next-step approach (partial overview)

Second-line protocol

For patients who have not responded to first-line eccentric training, further management may involve adjunct therapies directed at tendon neovascularisation and pain, including both topical and targeted injection approaches used alongside exercise. The full selection criteria, sequencing, and complete regimen are available in the structured protocol.

Treatment targets

Resolution of Achilles tendon activity pain
Absence of neovascularisation on colour Doppler ultrasonography of the Achilles tendon
Decreased Achilles tendon thickness on ultrasonography at 24 weeks

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1136/bjsm.2007.035543

The topical glyceryl trinitrate was applied to the tendon as a patch that was renewed each day for 6 months.
In the Achilles tendon, activity pain in the treatment group was reduced at 12 and 24 weeks compared with placebo, and it also improved outcomes at 6 months.
A vascular sclerosant (Polidocanol—an aliphatic non-ionised nitrogen-free substance with a sclerosing and anaesthetic effect) was injected in the area with neovascularisation anterior to the tendon.
This research suggests a clinical role for sclerosing therapy in those who fail to respond to eccentric exercise.
Peritendinous injection has fewer effects on the tendon and could be a worthwhile adjunct to a considered management programme.
CSI may be most beneficial when used to relieve pain while continuing to undertake exercise programmes.
The tendons that were pain free had no neovascularisation either on the outside or the inside, but in the two non-successfully treated patients, vessels remained.
Ultrasonographically, tendon thickness had decreased and the structure looked more normal.

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