Achilles Tendinopathy Treatment: PRP, Shockwave, and Eccentric Loading

Achilles tendinopathy is the runner's nemesis and a common complaint in active adults of all ages. The Achilles is the largest tendon in the body, takes loads of 6 to 12 times body weight during running, and heals slowly when it gets into trouble. Patients often try to push through it, find that doesn't work, then end up frustrated by the months-long recovery from any meaningful active intervention.

This guide covers what Achilles tendinopathy actually is, why it splits into two patterns that need different approaches, and what evidence-supported treatment looks like.

What Achilles tendinopathy actually is

The Achilles is the tendon formed by the gastrocnemius and soleus muscles converging and inserting on the posterior calcaneus (heel bone). Tendinopathy involves degenerative changes within the tendon: disorganized collagen, abnormal neovascularization, microscopic tearing, mucoid degeneration. Despite the older "Achilles tendinitis" terminology, this is degenerative tendinopathy, not classic inflammation, in most cases.

The clinical pattern depends on which part of the tendon is affected.

Mid-portion Achilles tendinopathy. Pain and thickening in the tendon 2 to 6 cm above the calcaneal insertion. The most common pattern in runners and recreational athletes.

Insertional Achilles tendinopathy. Pain at the calcaneal attachment itself, often with bony changes (Haglund's deformity, a bony prominence at the posterior calcaneus). More common in older or more sedentary patients, and harder to treat than mid-portion.

Paratendinopathy. Inflammation of the paratenon (the loose connective tissue sheath around the Achilles), rather than the tendon itself. Less common, treated somewhat differently.

These patterns can overlap. A patient can have mid-portion tendinopathy that progresses to involve the insertion, or vice versa.

How it typically presents

Mid-portion. Posterior heel pain 2 to 6 cm above the calcaneus. Worse in the morning ("start-up pain") and after periods of sitting. Often eases with brief activity, then returns at the end of a longer run or workout. Thickening of the tendon is often palpable. The "painful arc" sign (palpating the tender area while moving the foot up and down) helps identify the affected portion.

Insertional. Pain right at the back of the heel, sometimes with a bony lump (Haglund's). Worse with shoes that press on the area, worse with stairs, worse with hills. The pain pattern is different from mid-portion: less of the morning start-up pattern, more of a constant ache that flares with specific activities.

Both. Stiffness in the morning, easing somewhat as the day progresses. Activity-specific exacerbation.

The asymptomatic imaging problem

Like most tendinopathies, Achilles imaging findings are common in asymptomatic adults. Ultrasound or MRI showing tendon thickening, intratendinous signal change, or even small intrasubstance tears can be incidental findings in patients with no symptoms. The clinical picture, not the imaging alone, drives the treatment recommendation.

The conservative care backbone

Whatever else you do for Achilles tendinopathy, the foundation is a structured eccentric loading program. The evidence for eccentric loading in mid-portion Achilles tendinopathy is among the strongest in tendinopathy management.

The Alfredson protocol. The original heavy-slow eccentric program: 3 sets of 15 repetitions, twice a day, every day for 12 weeks. Each repetition involves rising onto the toes (concentrically), then slowly lowering the heel below the level of the step (eccentrically). The contralateral leg is used to assist with the concentric phase if needed; the eccentric phase is done with the affected leg alone. Both straight-knee and bent-knee variants are included to target gastrocnemius and soleus separately.

The science. Eccentric loading produces tendon remodeling, including normalization of disorganized collagen, reduction in aberrant neovascularization, and improvement in tendon structural quality. The protocol is uncomfortable initially; some pain during loading is expected and acceptable up to a point.

Modification for insertional disease. The heel-drop below neutral that's central to the Alfredson protocol can aggravate insertional tendinopathy. The Jonsson modification limits the eccentric phase to neutral (not below), which preserves the loading benefit without the compressive aggravation of the insertion.

A structured eccentric program over 12 weeks resolves the symptoms in a meaningful percentage of mid-portion cases without any further intervention. The patient who arrives at our clinic having genuinely completed the Alfredson protocol and still has symptoms is a different patient from the one who tried it for two weeks and gave up.

Shockwave for Achilles tendinopathy

Shockwave has good evidence for chronic mid-portion Achilles tendinopathy, particularly cases that have failed eccentric loading.

Protocol. Typical course is 4 to 6 sessions, spaced 5 to 10 days apart. Treatment area is the affected tendon and surrounding tissue. Sessions run 8 to 15 minutes.

Combined with eccentric loading. The Rompe RCT and similar studies show that shockwave plus eccentric loading produces better results than either alone. We typically prescribe both together.

Insertional vs mid-portion response. Shockwave evidence is stronger for mid-portion than for insertional. Insertional cases sometimes respond but more variably.

Patient experience. Mild discomfort during sessions, some local soreness for 1 to 3 days after. Normal activity throughout the treatment course, with sensible modification of high-impact loading.

Expected response. Symptomatic improvement typically begins during the treatment course and continues for 6 to 8 weeks after the final session. 60 to 75 percent of patients with chronic mid-portion Achilles tendinopathy show meaningful improvement at 12 to 16 weeks.

PRP for Achilles tendinopathy

PRP delivers concentrated growth factors directly into the affected tendon, with biological effects similar to those seen in other tendinopathies.

Protocol. Ultrasound-guided injection of leukocyte-rich PRP into the affected tendon. Fenestration technique commonly used. Sometimes a second injection at 6 to 8 weeks for incomplete response.

Patient experience. Local anesthetic for comfort. Procedure itself brief. Some local soreness and potential inflammatory flare for 24 to 72 hours after.

Activity restriction. Limited running and high-impact loading for 4 to 6 weeks. Continuation of structured eccentric loading throughout.

Expected response. Improvement typically begins at 4 to 8 weeks, continuing through 12 to 16 weeks. 50 to 70 percent of patients show meaningful improvement.

Evidence base. The published evidence for PRP in Achilles tendinopathy is mixed in some specific endpoints but overall supportive, particularly for chronic refractory cases. Mautner and others have published prospective cohort data showing meaningful long-term improvement.

The combined approach we typically use

For most chronic Achilles tendinopathy patients at Apex:

Phase 1 (weeks 1 to 12): Structured eccentric loading program, modified for insertional disease if applicable. Shockwave course (4 to 6 sessions). Address footwear, surface, and training load. Address calf flexibility.

Re-evaluation at 12 weeks: If meaningful improvement, continue conservative measures with gradual return to activity. If incomplete improvement, consider PRP.

Phase 2 if needed (weeks 12 to 24): PRP injection. Continued eccentric loading. Progressive return to activity.

Re-evaluation at 24 weeks: Most patients have substantially improved by this point. The minority who haven't are candidates for further consideration, including possible surgical consultation.

Why we avoid cortisone in the Achilles

Intratendinous cortisone in the Achilles is associated with documented increased risk of tendon rupture. This isn't a theoretical concern; multiple case series and registry data show the risk pattern.

Some clinicians still use peritendinous (around the tendon, not into it) cortisone for Achilles paratendinopathy or retrocalcaneal bursitis. Even this use we approach cautiously. PRP at the same location is a better option for most patients.

If a clinic offers you a cortisone injection directly into your Achilles tendon, the right answer is no.

Insertional Achilles tendinopathy specifically

Insertional disease is harder than mid-portion for several reasons:

The tendon insertion is loaded in compression as well as tension. Standard eccentric loading below neutral can aggravate insertional disease.

Haglund's deformity (a bony prominence at the posterior calcaneus) often coexists and contributes to symptoms by impinging on the tendon insertion.

Footwear matters more. Shoes with rigid heel counters can directly compress and irritate the insertion area.

Recovery is typically slower and the response to active intervention is more variable.

Modified approach. Eccentric loading limited to neutral. Open-back or rear-cutout footwear to reduce direct pressure. Shockwave with attention to dose and area. PRP with image-guidance to the insertion site, sometimes with consideration of the retrocalcaneal bursa as a target.

When surgery is more often considered. Refractory insertional cases sometimes benefit from open or endoscopic Haglund's resection, debridement of degenerative tendon, and (in larger cases) tendon reattachment. The decision depends on imaging severity, response to conservative care, and patient activity goals.

What recovery looks like

For a typical mid-portion Achilles tendinopathy treated with the combined approach:

Weeks 1 to 4. Beginning eccentric loading. Shockwave sessions every 5 to 10 days. Modified activity (reduced running, no speed/hill work). Stretching, calf flexibility, footwear assessment.

Weeks 4 to 8. Continued loading. Last shockwave sessions. Early signs of improvement for many patients.

Weeks 8 to 12. Clear improvement for most responders. Continued loading. Progressive return to running volume.

Weeks 12 to 16. Most patients clearly better. Continued loading reduced from daily to several times weekly.

Weeks 16 to 24. Return to most activity. PRP if response is incomplete.

Months 6 to 12. Sustained improvement in most responders. Continued attention to loading, flexibility, and training load.

When to think surgery

Surgical management of chronic Achilles tendinopathy includes various options:

Debridement of degenerative tendon tissue.

Tendon repair if significant intratendinous tearing is present.

Tendon transfer (FHL transfer) for larger areas of disease.

Haglund's resection for insertional disease with bony deformity.

Open or minimally-invasive techniques depending on case specifics.

Surgical recovery is significant: typically 6 to 12 weeks of restricted weight bearing, several months of progressive rehabilitation, and 6 to 12 months before return to full sport.

Surgery is reserved for severe refractory cases that have failed:

• A full structured eccentric loading program
• A shockwave course
• PRP series
• Activity modification, footwear changes, biomechanical assessment

Most patients who reach surgical consideration have very chronic, very refractory cases.

Specific patient profiles

The 42-year-old recreational runner with 8 months of right mid-portion Achilles pain. Eccentric loading plus shockwave course. PRP if incomplete response at 12 weeks. Expected return to easy running by week 10, back to most training by week 16.

The 58-year-old desk worker with chronic insertional Achilles pain and Haglund's. Modified eccentric loading. Shockwave. Footwear changes. PRP if incomplete response. Surgical consultation if all else fails.

The 35-year-old triathlete with bilateral mid-portion Achilles symptoms. Aggressive eccentric loading, shockwave, training volume management. Often both sides respond well to disciplined approach.

The 67-year-old with chronic Achilles pain and history of multiple prior cortisone injections. Imaging to assess tendon integrity (rupture risk concern). Conservative approach prioritized. Possible PRP if tendon integrity supports it.

The 28-year-old who suddenly developed posterior heel pain after a misstep. Possible acute partial tear or rupture. Imaging first, treatment specific to findings.

What you can do alongside treatment

Whatever the intervention, certain things help:

Calf flexibility. Daily gastrocnemius and soleus stretching.

Hill work and speed work modification. During active recovery, reduce or eliminate.

Footwear assessment. Many runners are in shoes that are wrong for their gait or training surface. A gait analysis can be valuable.

Surface variation. Mix surfaces if you can. Concrete is the hardest on tendons; trail and softer surfaces are easier.

Training load management. Sudden volume increases are a common trigger. Maintain a sensible buildup.

How to book

To request a consultation about your Achilles, request a consultation or call (972) 768-2328. We're at 2111 Kirkwood Blvd, Suite 110b, Southlake, TX 76092.

For runners and athletes, the consultation includes specific attention to training load, footwear, and biomechanical contributors. We work with several local sports medicine PTs we trust.

A short note from Dr. Abdullah

Achilles tendinopathy rewards patience and discipline. The patients who do best with our protocol are the ones who commit to the eccentric loading program for the full 12 weeks, modify their training intelligently, and trust that the tendon biology takes time. The patients who do worst are the ones who do the loading inconsistently, try to maintain full training volume, and want a one-shot fix that doesn't really exist for this condition. We try to be straight about the timeline up front so expectations match what's realistic.