Mid-portion Achilles pain in a runner requesting injection
Ms B, 41, is a parkrun regular who developed right mid-portion Achilles pain 14 weeks ago after increasing weekly distance from 20 to 35 km. She stopped running for 4 weeks, used ice and ibuprofen gel, and returned gradually, but pain is now 6/10 on first steps and 4/10 during a 5 km run; it settles after 10 minutes and is worse the next morning. VISA-A score is 54. She has had three physiotherapy sessions of ultrasound and stretching with no change. She is training for a 10 km in 8 weeks, works 12-hour shifts as a nurse, and asks about a corticosteroid injection so she can get back on track. Examination: tender 3 cm above the insertion, pain on single-leg heel raise at 12 repetitions, no swelling, negative Simmonds-Thompson test.
1. Critique the diagnosis and previous management. What features support or refute the main alternatives?
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The most likely diagnosis is mid-portion Achilles tendinopathy. The tenderness is 3 cm above the insertion, which fits the mid-portion rather than insertional disease; pain on single-leg heel raise and morning stiffness after load are typical. A negative Simmonds-Thompson test and absence of swelling make a complete rupture or large partial tear unlikely, though not impossible.
Features that argue against insertional tendinopathy are the location and the absence of pain at the insertion. Paratenonitis would usually produce more diffuse crepitus and swelling. A partial tear remains a small possibility if there was a sudden event, but there was not.
The previous management was largely passive. Four weeks of complete rest is not recommended because tendon capacity falls; ultrasound and stretching have little evidence for mid-portion tendinopathy. The key error is that load was increased again without a strength base. The VISA-A of 54 confirms substantial functional limitation. This matters because the patient attributes failure to 'not doing enough' and now seeks a passive fix, when the main deficit is calf capacity and load progression.
2. Design a 12-week loading programme and return-to-running plan, including progression and monitoring rules.
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I would use a progressive calf-loading programme, not rest, and set explicit pain rules: pain ≤3/10 during exercise and no worse the next morning.
Weeks 1–4: heavy slow resistance or progressive eccentric heel raises, 3 times weekly, 3–4 sets of 6–15 repetitions, 3 seconds up and 3 seconds down. Start with double-leg, progress to single-leg. Add seated calf raises for soleus. Keep walking and avoid hills and sprinting.
Weeks 5–8: increase to 4 sets, add external load, and begin run–walk intervals (1 minute run/2 minutes walk) on flat ground every other day if pain rules are met. Continue strength work twice weekly. Monitor first-step pain, single-leg heel-raise repetitions, and 24-hour response.
Weeks 9–12: progress to continuous running and then speed, but only if single-leg heel raises are ≥20–25 with minimal pain and morning stiffness is settling. The 10 km in 8 weeks is achievable only as a participation goal, not a personal best.
I would review every 2–3 weeks. If pain increases for more than 48 hours, I would reduce volume by 30–50% rather than stop completely.
3. How would you counsel her about corticosteroid injection and the 10 km target?
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I would explain that a corticosteroid injection can reduce pain for a few weeks, but it does not restore tendon capacity, and in Achilles tendinopathy it has been associated with worse long-term outcomes and a small risk of rupture. It is therefore not my first-line recommendation, especially while she is trying to increase running load.
I would use shared decision-making:
- If she chooses injection, she needs relative rest from running for about 2 weeks and a structured strength programme afterwards, not an immediate return to training.
- If she declines, the loading programme is still the main treatment and may be slower but safer.
For the 10 km, I would reframe the goal: finishing may be realistic, but racing it at 8 weeks risks a flare. I would set a decision point at 6 weeks: if she can run 5 km continuously with pain ≤2/10 and no next-day increase, she can proceed; if not, she should defer. I would document this advice so the plan is clearly shared.