A Faster Fix? Load Progression in Mid-Portion Achilles Tendinopathy
Mr. Ferreira is a 38-year-old recreational soccer player with a four-month history of pain in the left Achilles, 3 cm above the calcaneal insertion. He trains twice weekly and plays a match most weekends. Morning stiffness lasts about 25 minutes and the first steps are 5/10; pain during activity reaches 6/10 and is still 3/10 the next morning. His VISA-A score is 52/100. He has been doing 30 single-leg heel raises every day, which he was told would 'break down the scar tissue'; the last 10 reps are 8/10 and he limps for the rest of the evening. Examination shows a thickened, tender mid-tendon with a painful arc on loading, negative Simmonds-Thompson test, single-leg heel raise to 18 repetitions, and pain on hopping. He wants to keep playing and has a regional tournament in six weeks. He asks whether he should stop all sport and whether a cortisone injection would be quicker.
1. Critique his current programme and answer his two questions using pain-monitoring principles.
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The clinical picture Mid-portion Achilles tendinopathy is a load-tolerance problem, not scar tissue that needs breaking down. The history fits: 3 cm above the insertion, thickened and tender, painful on loading and hopping, negative Thompson, morning stiffness. His single-leg heel raise of 18 repetitions quantifies the deficit.
What is wrong with his programme He is failing both commonly used load-monitoring rules. Pain during exercise is 8/10 against a usual ceiling of about 5/10, and pain is still 3/10 the following morning - above his baseline - rather than settling within 24 hours. He limps afterwards, which changes ankle loading and adds a compensatory problem. Thirty repetitions daily with no recovery day gives the tendon no chance to adapt, and 30 bodyweight repetitions is a fixed dose that does not progress. The programme is therefore too heavy and too monotonous at the same time.
Answers to his questions
- Should he stop all sport? No. Complete rest reduces tendon capacity and does not resolve the problem. He should modify: keep training with warm-up, avoid sprinting, jumping and hill work for two to three weeks, and hold off matches until the pain rules are met.
- Injection? A corticosteroid injection can reduce pain for a few weeks but is associated with poorer outcomes at 6-12 months and higher recurrence in tendinopathy. It is not a shortcut, and it must not be used to allow continued loading of an unrehabilitated tendon.
Be honest about the tournament: pain-free competitive play in six weeks is unlikely; the realistic goal is controlled loading and a graded return.
2. Write the loading progression you would prescribe for the next six weeks, with the rules for advancing or backing off.
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Governing rules Progress load, not pain. Advance when pain during exercise is 5/10 or less and morning stiffness and pain are back to baseline within 24 hours. If pain exceeds that or morning stiffness worsens, hold the load for a week before reducing it. Change one variable at a time and keep at least one rest day between loading days.
Weeks 1-2 - restore tolerance Slow, heavy-ish heel raises: 3 sets of 15 with a 3-second lift and 3-second lower, knee straight and knee bent, alternate days. Start with bodyweight or a light backpack; stop the set when technique fails or pain passes 5/10. Add a temporary heel raise in the shoe if walking is painful. Keep one modified training session per week, no sprinting or jumping.
Weeks 3-4 - build strength Progress to 4 sets of 6-8 repetitions with a 3-second up and 3-second down tempo, adding load (weighted vest or backpack) so the last two repetitions are hard but pain stays within the rule; three sessions per week on non-consecutive days. Keep the knee-bent variation for soleus. Introduce double-leg low-amplitude hops only if hopping pain is settling.
Weeks 5-6 - reintroduce energy storage Add plyometric progression (double-leg to single-leg hops, then low-level bounding) twice weekly, and a running progression of walk-jog intervals on alternate days if pain rules hold. Sport-specific dribbling and passing without sprinting. Re-score VISA-A at week 6.
If he cannot tolerate the week 1 dose at all, that is diagnostic information - reassess the diagnosis rather than pushing harder.
3. What would you measure, and when would you refer on?
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Measures
- VISA-A at baseline and at six weeks - the disease-specific patient-reported measure, and 52/100 gives a clear starting point.
- Single-leg heel raise endurance to fatigue, which doubles as a loaded provocation test and tracks capacity.
- Pain numerical rating scale during loading, at 24 hours, and morning stiffness duration.
- A global rating of change and a hop or drop-countermovement jump test when he is returning to sport, plus training and match exposure recorded weekly.
- Adherence and the pain-monitoring log, because the commonest cause of failure is a dose that ignored the rules.
Referral triggers
- No meaningful improvement after 12 weeks of well-conducted progressive loading, or deterioration despite appropriate load management - refer for consideration of extracorporeal shockwave therapy or a surgical opinion.
- A positive Simmonds-Thompson squeeze test, a palpable gap, or sudden weakness and a snap during activity - suspect rupture and refer immediately.
- Bilateral symptoms, unusual systemic features, a family history of hypercholesterolaemia, diabetes, or an inflammatory picture - screen for a systemic contributor before assuming a simple tendinopathy.
- Insertional rather than mid-portion pain changes the exercise selection (avoid loading into dorsiflexion over a wedge), so locate the pain precisely before prescribing.
- Any request for injection or medication is a referral conversation with the physician, not a physiotherapy decision.