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Achilles tendinopathy

Nature Reviews Disease Primers volume 11, Article number: 20 (2025) Cite this article

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Abstract

Achilles tendon pathologies are prevalent, impacting ~6% of the general population and up to 50% of elite endurance runners over their lifetimes. These conditions substantially affect quality of life and work productivity, leading to substantial societal costs. Achilles tendinopathy (AT) is a condition marked by localized pain and functional impairment related to mechanical loading. AT can considerably impair participation and potentially also performance in sports and daily activities. The aetiology of AT is multifactorial and repetitive overloading of the tendon is often observed as the inciting factor by health professionals. However, AT can also be associated with adverse effects of certain medication, ageing and various comorbidities. Characteristic tendon changes include proteoglycan accumulation, fluid accumulation with swelling and hypervascularization. Tissue disorganization advances as pathological changes in matrix structure are driven by altered cellular function and makeup, often accompanied by persistent inflammation. Treatment strategies include various interventions, although these can be protracted and challenging for both patients and health-care providers, often with high failure rates. Current research focuses on understanding the pathological processes at the cellular and molecular levels to distinguish between disease categories and to investigate the role of inflammation, metabolic maladaptation and mechanical stress. Emerging therapeutic approaches need to be developed to address these underlying mechanisms. These approaches focus on optimizing rehabilitation protocols and advancing the development of adjunct therapies, such as advanced therapy medicinal products, alongside the integration of precision medicine to improve treatment outcomes.

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Fig. 1: Achilles tendon structure and tendinopathy.
Fig. 2: Multiscale interplay of structural organization and functional mechanics in tendon tissue.
Fig. 3: Pathological changes identified in diseased Achilles tendon and entheseal tissues.
Fig. 4: Pain location of AT and several differential diagnoses.
Fig. 5: First line of management in stages of an athlete with Achilles tendinopathy.
Fig. 6: Minimally invasive in-office needle Achilles tendoscopy.

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Acknowledgements

The authors acknowledge support from TENET COST Action CA22170 for fostering collaboration and networking opportunities. The authors thank all researchers, clinicians and physiotherapists working on Achilles tendinopathy. The authors have made every effort to cite the relevant and current literature but apologise if they have overlooked anyone or any relevant publications.

Author information

Authors and Affiliations

  1. Institute of Tendon and Bone Regeneration, Paracelsus Medical University, Salzburg, Austria

    Andreas Traweger

  2. Department of Physical Therapy, Centre for Aging SMART, University of British Columbia, Vancouver, British Columbia, Canada

    Alex Scott

  3. Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark

    Michael Kjaer

  4. Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark

    Michael Kjaer

  5. MOVANT Research Group, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp, Wilrijk, Belgium

    Evi Wezenbeek

  6. Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium

    Evi Wezenbeek

  7. Health Sciences College of Trairi, Federal University of Rio Grande do Norte, Santa Cruz, Brazil

    Rodrigo Scattone Silva

  8. NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA

    John G. Kennedy & James J. Butler

  9. Health Research Institute of the Balearic Islands (IdISBa), Research Unit Son Espases University Hospital (HUSE), Palma, Spain

    Manuel Gomez-Florit

  10. Group of Cell Therapy and Tissue Engineering (TERCIT), Research Institute on Health Sciences (IUNICS), University of the Balearic Islands (UIB), Palma, Spain

    Manuel Gomez-Florit

  11. School of Medicine and Biomedical Sciences (ICBAS), Unit for Multidisciplinary Research in Biomedicine (UMIB), University of Porto, Porto, Portugal

    Manuela E. Gomes

  12. Department of Orthopaedics, Balgrist, University of Zurich, Zurich, Switzerland

    Jess G. Snedeker

  13. Institute for Biomechanics, ETH Zurich, Zürich, Switzerland

    Jess G. Snedeker

  14. Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK

    Stephanie G. Dakin

  15. Experimental Trauma Surgery, Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany

    Britt Wildemann

Authors
  1. Andreas Traweger
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  2. Alex Scott
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  3. Michael Kjaer
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  4. Evi Wezenbeek
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  5. Rodrigo Scattone Silva
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  6. John G. Kennedy
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  8. Manuel Gomez-Florit
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  9. Manuela E. Gomes
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Contributions

Introduction (A.T. and B.W.); Epidemiology (M.K. and A.S.); Mechanisms/pathophysiology (S.G.D. and J.G.S.); Diagnosis, screening and prevention (E.W. and R.S.S.), Management (R.S.S., J.G.K., J.J.B. and A.S.); Quality of life (A.S., M.K. and E.W.); Outlook (M.G.-F., M.E.G., A.T. and B.W.); overview of Primer (A.T. and B.W.).

Corresponding authors

Correspondence to Andreas Traweger or Britt Wildemann.

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Competing interests

J.G.K. is a consultant for Arthrex and In2Bones. The other authors declare no competing interests.

Peer review

Peer review information

Nature Reviews Disease Primers thanks S. Rodeo, P. Kirwan, R. de Vos and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Glossary

Arc sign

A clinical test used to diagnose Achilles tendinopathy. It involves identifying a tender area of intra-tendinous swelling that moves with the tendon.

Dynamometry

A method for measuring muscle strength using specialized instruments.

Enthesis

The specialized interface where the Achilles tendon attaches to bone, transitioning from soft to hard tissue to efficiently transmit mechanical loads and reduce stress concentration.

Enthesophytes

Abnormal bony outgrowths that develop at the enthesis, typically in response to chronic mechanical stress, inflammation or degenerative conditions.

Exostosis

A bony outgrowth that forms on the calcaneus (heel bone).

Function of the kinetic chain

Different body segments (that is, the ankle, knee and hip) work together to produce movement, with each segment contributing to the overall motion. In optimal circumstances, the different body segments work synergically, as links in a chain, for force transmission and energy dissipation.

Heavy-load Alfredson eccentric protocol

One of the first exercise protocols described for the exercise-based management of Achilles tendinopathy, involving 180 daily repetitions of single-leg eccentric exercises on a step with external load for the calf muscles.

Minimum clinically important difference

Smallest improvement considered worthwhile by a patient.

Plyometric exercises

Exercises involving repeated rapid eccentric and concentric contractions, optimizing movement via the stretch–shortening cycle.

Royal London Hospital test

A diagnostic test for Achilles tendinopathy, involving palpation and assessment of pain in the tendon when it is under tension.

Sever disease

A condition in children that causes heel pain due to stress on the growth plate in the heel (calcaneus), typically during periods of rapid growth.

Silbernagel protocol

Exercise-based intervention composed of various heel rise concentric–eccentric exercises that progress from double-leg to single-leg and finally to plyometric exercises, using the pain monitoring model as a guide for progression.

Stretch–shortening cycle

The process where a muscle rapidly stretches (eccentric contraction) before shortening (concentric contraction) to enhance performance, as in jumping or running.

Tendon xanthoma

A subcutaneous deposit containing lipid and cholesterol presenting as free mobile papules or as nodules on the tendon.

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Traweger, A., Scott, A., Kjaer, M. et al. Achilles tendinopathy. Nat Rev Dis Primers 11, 20 (2025). https://doi.org/10.1038/s41572-025-00602-9

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