Achilles tendinopathy: More than just an issue in the tissue!

Seán Mc Auliffe is a clinical research physiotherapist at Aspetar Orthopaedic and Sports Medicine hospital in Qatar. He completed his PhD in 2017 at the University of Limerick, Ireland, under the supervision of Dr. Kieran O’Sullivan and Dr. Karen Mc Creesh, titled; “The relationship between structure, function and pain in Achilles tendinopathy”.

As part of my PhD we performed a series of qualitative interviews amongst individuals with persistent Achilles tendinopathy (AT). Specifically the interviews sought to investigate the impact of AT on daily activities, effect on personal life as well as beliefs surrounding their pain. Four main themes emerged from the interviews: (i) pain as a feature of everyday life (ii) participant’s experience with the management process (iii) identifying with and self-managing AT and (iv) looking to the future.

Loss of self

Participants highlighted the implications of giving up recreational activities (e.g. running) had on their social life and sense of personal achievement and sense of self as a result of AT.

“Frustration, needing …. Wanting to run. Seeing my peers going to races, winning races or getting PBs. Progressing … and I’m stuck here. That has been horrendous I have to say. Now, I know there are worse things in life that can happen. But it’s been horrible.” Participant 6

Experience with treatment process

Another theme that emerged was the participants experience with the treatment process. Participants expressed the belief that, in order for a treatment to be beneficial, a forceful hands-on treatment was required.

“He wore a kind of a knuckle duster and really rubbed them hard. And I think that’s the only thing that got rid of the morning stiffness.” Participant 6

Participants also outlined their disbelief and lack of confidence in relation to a commonly prescribed exercise intervention in AT.

“There was a therapy that was recommended to me maybe at the start of the year, it was called heel drops or painful heel drops? They’re on the edge of the steps and you basically flex, you basically flex down and flex up…Was it 10 minutes a night every night for 12 weeks but in my head that was crazy.” Participant 5

Rest as a management approach

Rest was often cited as a self-management strategy in many of the interviews. Often participants expressed their belief that rest would be appropriate in allowing the pain to settle or ensure that time necessary for healing. The adoption of this management approach was as a result of participant’s own opinion but as a result of advice from health care practitioners or non health care practitioners.

“I possibly didn’t rest it enough. That’ s the only assumption I can come up with that I didn’t rest it enough Yeah. As in I’ve stopped running altogether in the hope that the rest will allow it to recover. The problem is its back to the whole thing of not knowing is that the problem.” Participant 5

Fear of future prognosis

A common theme reported in the study was fear, concerns and uncertainty surrounding potential future damage to participant’s Achilles tendon. Many participants felt that if they continued to exercise and or failed to address their AT it might lead to greater disability but more specifically the risk of rupturing their Achilles tendon in the future.

“Yeah it could like. It probably… I’d be thinking that like. By running on it as it is, i think it would. It might get to the stage where it will rupture… If I don’t get it fixed like.” Participant 3

Implications for clinical practice:

Unfortunately, there appears to be an assumption that AT is just an issue in the tissue and is somehow different from other persistent or chronic MSK complaints such as low back pain, neck pain or even persistent knee pain. Results of this study suggests that persistent AT is associated with a significant psychosocial burden, particularly in terms of participation in daily life and valued activities. It is important as a clinician that we ask ourselves:

How often do you discuss psychosocial factors with your patient with AT?

Specifically, how often do we discuss;

  • Explanation of their pain?
  • Expected recovery time?
  • Importance of rehabilitation?


It is feasible to suggest that as clinicians we tend to overlook or neglect this aspect of the treatment process in favour for other treatment modalities or interventions. Consequently, results of this study suggest that clinicians may need to spend appropriate time discussing and addressing these psychosocial factors in clinical practice as part of their overall management approach. One potential approach to address these factors may be simply becoming more aware of the language and terminology we use when treating people with AT.

The potential negative consequences of terminology such as “You have degenerative/torn/damaged tendon” or “You shouldnt run with a damaged tendon or you will rupture it” are often used by clinicians without understanding the potential impact of this language. This negative reinforcement may enhance and amplify fear and catastrophising and place undue focus on structure or promote the belief that loading or strengthening exercises are to be avoided in people with AT. Clinicians may need to alter their language or explanations and adopt language associated with positive reinforcement such as “A structured exercise program will improve the load tolerance, make it stronger and decrease the sensitivity of your tendon.” or ‘Movements will be painful at first – like an ankle sprain – but they will get better as you increase the load tolerance of the tendon.

Ultimately this may reduce fear and catastrophising associated with AT and promote the belief that progressive exercise program is needed to increase load tolerance which may improve adherence rates and optimise patient outcomes.

Negative Reinforcement

  • May enhance and amplify fear and catastrophising
  • Undue focus on structure
  • Belief that pain = tendon damage
  • Belief that loading is harmful to the tendon

Positive Reinforcement

  • Reduce fear and catastrophising
  • Avoid treatment emphasis on fixing tendon structure
  • Emphasis that pain ≠ damage
  • Promote belief that progressive exercise program is needed to increase load tolerance

AT is often a persistent and frustrating msk complaint. Emerging research as outlined above suggest that it is more than just an “issue in the tissue”. The challenge is for us as clinicians to adapt accordingly and become more aware of the potential influence of psychosocial factors as part of the overall management process.


Or in the words of Louis Gifford:


Deal with the person (top- down) before performing any physical process like rehab or treatment (bottom-up).

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