Achilles tendinopathy prevention: An evidence-based approach
DOI:
https://doi.org/10.64268/jospa.v1i1.3Keywords:
Achilles tendinopathy, Biomechanics, Eccentric training, Load management, Tendon healthAbstract
Background: Achilles tendinopathy is a common musculoskeletal disorder causing pain and impaired tendon function, primarily affecting athletes and individuals engaged in repetitive activities like running and jumping. It progresses through stages of tendon health, disrepair, and degeneration, often leading to chronic overuse injuries. Aims: This study aims to identify evidence-based prevention and management strategies by analyzing intrinsic factors (e.g., flexibility, muscle strength, tendon stiffness) and extrinsic factors (e.g., training loads, footwear). It proposes an integrated prevention framework that combines biomechanical, physiological, and contextual risk factors to guide athletes, coaches, and healthcare professionals. Methods: A systematic review of 250 studies from PubMed, Scopus, Google Scholar, and Consensus AI resulted in the selection of 34 high-quality studies. The review focused on Achilles tendinopathy prevention and management strategies, particularly exercise interventions, load management, and biomechanical factors. Results: The findings highlight the importance of intrinsic and extrinsic factors in reducing tendinopathy risk. Key strategies include eccentric calf exercises, dynamic and static stretching, targeted strength training, optimized load management, and biomechanical interventions such as footwear modification. Unlike previous studies that examined these components separately, this research presents a comprehensive prevention framework. Conclusion: This study integrates multiple risk factors into a cohesive model for Achilles tendinopathy prevention. It emphasizes the necessity of a multidimensional approach over isolated interventions. Future research should focus on experimental validation and longitudinal studies to assess the long-term effectiveness of this framework across diverse populations.
References
Adam, N. C., Cr, S., Herzog, W., Amis, A. A., Arampatzis, A., & Taylor, W. R. (2023). In vivo strain patterns in the achilles tendon during dynamic activities: A comprehensive survey of the literature. Sports Medicine - Open, 9(1). https://doi.org/10.1186/s40798-023-00604-5 DOI: https://doi.org/10.1186/s40798-023-00604-5
Alfredson, H., Pietilä, T., Jonsson, P., & Lorentzon, R. (1998). Heavy-load eccentric calf muscle training for the treatment of chronic achilles tendinosis. The American Journal of Sports Medicine, 26(3), 360–366. https://doi.org/10.1177/03635465980260030301 DOI: https://doi.org/10.1177/03635465980260030301
Altman, A. R., & Davis, I. S. (2012). A kinematic method for footstrike pattern detection in barefoot and shod runners. Gait & Posture, 35(2), 298–300. https://doi.org/10.1016/j.gaitpost.2011.09.104 DOI: https://doi.org/10.1016/j.gaitpost.2011.09.104
Arya, S., & Kulig, K. (2010). Tendinopathy alters mechanical and material properties of the Achilles tendon. Journal of Applied Physiology (Bethesda, Md.: 1985), 108(3), 670–675. https://doi.org/10.1152/japplphysiol.00259.2009 DOI: https://doi.org/10.1152/japplphysiol.00259.2009
Baggett, B. D., & Young, G. (1993). Ankle joint dorsiflexion. Establishment of a normal range. Journal of the American Podiatric Medical Association, 83(5), 251–254. https://doi.org/10.7547/87507315-83-5-251 DOI: https://doi.org/10.7547/87507315-83-5-251
Bennett, P., Sc, D., Sc, B., Sc, M., & Bus, G. (1998). The Foot Health Status Questionnaire (FHSQ): A new instrument for measuring outcomes of footcare. https://www.semanticscholar.org/paper/The-Foot-Health-Status-Questionnaire-(FHSQ)%3A-a-new-Bennett-Sc/ed4e4fb20d77d8ef2a25c8f55027fb6a0314431d
Branthwaite, H., Chockalingam, N., & Greenhalgh, A. (2013). The effect of shoe toe box shape and volume on forefoot interdigital and plantar pressures in healthy females. Journal of Foot and Ankle Research, 6(1), 28. https://doi.org/10.1186/1757-1146-6-28 DOI: https://doi.org/10.1186/1757-1146-6-28
Challoumas, D., Crosbie, G., O’Neill, S., Pedret, C., & Millar, N. L. (2023). Effectiveness of exercise treatments with or without adjuncts for common lower limb tendinopathies: A living systematic review and network meta-analysis. Sports Medicine - Open, 9(1). https://doi.org/10.1186/s40798-023-00616-1 DOI: https://doi.org/10.1186/s40798-023-00616-1
Cushman, D. M., Stokes, D., Vu, L., Corcoran, B., Fredericson, M., Eby, S. F., & Teramoto, M. (2025). Ultrasound as a predictor of time-loss injury for the patellar tendon, achilles tendon and plantar fascia in division I collegiate athletes. British Journal of Sports Medicine, 59(4), 1-9. https://doi.org/10.1136/bjsports-2024-109066 DOI: https://doi.org/10.1136/bjsports-2024-109066
Deroost, F., Petrella, D., Mylle, I., & Vanwanseele, B. (2025). Patients with achilles tendinopathy use compensation strategies to reduce tendon load during rehabilitation exercises. Clinical Biomechanics, 122. 106403. https://doi.org/10.1016/j.clinbiomech.2024.106403 DOI: https://doi.org/10.1016/j.clinbiomech.2024.106403
Drew, M. K., & Finch, C. F. (2016). The Relationship Between Training Load and Injury, Illness and Soreness: A Systematic and Literature Review. Sports Medicine, 46(6), 861–883. https://doi.org/10.1007/s40279-015-0459-8 DOI: https://doi.org/10.1007/s40279-015-0459-8
Fan, H., Shrestha, L., Guo, Y., Huang, T., & Sun, Y. (2021). The twisted structure of the rat achilles tendon. Journal of Anatomy, 239(5). https://doi.org/10.1111/joa.13504 DOI: https://doi.org/10.1111/joa.13504
Funaro, A., Shim, V., Mylle, I., & Vanwanseele, B. (2025). Subject-specific biomechanics influences tendon strains in patients with achilles tendinopathy. Scientific Reports, 15(1). 1084. https://doi.org/10.1038/s41598-024-84202-9 DOI: https://doi.org/10.1038/s41598-024-84202-9
Gillinov, S. M., Laux, S., Kuivila, T., Hass, D., & Joy, S. M. (2015). Effect of Minimalist Footwear on Running Efficiency: A Randomized Crossover Trial. Sports Health, 7(3), 256–260. https://doi.org/10.1177/1941738115571093 DOI: https://doi.org/10.1177/1941738115571093
Grier, T., Canham-Chervak, M., Bushman, T., Anderson, M., North, W., & Jones, B. H. (2016). Minimalist Running Shoes and Injury Risk Among United States Army Soldiers. The American Journal of Sports Medicine, 44(6), 1439–1446. https://doi.org/10.1177/0363546516630926 DOI: https://doi.org/10.1177/0363546516630926
Herrington, L., & McCulloch, R. (2007). The role of eccentric training in the management of Achilles tendinopathy: A pilot study. Physical Therapy in Sport, 8(4), 191–196. https://doi.org/10.1016/j.ptsp.2007.07.001 DOI: https://doi.org/10.1016/j.ptsp.2007.07.001
Hörterer, H., Oppelt, S., Pfahl, K., Harrasser, N., Böcker, W., Polzer, H., Walther, M., & Baumbach, S. F. (2025). Outcomes of revision surgery for surgically treated insertional achilles tendinopathy. Archives of Orthopaedic and Trauma Surgery, 145(52). https://doi.org/10.1007/s00402-024-05693-9 DOI: https://doi.org/10.1007/s00402-024-05693-9
Houttu, V., Boulund, U., Nicolaou, M., Holleboom, A. G., Grefhorst, A., Galenkamp, H., Born, B.-J. H. van den, Zwinderman, K., & Nieuwdorp, M. (2021). Physical activity and dietary composition relate to differences in gut microbial patterns in a multi-ethnic cohort—the HELIUS study. Metabolites, 11(12). https://doi.org/10.3390/metabo11120858 DOI: https://doi.org/10.3390/metabo11120858
Ikpeze, T. C., Omar, A., & Elfar, J. H. (2015). Evaluating Problems With Footwear in the Geriatric Population. Geriatric Orthopaedic Surgery & Rehabilitation, 6(4), 338–340. https://doi.org/10.1177/2151458515608672 DOI: https://doi.org/10.1177/2151458515608672
James, S. L., Bates, B. T., & Osternig, L. R. (1978). Injuries to runners. The American Journal of Sports Medicine, 6(2), 40–50. https://doi.org/10.1177/036354657800600202 DOI: https://doi.org/10.1177/036354657800600202
Järvinen, T. A. H., Kannus, P., Maffulli, N., & Khan, K. M. (2005). Achilles tendon disorders: Etiology and epidemiology. Foot and Ankle Clinics, 10(2), 255–266. https://doi.org/10.1016/j.fcl.2005.01.013 DOI: https://doi.org/10.1016/j.fcl.2005.01.013
Johanson, M. A., Allen, J. C., Matsumoto, M., Ueda, Y., & Wilcher, K. M. (2010). Effect of Heel Lifts on Plantarflexor and Dorsiflexor Activity During Gait. Foot & Ankle International, 31(11), 1014–1020. https://doi.org/10.3113/FAI.2010.1014 DOI: https://doi.org/10.3113/FAI.2010.1014
Judd, A., Wild, K., Puxley, L., & Barker-Davies, R. (2025). UK defence rehabilitation consensus agreement for the conservative management of achilles and patellar tendinopathy: A modified delphi approach. BMJ Military Health. 1-6. https://doi.org/10.1136/military-2024-002893 DOI: https://doi.org/10.1136/military-2024-002893
Kenneally, M., Casado, A., Gomez-Ezeiza, J., & Santos-Concejero, J. (2020). Training intensity distribution analysis by race pace vs. physiological approach in world‐class middle‐ and long‐distance runners. European Journal of Sport Science, 21(6). https://doi.org/10.1080/17461391.2020.1773934 DOI: https://doi.org/10.1080/17461391.2020.1773934
Klein, M., Patterson, C., Karim, A., & Cuddeford, T. (2025). Hopping kinetic differences in masters runners with and without achilles tendinopathy. Sports Biomechanics. Latest Articles. https://doi.org/10.1080/14763141.2025.2451689 DOI: https://doi.org/10.1080/14763141.2025.2451689
Koohi-Hosseinabadi, O., Shahriarirad, R., Dehghanian, A., Amini, L., Barzegar, S., Daneshparvar, A., Alavi, O., Khazraei, S.-P., Hosseini, S., Arabi Monfared, A., Khorram, R., Tanideh, N., & Ashkani-Esfahani, S. (2025). In-vitro and in-vivo assessment of biocompatibility and efficacy of ostrich eggshell membrane combined with platelet-rich plasma in achilles tendon regeneration. Scientific Reports, 15(841). https://doi.org/10.1038/s41598-025-85131-x DOI: https://doi.org/10.1038/s41598-025-85131-x
Lee, W. C., Ng, G. Y. F., Zhang, Z., Malliaras, P., Masci, L., & Fu, S. C. (2020). Changes on tendon stiffness and clinical outcomes in athletes are associated with patellar tendinopathy after eccentric exercise. Clinical Journal of Sport Medicine, 30(1). https://doi.org/10.1097/jsm.0000000000000562 DOI: https://doi.org/10.1097/JSM.0000000000000562
Ling, S. K.-K., Mak, C. T.-K., Lo, J. P.-Y., & Yung, P. S.-H. (2024). Effect of platelet-rich plasma injection on the treatment of achilles tendinopathy: A systematic review and meta-analysis. Orthopaedic Journal of Sports Medicine, 12(11). https://doi.org/10.1177/23259671241296508 DOI: https://doi.org/10.1177/23259671241296508
Luijten, S. C. M., Nauta, J., Janssen, T., Holla, J., Jenniskens, S. C. N., & Verhagen, E. (2024). Systematic development of an injury and illness prevention programme for athletes with a physical impairment: The TIPAS study. BMJ Open Sport &Amp; Exercise Medicine, 10(3). https://doi.org/10.1136/bmjsem-2024-001945 DOI: https://doi.org/10.1136/bmjsem-2024-001945
Mahieu, N. N., Witvrouw, E., Stevens, V., Van Tiggelen, D., & Roget, P. (2006). Intrinsic Risk Factors for the Development of Achilles Tendon Overuse Injury: A Prospective Study. The American Journal of Sports Medicine, 34(2), 226–235. https://doi.org/10.1177/0363546505279918 DOI: https://doi.org/10.1177/0363546505279918
Mallows, A., Masci, L., Morrissey, D., Murphy, M., … Vicenzino, B. (2021). ICON 2020—International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy. Sports Medicine, 52(3). https://doi.org/10.1007/s40279-021-01588-6
Matthews, W., Ellis, R., Furness, J., Rathbone, E., & Hing, W. (2020). Staging achilles tendinopathy using ultrasound imaging: The development and investigation of a new ultrasound imaging criteria based on the continuum model of tendon pathology. BMJ Open Sport &Amp; Exercise Medicine, 6(1). https://doi.org/10.1136/bmjsem-2019-000699 DOI: https://doi.org/10.1136/bmjsem-2019-000699
McClean, Z. J., Pasanen, K., Lun, V., Charest, J., Herzog, W., Werthner, P., Black, A., Vleuten, R. V., Lacoste, E., & Jordan, M. J. (2024). A biopsychosocial model for understanding training load, fatigue, and musculoskeletal sport injury in university athletes: A scoping review. Journal of Strength &Amp; Conditioning Research, 38(6). https://doi.org/10.1519/jsc.0000000000004789 DOI: https://doi.org/10.1519/JSC.0000000000004789
Mencarelli, N., Arena, D., Salamone, M., Pietrangelo, L., Berardi, A. C., Cataldi, A., Carradori, S., & Gallorini, M. (2025). The combination of hyaluronic acids and collagen boosts human achilles tendon-derived cell escape from inflammation and matrix remodeling in vitro. Inflammation Research, 74(4). https://doi.org/10.1007/s00011-024-01975-5 DOI: https://doi.org/10.1007/s00011-024-01975-5
Murtaugh, B., & Ihm, J. M. (2013). Eccentric training for the treatment of tendinopathies. Current Sports Medicine Reports, 12(3), 175–182. https://doi.org/10.1249/JSR.0b013e3182933761 DOI: https://doi.org/10.1249/JSR.0b013e3182933761
O’Brien, M. (2005). The anatomy of the achilles tendon. Foot and Ankle Clinics, 10(2), 225–238. https://doi.org/10.1016/j.fcl.2005.01.011 DOI: https://doi.org/10.1016/j.fcl.2005.01.011
O’Neill, S., Barry, S., & Watson, P. (2019). Plantarflexor strength and endurance deficits associated with mid-portion Achilles tendinopathy: The role of soleus. Physical Therapy in Sport: Official Journal of the Association of Chartered Physiotherapists in Sports Medicine, 37, 69–76. https://doi.org/10.1016/j.ptsp.2019.03.002 DOI: https://doi.org/10.1016/j.ptsp.2019.03.002
Petechuk, V. (2024). Injury prevention during sports classes for high school students with sports-oriented education. Health-Saving Technologies, Rehabilitation and Physical Therapy, 5(1). https://doi.org/10.58962/hstrpt.2024.5.1.49-55 DOI: https://doi.org/10.58962/HSTRPT.2024.5.1.49-55
Pham, L., Gaudette, L. W., Funk, M. M., Vogel, K. E. L., Bruneau, M. M., Grävare Silbernagel, K., Tam, J., & Tenforde, A. S. (2025). Association of functional measures to injury severity in runners with achilles tendinopathy. PM and R. 1-4. https://doi.org/10.1002/pmrj.13314 DOI: https://doi.org/10.1002/pmrj.13314
Prudêncio, D. A., Maffulli, N., Migliorini, F., Serafim, T. T., Nunes, L. F., Sanada, L. S., & Okubo, R. (2023). Eccentric exercise is more effective than other exercises in the treatment of mid-portion Achilles tendinopathy: Systematic review and meta-analysis. BMC Sports Science, Medicine and Rehabilitation, 15(1). https://doi.org/10.1186/s13102-023-00618-2 DOI: https://doi.org/10.1186/s13102-023-00618-2
Rabin, A., Kozol, Z., & Finestone, A. S. (2014). Limited ankle dorsiflexion increases the risk for mid-portion Achilles tendinopathy in infantry recruits: A prospective cohort study. Journal of Foot and Ankle Research, 7(1), 48. https://doi.org/10.1186/s13047-014-0048-3 DOI: https://doi.org/10.1186/PREACCEPT-2575054011408612
Rabusin, C. L., Menz, H. B., McClelland, J. A., Tan, J. M., Whittaker, G. A., Evans, A. M., & Munteanu, S. E. (2019). Effects of heel lifts on lower limb biomechanics and muscle function: A systematic review. Gait & Posture, 69, 224–234. https://doi.org/10.1016/j.gaitpost.2019.01.023 DOI: https://doi.org/10.1016/j.gaitpost.2019.01.023
Ridge, S., Olsen, M., Bruening, D., Jurgensmeier, K., Griffin, D., Davis, I., & Johnson, A. (2018). Walking in Minimalist Shoes Is Effective for Strengthening Foot Muscles. Faculty Publications. https://scholarsarchive.byu.edu/facpub/3159
Seymore, K. D., Smitheman, H. P., Smith, A. K., Pohlig, R. T., Couppé, C., & Silbernagel, K. G. (2025). Metabolic risk factors relate to worse tendon health in individuals with achilles tendinopathy. Journal of Orthopaedic Research. 06 January 2025. https://doi.org/10.1002/jor.26038 DOI: https://doi.org/10.1002/jor.26038
Silbernagel, K. G., Malliaras, P., Vos, R.-J. de, Hanlon, S., Molenaar, M., Alfredson, H., Akker‐Scheek, I. van den, Antflick, J., Ark, M. van, Färnqvist, K., Haleem, Z., Kaux, J.-F., Kirwan, P., Kumar, B., Lewis, T., Mallows, A., Masci, L., Morrissey, D., Murphy, M., … Vicenzino, B. (2021). ICON 2020—International scientific tendinopathy symposium consensus: A systematic review of outcome measures reported in clinical trials of achilles tendinopathy. Sports Medicine, 52(3). https://doi.org/10.1007/s40279-021-01588-6 DOI: https://doi.org/10.1007/s40279-021-01588-6
Sinclair, J. K., Brooks, D., Taylor, P. J., & Liles, N. (2021). Effects of running in minimal, maximal and traditional running shoes: A musculoskeletal simulation exploration using statistical parametric mapping and bayesian analyses. Footwear Science, 13(2). https://doi.org/10.1080/19424280.2021.1892834 DOI: https://doi.org/10.1080/19424280.2021.1892834
Stanish, W. D., Rubinovich, R. M., & Curwin, S. (1986). Eccentric Exercise in Chronic Tendinitis. Clinical Orthopaedics and Related Research®, 208, 65. DOI: https://doi.org/10.1097/00003086-198607000-00014
Svensson, R. B., Heinemeier, K. M., Couppé, C., Kjaer, M., & Magnusson, S. P. (2016). Effect of aging and exercise on the tendon. Journal of Applied Physiology, 121(6), 1353–1362. https://doi.org/10.1152/japplphysiol.00328.2016 DOI: https://doi.org/10.1152/japplphysiol.00328.2016
Takeuchi, K., Akizuki, K., & Nakamura, M. (2021). Association between static stretching load and changes in the flexibility of the hamstrings. Scientific Reports, 11(1). https://doi.org/10.1038/s41598-021-01274-7 DOI: https://doi.org/10.1038/s41598-021-01274-7
Tarantino, D., Mottola, R., Resta, G., Gnasso, R., Palermi, S., Corrado, B., Sirico, F., Ruosi, C., & Aicale, R. (2023). Achilles tendinopathy pathogenesis and management: A narrative review †. International Journal of Environmental Research and Public Health, 20(17). https://doi.org/10.3390/ijerph20176681 DOI: https://doi.org/10.3390/ijerph20176681
Tatiya, D., Chitapure, T., Shaikh, A., & Jaju, A. (2021). The role of eccentric training and pain neuroscience education (PNE) to improve quadriceps muscle strength, and function in post ACL repair: A case report. International Journal of Kinesiology and Sports Science, 9(3). https://doi.org/10.7575/aiac.ijkss.v.9n.3p40 DOI: https://doi.org/10.7575/aiac.ijkss.v.9n.3p40
Vila Suarez, H. (2023). The effects of a high intensity resistance and eccentric strength training program on the performance of handball players. Retos, 50. https://doi.org/10.47197/retos.v50.98948 DOI: https://doi.org/10.47197/retos.v50.98948
Visnes, H., & Bahr, R. (2007). The evolution of eccentric training as treatment for patellar tendinopathy (jumper’s knee): A critical review of exercise programmes. https://doi.org/10.1136/bjsm.2006.032417 DOI: https://doi.org/10.1136/bjsm.2006.032417
Waugh, C. M., Korff, T., Fath, F., & Blazevich, A. J. (2013). Rapid Force Production in Children and Adults: Mechanical and Neural Contributions. Medicine & Science in Sports & Exercise, 45(4), 762–771. https://doi.org/10.1249/MSS.0b013e31827a67ba DOI: https://doi.org/10.1249/MSS.0b013e31827a67ba
Wells, G. A., Shea, B., O’Connell, D., Peterson, J., Welch, V., Losos, M., & Tugwell, P. (2000). The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses.
Werkhausen, A., Albracht, K., Cronin, N. J., Paulsen, G., Bojsen-Møller, J., & Seynnes, O. R. (2018). Effect of Training-Induced Changes in Achilles Tendon Stiffness on Muscle-Tendon Behavior During Landing. Frontiers in Physiology, 9, 794. https://doi.org/10.3389/fphys.2018.00794 DOI: https://doi.org/10.3389/fphys.2018.00794
Wiesinger, H.-P., Kösters, A., Müller, E., & Seynnes, O. R. (2015). Effects of Increased Loading on In Vivo Tendon Properties: A Systematic Review. Medicine and Science in Sports and Exercise, 47(9), 1885–1895. https://doi.org/10.1249/MSS.0000000000000603 DOI: https://doi.org/10.1249/MSS.0000000000000603
Zhang, T., Zhao, Y., Adams, R., Malliaras, P., Witchalls, J., Fu, W., & Han, J. (2025). The effect of anti-pronation and anti-supination taping on neuromuscular control in recreational athletes with achilles tendinopathy: A randomized controlled cross-over trial. Physical Therapy in Sport, 71, 92–99. https://doi.org/10.1016/j.ptsp.2024.12.006 DOI: https://doi.org/10.1016/j.ptsp.2024.12.006
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Joshua Sargeant, Victor Romano

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.