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1 · SNAPSHOT

Achilles Tendinopathy body chart — Illustrative, not diagnostic. Canva body chart for Achilles Tendinopathy.

Who: Runners and jumpers, and middle-aged adults who never run anywhere. In primary care, only 35% of cases had a recorded sports relationship.
What: Load-related pain either 2–6 cm above the heel (midportion) or at the bone (insertional).
How it behaves: Stiff and sore on the first steps in the morning or after sitting, warms up with movement, worse the day after a load spike.

The illness script in one line: load-related posterior heel pain with morning stiffness, where the first question is where exactly it hurts — because that answer changes the treatment.

The numbers that matter:

	Figure
Primary-care incidence, all ages	1.85 per 1,000 registered patients per year
Primary-care incidence, adults 21–60	2.35 per 1,000 per year
Cases with a recorded sports relationship	35%
Recreational runners over a running season	5.2% (95% CI 4.2–6.2)
Marathon registrants	7.4%

(General population: [1], n = 57,725. Runners: [2], prospective cohort of 1,929.)

You may have been taught that 52% of runners get this in their lifetime. That figure is not sourceable — it traces to a narrative review citing a cohort of male former elite athletes with a median age of 69, and that paper reports odds ratios, not a lifetime rate. Use 5.2% per running season.

⚠️ No Australian guideline exists for this presentation, and the guideline coverage is lopsided. Anchored to the JOSPT Midportion Achilles Tendinopathy CPG [3], which is midportion only. The only guideline covering insertional as well is the Dutch multidisciplinary guideline [4], whose searches ran to May 2019 and therefore predate four of the trials on this page. Half of this condition has no current guideline behind it. Say so.

Pattern > Label. "Achilles tendinopathy" is two conditions wearing one name.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages, in the order your course teaches them. Insidious, so run BEHAVIOUR before HISTORY.

MAIN PROBLEM

The activity they've lost. Running distance, hills, jumping, stairs, or just walking the dog first thing.

BODY CHART — this is where the diagnosis is made

Ask them to point with one finger, and take the answer seriously. The subjective report of pain located 2–6 cm above the calcaneal insertion had sensitivity 78%, specificity 77% for Achilles tendinopathy, with kappa 0.75–0.81. Of ten tests examined in that study, only that history item and pain on palpation were accurate and reliable enough to recommend ([5], n = 21, ultrasound reference).

Where they point	What it means
2–6 cm above the heel bone	Midportion
At the back of the heel bone itself	Insertional — and anatomically inseparable from retrocalcaneal bursitis, Haglund deformity and calcific enthesopathy, which coexist [6]
Deep, behind the tendon, on forced plantarflexion	Posterior ankle impingement
A teenager, at the growth plate	Sever's — or, if there's a systemic story, see §4

BEHAVIOUR

Aggs: running (especially hills and speed), jumping, stairs, and — for insertional — anything that pushes the ankle into dorsiflexion, including the calf stretch someone has already told them to do.
Eases: warming up, then worse afterwards. Rest overnight, then stiff again in the morning.
Severity: VAS 0–10 at best / at worst / right now.
The classic: morning stiffness and first-step pain, easing within minutes of walking.
24-hr pattern: worse the day after a load spike, not during it. Get the training history in days, not weeks.
Irritability: vigour, severity, time to settle. It sets your starting load, and it's the whole plan in this pattern.

HISTORY

Load change, not load amount. New shoes, a new surface, hill repeats, a return after a break, a change in job. Ask what was different in the fortnight before it started.
Previous episode in the last 12 months is the strongest risk factor in runners (Lagas 2020).
Ask about antibiotics. See §4 — this is not a box-tick.
What have they already tried? If they've been stretching hard and it's insertional, you've found the problem.

SPECIAL / SCREENING QUESTIONS

General health, inflammatory features, back or other joint pain, uveitis, family history, medications including fluoroquinolones and corticosteroids. See §4.

The risk-factor questions that don't earn their place

A systematic review of ten cohort studies found limited evidence for nine risk factors — and 26 other putative risk factors showed no association, explicitly including being overweight, static foot posture, and physical activity level [7].

So the flat-feet conversation and the weight conversation are not supported here. What is on the list: prior lower-limb tendinopathy or fracture, ofloxacin use, moderate alcohol, training in cold weather, and decreased isokinetic plantarflexor strength.

Assessing this region? Download the Ankle & Foot assessment template →

3 · HYPOTHESIS RANKING

Top competing patterns, one discriminating feature each.

Competing pattern	The one discriminating feature
Achilles rupture	Sudden, often a "kick in the back of the leg". Calf squeeze test — see §4. Missed as an ankle sprain in a fifth to a quarter of cases
Insertional (if you thought midportion)	Pain at the bone, provoked by dorsiflexion rather than relieved by it. The single most consequential distinction on this page
Posterior ankle impingement	Pain on forced plantarflexion, tender behind the tendon, dorsiflexion usually normal
Retrocalcaneal bursitis / Haglund	Deep posterior heel pain aggravated by shoe-counter pressure. Coexists with insertional tendinopathy — treat them as one entity, not two
Sever's (calcaneal apophysitis)	Age 8–14, tender on medial-lateral calcaneal squeeze. Apophyseal, not tendinous
Juvenile spondyloarthropathy	A teenager or young adult with heel enthesopathy plus asymmetric lower-limb arthritis, uveitis or a family history [8]

The differential separates retrocalcaneal bursitis from insertional tendinopathy by a single palpation point. The anatomy doesn't cooperate — enthesitis, retrocalcaneal bursitis, insertional tendinopathy and Haglund deformity are described as one "enthesis organ" region and routinely coexist (Mascarenhas 2020). Treat the region, not the label.

Jones' hypothesis categories that change your plan here: sources of symptoms (midportion vs insertional — everything hangs on it), contributing factors (the load change), and precautions (rupture, and the antibiotic history).

Midportion or insertional isn't a naming exercise. It's the difference between stretching them and not.

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever.

Rupture — and the one test that earns its place

Across all the clinical measures reviewed, the calf-squeeze (Thompson/Simmonds) test had both the highest sensitivity and the highest specificity [9]:

	Figure
Best sensitivity	0.96 (95% CI 0.93–0.99), −LR 0.04 (0.02–0.10)
Best specificity	0.93 (0.84–1.00), +LR 13.71 (3.54–51.24)

That is an unusually good test, and it takes ten seconds. Achilles rupture is misdiagnosed as an ankle sprain in a fifth to a quarter of cases, and only about one in ten patients report any warning symptoms — so "it came out of nowhere" is the norm, not a reason to relax.

Do the calf squeeze on any acute posterior calf presentation. Prone, knee flexed, squeeze the calf, watch for plantarflexion. No movement = refer today.

Fluoroquinolones — ask, every time

Outcome	Pooled odds ratio
Achilles tendinitis	3.95 (95% CI 3.11–5.01)
Achilles rupture	2.52 (1.81–3.52)
Any tendon disorder	1.98 (1.62–2.43)

([10], 15 observational studies. Estimates remained significant in patients aged 60+. By drug, the rupture signal was significant for ofloxacin and norfloxacin but not ciprofloxacin or levofloxacin.)

Roughly quadrupled odds of tendinitis. The window of highest risk is the first month of treatment. This is a two-second question that occasionally changes everything.

Everything else to screen

Signs / symptoms	Implication
Sudden onset, palpable gap, positive calf squeeze	Rupture — same-day referral
Recent fluoroquinolone, or corticosteroid use	Drug-associated tendinopathy or rupture
Teenager with heel pain plus other joints, uveitis, family history	Juvenile spondyloarthropathy
Multiple entheses, morning stiffness > 30 min, inflammatory back pain	Spondyloarthropathy
Hot, red, systemically unwell	Infection
Night pain unchanged by position, weight loss, cancer history	Malignancy
Calf pain, swelling, warmth after immobilisation or travel	DVT

Any acute posterior calf pain gets a calf squeeze. Ten seconds, and it's the best test on this page.
Ask about antibiotics. Tendinitis odds are quadrupled on a fluoroquinolone.
A teenager with heel pain and a second joint is not Sever's.

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Guideline anchor

No Australian guideline for this presentation.

Anchored to Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2024 — JOSPT Clinical Practice Guideline (Chimenti et al.)

PubMed

No Australian clinical practice guideline or clinical care standard exists for Achilles tendinopathy. ACSQHC has no standard for tendinopathy generally and RACGP has no equivalent guideline.

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The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 26

Show

Every source on this page resolves and title-verifies against PubMed. Newest first.

2011de Jonge et al. (2011). Incidence of midportion Achilles tendinopathy in the general population. British journal of sports medicine, 45(13), 1026-8. https://doi.org/10.1136/bjsports-2011-090342
2020Lagas et al. (2020). Incidence of Achilles tendinopathy and associated risk factors in recreational runners: A large prospective cohort study. Journal of science and medicine in sport, 23(5), 448-452. https://doi.org/10.1016/j.jsams.2019.12.013
2024Chimenti et al. (2024). Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision - 2024. The Journal of orthopaedic and sports physical therapy, 54(12), CPG1-CPG32. https://doi.org/10.2519/jospt.2024.0302
2021de Vos et al. (2021). Dutch multidisciplinary guideline on Achilles tendinopathy. British journal of sports medicine, 55(20), 1125-1134. https://doi.org/10.1136/bjsports-2020-103867
2013Hutchison et al. (2013). What is the best clinical test for Achilles tendinopathy?. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons, 19(2), 112-7. https://doi.org/10.1016/j.fas.2012.12.006
2020Mascarenhas (2020). A Narrative Review of the Classification and Use of Diagnostic Ultrasound for Conditions of the Achilles Tendon. Diagnostics (Basel, Switzerland), 10(11). https://doi.org/10.3390/diagnostics10110944
2019van der Vlist et al. (2019). Clinical risk factors for Achilles tendinopathy: a systematic review. British journal of sports medicine, 53(21), 1352-1361. https://doi.org/10.1136/bjsports-2018-099991
2016Adrovic et al. (2016). Juvenile Spondyloarthropathies. Current rheumatology reports, 18(8), 55. https://doi.org/10.1007/s11926-016-0603-y
2014Reiman et al. (2014). The utility of clinical measures for the diagnosis of achilles tendon injuries: a systematic review with meta-analysis. Journal of athletic training, 49(6), 820-9. https://doi.org/10.4085/1062-6050-49.3.36
2019Alves et al. (2019). Fluoroquinolones and the risk of tendon injury: a systematic review and meta-analysis. European journal of clinical pharmacology, 75(10), 1431-1443. https://doi.org/10.1007/s00228-019-02713-1
2001Robinson et al. (2001). The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. British journal of sports medicine, 35(5), 335-41. https://doi.org/10.1136/bjsm.35.5.335
2021Lagas et al. (2021). Victorian Institute of Sport Assessment-Achilles (VISA-A) Questionnaire-Minimal Clinically Important Difference for Active People With Midportion Achilles Tendinopathy: A Prospective Cohort Study. The Journal of orthopaedic and sports physical therapy, 51(10), 510-516. https://doi.org/10.2519/jospt.2021.10040
2015Docking et al. (2015). Tendinopathy: Is Imaging Telling Us the Entire Story?. The Journal of orthopaedic and sports physical therapy, 45(11), 842-52. https://doi.org/10.2519/jospt.2015.5880
2012van der Plas et al. (2012). A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy. British journal of sports medicine, 46(3), 214-8. https://doi.org/10.1136/bjsports-2011-090035
2025Pringels et al. (2025). Effectiveness of reducing tendon compression in the rehabilitation of insertional Achilles tendinopathy: a randomised clinical trial. British journal of sports medicine, 59(9), 640-650. https://doi.org/10.1136/bjsports-2024-109138
2008Jonsson et al. (2008). New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. British journal of sports medicine, 42(9), 746-9. https://doi.org/10.1136/bjsm.2007.039545
2007Silbernagel et al. (2007). Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. The American journal of sports medicine, 35(6), 897-906. https://doi.org/10.1177/0363546506298279
2015Beyer et al. (2015). Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. The American journal of sports medicine, 43(7), 1704-11. https://doi.org/10.1177/0363546515584760
2023Maetz et al. (2023). Systematic Review and Meta-analyses of Randomized Controlled Trials Comparing Exercise Loading Protocols With Passive Treatment Modalities or Other Loading Protocols for the Management of Midportion Achilles Tendinopathy. Orthopaedic journal of sports medicine, 11(5), 23259671231171178. https://doi.org/10.1177/23259671231171178
2013Malliaras et al. (2013). Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports medicine (Auckland, N.Z.), 43(4), 267-86. https://doi.org/10.1007/s40279-013-0019-z
1998Alfredson et al. (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. The American journal of sports medicine, 26(3), 360-6. https://doi.org/10.1177/03635465980260030301
2021Kearney et al. (2021). Effect of Platelet-Rich Plasma Injection vs Sham Injection on Tendon Dysfunction in Patients With Chronic Midportion Achilles Tendinopathy: A Randomized Clinical Trial. JAMA, 326(2), 137-144. https://doi.org/10.1001/jama.2021.6986
2022Johannsen et al. (2022). Effect of Ultrasonography-Guided Corticosteroid Injection vs Placebo Added to Exercise Therapy for Achilles Tendinopathy: A Randomized Clinical Trial. JAMA network open, 5(7), e2219661. https://doi.org/10.1001/jamanetworkopen.2022.19661
2021Mansur et al. (2021). Shockwave Therapy Plus Eccentric Exercises Versus Isolated Eccentric Exercises for Achilles Insertional Tendinopathy: A Double-Blinded Randomized Clinical Trial. The Journal of bone and joint surgery. American volume, 103(14), 1295-1302. https://doi.org/10.2106/JBJS.20.01826
2021Zhi et al. (2021). Nonoperative treatment of insertional Achilles tendinopathy: a systematic review. Journal of orthopaedic surgery and research, 16(1), 233. https://doi.org/10.1186/s13018-021-02370-0
2011Silbernagel et al. (2011). The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up. The American journal of sports medicine, 39(3), 607-13. https://doi.org/10.1177/0363546510384789

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