Pain in the Achilles Tendon

posted Apr 30, 2012, 2:33 PM by LASP Team

The Achilles tendon is the single tendon of the calf muscles, inserting into the heel bone.

Achilles Tendonopathy is a painful condition, most often due to overuse. Tendons respond poorly to overuse, therefore healing is slow. This can leave a tendon damaged, which decreases tendon strength and leaves it less able to tolerate load, thus vulnerable to further injury.

Treatment of Achilles Tendinopathy is initially conservative, including rest, equipment changes, strength and flexibility exercises and medication. But what options do you have if the initial conservative management fails?

The staff at Lifestyle and Sports Physiotherapy recently performed a review of research papers to find out which injections are the most effective at decreasing pain in Achilles Tendinopathies.


Anti-inflammatory medications

·         Provide temporary pain relief but do not appear to have a long term benefit (but actually may cause worse pain in the long term).



Prolotherapy uses a dextrose (sugar water) solution, which is injected into the tendon where it attaches to the bone. This causes a localized inflammation in these areas which then increases the blood supply and flow of nutrients and stimulates the tissue to repair itself.

·         May be an option if other options don’t work.  Pilot study found a reduction in pain levels at rest, normal activities and during sport in >78% of participants.

·         Combined with Physiotherapy exercises it may give a more rapid improvement in symptoms than Physiotherapy exercises alone.



A type of ‘Sclerosing’ Injection, where a medicine is injected into the blood vessels, which makes them shrink.

·         Small volumes (5mg/mL) achieved patient satisfaction in (on average) 2.5 treatments and to decrease pain.

·         It appears to provide pain relief if the involved tendon has changes in blood supply as seen on Doppler Ultrasound.


PRP Injections:

Platelet Rich Plasma (PRP) has a significantly increased platelet concentration compared to normal blood. During the healing process, platelets are activated . They then release the granules which contain growth factors which stimulate the healing process.

·         A PRP injection did not result in greater improvement in pain and activity compared with a saline injection, however both groups showed significant improvements in pain, when compared to conservative management.


In summary there is insufficient evidence to make a judgement on which injection most effective at decreasing pain in Achilles Tendonopathies. 

There is good evidence to support specific exercise therapy as prescribed by a physiotherapist for Achilles Tendinopathy. This approach is generally pursued by most people before considering injections. If exercise alone fails to improve your symptoms, then injection therapy may be indicated, in consultation with your Physiotherapist, GP or Specialist. Each of the injections has inherit risks and side effects that should be discussed carefully with your doctor

For more information or to have your questions answered, please contact one of our Physiotherapists on (02) 4647 3373.


Metcalfe D, Achten J, Costa ML. Glucocorticoid injections in lesions of the achilles tendon. Foot Ankle Int. 2009 Jul;30(7):661-5.

Willberg L, Sunding K, Ohberg L, Forssblad M, Fahlström M, Alfredson H. Sclerosing injections to treat midportion Achilles tendinosis: a randomised controlled study evaluating two different concentrations of Polidocanol. Knee Surg Sports Traumatol Arthrosc. 2008 Sep;16(9):859-64. Epub 2008 Jul 17.

Hoksrud A, Ohberg L, Alfredson H, Bahr R. Ultrasound-guided sclerosis of neovessels in painful chronic patellar tendinopathy: a randomized controlled trial. Am J Sports Med. 2006 Nov;34(11):1738-46. Epub 2006 Jul 10.

Connell DA, Ali KE, Ahmad M, Lambert S, Corbett S, Curtis M. Ultrasound-guided autologous blood injection for tennis elbow. Clin J Sport Med. 2009 Jan;19(1):54-64.

Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med. 2009 Jan;19(1):54-64.

James SL, Ali K, Pocock C, Robertson C, Walter J, Bell J, Connell D Ultrasound guided dry needling and autologous blood injection for patellar tendinosis. Br J Sports Med. 2007 Aug;41(8):518-21; discussion 522. Epub 2007 Mar 26.

Brown R, Orchard J, Kinchington M, Hooper A, Nalder G. Aprotinin in the management of Achilles tendinopathy: a randomised controlled trial [with consumer summary]. British Journal of Sports Medicine 2006 Mar;40(3):275-279

D Rabago, T M Best, A E Zgierska, E Zeisig, M Ryan, and D Crane. A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma. Br. J. Sports Med., July 1, 2009; 43(7): 471 - 481.

Orchard J, Massey A, Brown R, Cardon-Dunbar A, Hofmann J. Successful management of tendinopathy with injections of the MMP-inhibitor aprotinin. Clin Orthop Relat Res. 2008 Jul;466(7):1625-32. Epub 2008 May 1.

Michael J Yelland, Kent R Sweeting, John A Lyftogt, Shu Kay Ng, Paul A Scuffham and Kerrie A Evans. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med. Published Online First: 22 June 2009

Maxwell NJ, Ryan MB, Taunton JE, Gillies JH, Wong AD. Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: a pilot study. Am J Roentgenol (2007) 189:W215–20

de Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, Verhaar JA, Weinans H, Tol JL. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA. 2010 Jan 13;303(2):144-9