Mid-substance Achilles tendinopathy affects the middle portion of the Achilles tendon and can cause pain, stiffness and swelling at the back of the ankle. Symptoms often develop gradually and may affect walking, exercise and daily activities.

Mr Edward Dawe is a Consultant Foot & Ankle Surgeon specialising in the assessment and treatment of Achilles tendinopathy, offering both non-surgical and surgical treatment options where appropriate. Clinics are available in Chichester, Worthing and Haywards Heath.

What is Achilles tendinopathy?

Achilles tendinopathy is a condition in which the tendon becomes damaged and degenerative over time. In mid-substance Achilles tendinopathy, this affects the main body of the tendon rather than the point where it attaches to the heel bone.

Symptoms of Achilles tendinopathy

Common symptoms include:

  • Pain in the middle part of the Achilles tendon
  • Stiffness, particularly first thing in the morning or after rest
  • Swelling or thickening of the tendon
  • Pain during or after walking, running or exercise
  • Tenderness when pressing on the tendon

Non-surgical treatment

Many patients improve with non-surgical treatment. Options may include:

  • Activity modification
  • Physiotherapy
  • Calf strengthening exercises
  • Supportive footwear
  • Pain relief medication

These treatments aim to reduce symptoms and improve function, although recovery can take time.

Most patients with mid-portion Achilles pain improve without surgery.
Treatment focuses on reducing strain on the tendon and gradually restoring strength and function.

Activity modification

Symptoms are often aggravated by overuse or sudden increases in activity.
Reducing or modifying aggravating activities can help settle symptoms, particularly in the early stages.

Structured loading exercises

Progressive loading of the tendon is an important part of treatment.
This usually involves a structured exercise programme designed to gradually increase the load through the Achilles tendon and improve its capacity to tolerate activity.

Calf stretching

Calf tightness can contribute to increased strain on the Achilles tendon.
Stretching exercises may help reduce tension through the calf and improve flexibility.

Physiotherapy

A physiotherapist can guide rehabilitation, adjust loading programmes and help progress exercises safely.

Shockwave therapy

Shockwave therapy may be used in selected cases where symptoms persist despite initial treatment.

Footwear and support

Changes in footwear or the use of heel lifts may help reduce strain on the tendon in some patients.

​Recovery can take time, and symptoms often improve gradually over several months.
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​The diagram below illustrates common non-operative management strategies for mid-substance Achilles tendinopathy.

Surgical treatment

Surgery may be considered if symptoms persist despite non-surgical management and continue to affect daily activities or sport.

Procedures may involve removing damaged tendon tissue and addressing any areas of degeneration. The most appropriate treatment depends on the severity of the condition and individual patient factors.

When to seek specialist advice

If pain in the Achilles tendon is persistent, worsening or limiting walking or exercise, a specialist assessment can help confirm the diagnosis and guide treatment.

Early assessment may help identify contributing factors and support recovery.

Frequently asked questions

What causes Achilles tendinopathy?
Achilles tendinopathy is often caused by repeated strain on the tendon, particularly with increased activity, training changes or calf tightness.
Is Achilles tendinopathy the same as Achilles tendinitis?
Achilles tendinopathy usually refers to degenerative changes within the tendon, whereas tendinitis suggests inflammation. In practice, both terms are often used interchangeably.
Can Achilles tendinopathy improve without surgery?
Yes, many patients improve with physiotherapy, activity modification and supportive measures, although recovery may take several months.
When is surgery needed for Achilles tendinopathy?
Surgery may be considered if symptoms persist despite non-surgical treatment and significantly affect daily activities or exercise.