Venugopal, Bone Joint J 2026 - An Update on Current Concepts and Management of Mid-Substance Achilles Tendinopathy

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An Update on Current Concepts and Management of Mid-Substance Achilles Tendinopathy.

Venugopal, Grice, et al.·Bone Joint J·2026·1 citations·Review article·Foot & Ankle

Purpose

This review provides a comprehensive overview of mid-substance Achilles tendinopathy (MAT), covering its aetiology, pathophysiology, diagnosis, and management strategies, both nonoperative and operative.

Methods

A detailed literature analysis was conducted, focusing on MAT's epidemiology, clinical presentation, imaging methods, and treatment options.
Key studies and meta-analyses were reviewed.
This review synthesizes the current evidence on the assessment and management of MAT.
It details the pathophysiology, epidemiology, and diagnostic process, including clinical evaluation, specific provocation tests, and the role of imaging.
A comprehensive analysis of both conservative and surgical treatment options is presented, evaluating their efficacy based on the available literature.

Results

MAT presents bimodally, with a male predominance.
Diagnosis is primarily clinical, supported by ultrasound and tools such as the Victorian Institute of Sport Assessment-Achilles score.
Nonoperative management is the cornerstone, with eccentric exercise rehabilitation standing as the most evidence-based and effective intervention.
For recalcitrant cases, high-volume image-guided injection (HVIGI) is a promising second-line option with a favourable safety profile.
Extracorporeal shockwave therapy (ESWT) may be considered as an adjunct.
Evidence for other adjuncts such as platelet-rich plasma and corticosteroids is weak, and their use is not recommended.
Surgical intervention is reserved for the approximately 20% to 29% of patients who fail conservative treatment.
Options include gastrocnemius recession, plantaris excision, and open or minimally invasive/endoscopic debridement, with tendon transfer indicated for large defects.
While most techniques report high success rates, a lack of high-level comparative evidence precludes a definitive surgical algorithm.

Conclusions

The management of MAT is fundamentally staged, beginning with a prolonged trial of eccentric exercises. HVIGI and ESWT are valuable next-step options. Surgery is considered for refractory cases, with a trend towards minimally invasive techniques owing to their lower complication profile. However, there is a paucity of randomized controlled trials, making surgeon preference and expertise a significant factor in choice of procedure. An evidence-based treatment algorithm is proposed to guide clinical decision-making.

Published abstract, Bone Joint J 2026. Copyright remains with the authors and publisher.

An Update on Current Concepts and Management of Mid-Substance Achilles Tendinopathy.

Venugopal, Grice, et al.Bone Joint J20261 citationsReview article

Effects of Bracing in Adolescents with Idiopathic Scoliosis.

Weinstein, Dobbs, et al.N Engl J Med20131,160 citationsRCT

Acetabular Defect Classification and Surgical Reconstruction in Revision Arthroplasty. A 6-Year Follow-Up Evaluation.

Paprosky, Lawrence, et al.J Arthroplasty19941,213 citationsRetrospective cohort

Adolescent Idiopathic Scoliosis: A New Classification to Determine Extent of Spinal Arthrodesis.

Lenke, Blanke, et al.J Bone Joint Surg Am20011,720 citationsDiagnostic study

Problems in the Management of Type III (Severe) Open Fractures: A New Classification of Type III Open Fractures.

Gustilo, Williams, et al.J Trauma19842,361 citationsRetrospective cohort

A System for the Surgical Staging of Musculoskeletal Sarcoma.

Enneking, Goodman, et al.Clin Orthop Relat Res19802,112 citationsRetrospective cohort

Fatty Muscle Degeneration in Cuff Ruptures. Pre- and Postoperative Evaluation by CT Scan.

Goutallier, Voisin, et al.Clin Orthop Relat Res19942,669 citationsProspective cohort

Dislocations after Total Hip-Replacement Arthroplasties.

Lewinnek, Zimmerman, et al.J Bone Joint Surg Am19782,549 citationsRetrospective cohort

The Three Column Spine and Its Significance in the Classification of Acute Thoracolumbar Spinal Injuries.

DenisSpine (Phila Pa 1976)19832,566 citationsRetrospective cohort

Traumatic Glenohumeral Bone Defects and Their Relationship to Failure of Arthroscopic Bankart Repairs: Significance of the Inverted-Pear Glenoid and the Humeral Engaging Hill-Sachs Lesion.

Burkhart, De BeerArthroscopy20001,884 citationsCase series

The Value of the Tip-Apex Distance in Predicting Failure of Fixation of Peritrochanteric Fractures of the Hip.

Baumgaertner, Keggi, et al.J Bone Joint Surg Am19951,441 citationsRetrospective cohort

Transchondral Fractures (Osteochondritis Dissecans) of the Talus.

Berndt, HartyJ Bone Joint Surg Am1959945 citationsBiomechanical study

Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis.

Weinstein, SPORT Investigators, et al.N Engl J Med20081,207 citationsRCT

Preoperative versus Postoperative Radiotherapy in Soft-Tissue Sarcoma of the Limbs: A Randomised Trial.

O'Sullivan, Zee, et al.Lancet20021,587 citationsRCT

Microvasculature of the Human Meniscus.

Arnoczky, WarrenAm J Sports Med19821,227 citationsAnatomic study

Neer Award 2005: The Grammont Reverse Shoulder Prosthesis: Results in Cuff Tear Arthritis, Fracture Sequelae, and Revision Arthroplasty.

Boileau, Hovorka, et al.J Shoulder Elbow Surg20061,115 citationsProspective cohort

Injuries Involving the Epiphyseal Plate

Salter, HarrisJ Bone Joint Surg Am19631,737 citationsRetrospective cohort

Cuff-Tear Arthropathy.

Neer, Fukuda, et al.J Bone Joint Surg Am1983774 citationsCase series

A System of Staging Musculoskeletal Neoplasms.

EnnekingClin Orthop Relat Res19861,083 citationsReview article

Fracture Fixation in the Operative Management of Hip Fractures (FAITH): An International, Multicentre, Randomised Controlled Trial.

Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) InvestigatorsLancet2017310 citationsRCT

Morphologic Study of the Glenoid in Primary Glenohumeral Osteoarthritis.

Walch, Khoury, et al.J Arthroplasty19991,142 citationsRetrospective cohort

The Reverse Shoulder Prosthesis for Glenohumeral Arthritis Associated with Severe Rotator Cuff Deficiency. A Minimum Two-Year Follow-Up Study of Sixty Patients.

Frankle, Vasey, et al.J Bone Joint Surg Am2005773 citationsRetrospective cohort

Effect of Achilles Tendon Lengthening on Neuropathic Plantar Ulcers: A Randomized Clinical Trial

Mueller, Johnson, et al.J Bone Joint Surg Am2003347 citationsRCT

Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes: A Prospective Study.

Hewett, Succop, et al.Am J Sports Med20053,495 citationsProspective cohort

Grammont Inverted Total Shoulder Arthroplasty in the Treatment of Glenohumeral Osteoarthritis with Massive Rupture of the Cuff. Results of a Multicentre Study of 80 Shoulders.

Sirveaux, Molé, et al.J Bone Joint Surg Br20041,598 citationsRetrospective cohort

Hip Morphology Influences the Pattern of Damage to the Acetabular Cartilage: Femoroacetabular Impingement as a Cause of Early Osteoarthritis of the Hip.

Beck, Ganz, et al.J Bone Joint Surg Br20051,955 citationsRetrospective cohort

Fractures of the Ankle. II. Combined Experimental-Surgical and Experimental-Roentgenologic Investigations.

Lauge-HansenArch Surg1950830 citationsBiomechanical study

The Natural History of Legg-Calvé-Perthes Disease.

Stulberg, Wallensten, et al.J Bone Joint Surg Am1981810 citationsRetrospective cohort

Arthroplasty of the Hip. A New Operation.

CharnleyLancet1961834 citationsCase series

Randomized Trial of Reamed and Unreamed Intramedullary Nailing of Tibial Shaft Fractures.

Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators, Walter, et al.J Bone Joint Surg Am2008445 citationsRCT

A New Classification of Thoracolumbar Injuries: The Importance of Injury Morphology, the Integrity of the Posterior Ligamentous Complex, and Neurologic Status.

Vaccaro, Oner, et al.Spine (Phila Pa 1976)2005866 citationsConsensus statement

A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds.

FLOW Investigators, Guyatt, et al.N Engl J Med2015347 citationsRCT

Curve Progression in Idiopathic Scoliosis.

Weinstein, PonsetiJ Bone Joint Surg Am1983641 citationsRetrospective cohort

The Outcome and Repair Integrity of Completely Arthroscopically Repaired Large and Massive Rotator Cuff Tears.

Galatz, Yamaguchi, et al.J Bone Joint Surg Am20042,135 citationsCase series

Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration.

Pfirrmann, Boos, et al.Spine (Phila Pa 1976)20013,960 citationsDiagnostic study

Displaced Proximal Humeral Fractures. I. Classification and Evaluation.

NeerJ Bone Joint Surg Am19701,957 citationsRetrospective cohort

Displaced Proximal Humeral Fractures. II. Treatment of Three-Part and Four-Part Displacement.

NeerJ Bone Joint Surg Am19701,283 citationsRetrospective cohort

The Treatment of Soft-Tissue Sarcomas of the Extremities: Prospective Randomized Evaluations of (1) Limb-Sparing Surgery Plus Radiation Therapy Compared with Amputation and (2) the Role of Adjuvant Chemotherapy.

Rosenberg, Wesley, et al.Ann Surg19821,347 citationsRCT

The Lateral Pillar Classification of Legg-Calvé-Perthes Disease.

Herring, Browne, et al.J Pediatr Orthop1992461 citationsRetrospective cohort

Natural History of Asymptomatic Rotator Cuff Tears: A Longitudinal Analysis of Asymptomatic Tears Detected Sonographically.

Yamaguchi, Middleton, et al.J Shoulder Elbow Surg2001498 citationsRetrospective cohort

The Rotator Crescent and Rotator Cable: An Anatomic Description of the Shoulder's "Suspension Bridge".

Burkhart, Jolson, et al.Arthroscopy1993469 citationsAnatomic study

Ectopic Ossification Following Total Hip Replacement. Incidence and a Method of Classification.

Brooker, Riley, et al.J Bone Joint Surg Am19732,880 citationsRetrospective cohort

Factors of Patellar Instability: An Anatomic Radiographic Study.

Dejour, Guier, et al.Knee Surg Sports Traumatol Arthrosc19941,987 citationsCase-control study

Posterolateral Rotatory Instability of the Elbow.

O'Driscoll, Morrey, et al.J Bone Joint Surg Am1991997 citationsCase series

Fractures of the Acetabulum: Classification and Surgical Approaches for Open Reduction. Preliminary Report.

Judet, Letournel, et al.J Bone Joint Surg Am1964980 citationsCase series

Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures. A Multicenter, Randomized Clinical Trial.

Canadian Orthopaedic Trauma SocietyJ Bone Joint Surg Am2007804 citationsRCT

Metastatic Disease in Long Bones. A Proposed Scoring System for Diagnosing Impending Pathologic Fractures.

MirelsClin Orthop Relat Res19891,222 citationsRetrospective cohort

Early versus Delayed Decompression for Traumatic Cervical Spinal Cord Injury: Results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS).

Fehlings, Rampersaud, et al.PLoS One20121,200 citationsProspective cohort

Three-Dimensional Analysis of the Proximal Part of the Humerus: Relevance to Arthroplasty

Robertson, Yamaguchi, et al.J Bone Joint Surg Am2000255 citationsAnatomic study

Impingement Lesions.

NeerClin Orthop Relat Res19831,827 citationsReview article

The SLAC Wrist: Scapholunate Advanced Collapse Pattern of Degenerative Arthritis.

Watson, BalletJ Hand Surg Am19841,138 citationsRetrospective cohort

Direct Decompressive Surgical Resection in the Treatment of Spinal Cord Compression Caused by Metastatic Cancer: A Randomised Trial.

Patchell, Young, et al.Lancet20052,356 citationsRCT

The Tibial Plateau Fracture. The Toronto Experience 1968--1975.

Schatzker, Bruce, et al.Clin Orthop Relat Res19791,029 citationsRetrospective cohort

The Disabled Throwing Shoulder: Spectrum of Pathology Part III: The SICK Scapula, Scapular Dyskinesis, the Kinetic Chain, and Rehabilitation.

Burkhart, Kibler, et al.Arthroscopy2003929 citations

Surgical Dislocation of the Adult Hip a Technique with Full Access to the Femoral Head and Acetabulum without the Risk of Avascular Necrosis.

Ganz, Berlemann, et al.J Bone Joint Surg Br20011,367 citationsCase series

Recession of the Gastrocnemius; an Operation to Relieve Spastic Contracture of the Calf Muscles.

StrayerJ Bone Joint Surg Am1950226 citationsCase series

Elbow Instability.

O'DriscollActa Orthop Belg199959 citationsReview article

Prevention of Infection in the Treatment of One Thousand and Twenty-Five Open Fractures of Long Bones: Retrospective and Prospective Analyses.

Gustilo, AndersonJ Bone Joint Surg Am19763,211 citationsRetrospective cohort

Patella Position in the Normal Knee Joint.

Insall, SalvatiRadiology19711,572 citationsDiagnostic study

Carpal Dislocations: Pathomechanics and Progressive Perilunar Instability.

Mayfield, Kilcoyne, et al.J Hand Surg Am1980816 citationsBiomechanical study

The Management of Acetabular Insufficiency Secondary to Metastatic Malignant Disease

HarringtonJ Bone Joint Surg Am1981303 citationsCase series

Acetabular Anatomy and the Transacetabular Fixation of Screws in Total Hip Arthroplasty

Wasielewski, Rubash, et al.J Bone Joint Surg Am1990290 citationsAnatomic study

"Modes of Failure" of Cemented Stem-Type Femoral Components: A Radiographic Analysis of Loosening.

Gruen, Amstutz, et al.Clin Orthop Relat Res19793,647 citationsRetrospective cohort

The Value of Postural Reduction in the Initial Management of Closed Injuries of the Spine with Paraplegia and Tetraplegia. I.

Frankel, Walsh, et al.Paraplegia19692,283 citationsRetrospective cohort

Operative Treatment in 120 Displaced Intraarticular Calcaneal Fractures. Results Using a Prognostic Computed Tomography Scan Classification.

Sanders, Walling, et al.Clin Orthop Relat Res1993891 citationsProspective cohort

Reconstruction of the Ulnar Collateral Ligament in Athletes.

Jobe, Lombardo, et al.J Bone Joint Surg Am1986758 citationsCase series

Replacement Arthroplasty for Glenohumeral Osteoarthritis.

NeerJ Bone Joint Surg Am1974598 citationsCase series

Fractures of the Neck of the Talus.

HawkinsJ Bone Joint Surg Am1970556 citationsRetrospective cohort

Degenerative Lumbar Spondylolisthesis with Spinal Stenosis. A Prospective Study Comparing Decompression with Decompression and Intertransverse Process Arthrodesis.

Herkowitz, KurzJ Bone Joint Surg Am19911,032 citationsProspective cohort

Limits of Movement in the Human Knee. Effect of Sectioning the Posterior Cruciate Ligament and Posterolateral Structures.

Grood, Noyes, et al.J Bone Joint Surg Am1988674 citationsBiomechanical study

Congenital Club Foot: The Results of Treatment

Ponseti, SmoleyClin Orthop Relat Res1963218 citationsRetrospective cohort

Femoroacetabular Impingement: A Cause for Osteoarthritis of the Hip.

Ganz, Siebenrock, et al.Clin Orthop Relat Res20033,410 citationsCase series

Arthroscopic Repair of Full-Thickness Tears of the Supraspinatus: Does the Tendon Really Heal?

Boileau, Krishnan, et al.J Bone Joint Surg Am20051,256 citationsProspective cohort

Closed Intramedullary Nailing of Femoral Fractures. A Report of Five Hundred and Twenty Cases.

Winquist, Clawson, et al.J Bone Joint Surg Am1984790 citationsCase series

Contact between the Glenoid and the Humeral Head in Abduction, External Rotation, and Horizontal Extension: A New Concept of Glenoid Track.

Yamamoto, Okada, et al.J Shoulder Elbow Surg2007743 citationsBiomechanical study

The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients.

Stiell, Worthington, et al.JAMA20011,283 citationsProspective cohort

The Prediction of Curve Progression in Untreated Idiopathic Scoliosis during Growth.

Lonstein, CarlsonJ Bone Joint Surg Am1984864 citationsRetrospective cohort

The Arterial Vascularization of the Humeral Head. An Anatomical Study.

Gerber, Vinh, et al.J Bone Joint Surg Am1990441 citationsAnatomic study

The Tension-Stress Effect on the Genesis and Growth of Tissues. Part I. The Influence of Stability of Fixation and Soft-Tissue Preservation.

IlizarovClin Orthop Relat Res19892,120 citationsBasic science

The Results of Repair of Massive Tears of the Rotator Cuff.

Gerber, Hodler, et al.J Bone Joint Surg Am20001,424 citationsProspective cohort

SLAP Lesions of the Shoulder.

Snyder, Friedman, et al.Arthroscopy19901,264 citationsCase series

The Stabilizing System of the Spine. Part I. Function, Dysfunction, Adaptation, and Enhancement.

PanjabiJ Spinal Disord19922,145 citationsReview article

Pelvic Ring Fractures: Should They Be Fixed?

TileJ Bone Joint Surg Br19881,009 citationsReview article

The Treatment of Certain Cervical-Spine Disorders by Anterior Removal of the Intervertebral Disc and Interbody Fusion.

Smith, RobinsonJ Bone Joint Surg Am19581,855 citationsCase series

Functional and Structural Outcome after Arthroscopic Full-Thickness Rotator Cuff Repair: Single-Row versus Dual-Row Fixation

Sugaya, Moriishi, et al.Arthroscopy2005918 citationsRetrospective cohort

Radiculopathy and Myelopathy at Segments Adjacent to the Site of a Previous Anterior Cervical Arthrodesis.

Hilibrand, Bohlman, et al.J Bone Joint Surg Am19991,674 citationsRetrospective cohort

Injectable Collagenase Clostridium Histolyticum for Dupuytren's Contracture.

Hurst, CORD I Study Group, et al.N Engl J Med2009697 citationsRCT

The Natural History of Perthes' Disease.

CatterallJ Bone Joint Surg Br1971698 citationsRetrospective cohort

A New Periacetabular Osteotomy for the Treatment of Hip Dysplasias. Technique and Preliminary Results.

Ganz, Mast, et al.Clin Orthop Relat Res19881,133 citationsCase series

Hallux Rigidus. Grading and Long-Term Results of Operative Treatment.

Coughlin, ShurnasJ Bone Joint Surg Am2003544 citationsCase series

Anterior Acromioplasty for the Chronic Impingement Syndrome in the Shoulder. 1972.

NeerJ Bone Joint Surg Am1972536 citationsCase series

Treatment of Scoliosis. Correction and Internal Fixation by Spine Instrumentation.

HarringtonJ Bone Joint Surg Am1962997 citationsCase series

Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects. A Prospective Investigation.

Boden, Wiesel, et al.J Bone Joint Surg Am1990668 citationsProspective cohort

Hip Arthroscopy versus Best Conservative Care for the Treatment of Femoroacetabular Impingement Syndrome (UK FASHIoN): A Multicentre Randomised Controlled Trial.

Griffin, FASHIoN Study Group, et al.Lancet2018542 citationsRCT

The Posterior Stabilized Condylar Prosthesis: A Modification of the Total Condylar Design. Two to Four-Year Clinical Experience.

Insall, Burstein, et al.J Bone Joint Surg Am1982470 citationsRetrospective cohort

Clinical Application of the Tension-Stress Effect for Limb Lengthening.

IlizarovClin Orthop Relat Res19901,220 citationsBasic science

Treatment of Deep Cartilage Defects in the Knee with Autologous Chondrocyte Transplantation.

Brittberg, Peterson, et al.N Engl J Med19945,478 citationsCase series

The Prehensile Movements of the Human Hand.

NapierJ Bone Joint Surg Br19561,552 citationsAnatomic study

A Biomechanical Study of Normal Functional Elbow Motion.

Morrey, Chao, et al.J Bone Joint Surg Am19811,380 citationsBiomechanical study

Observations on the Function of the Shoulder Joint.

Inman, Abbott, et al.J Bone Joint Surg Am19441,367 citationsBiomechanical study

The Disabled Throwing Shoulder: Spectrum of Pathology Part I: Pathoanatomy and Biomechanics.

Burkhart, Kibler, et al.Arthroscopy20031,304 citationsReview article

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An Update on Current Concepts and Management of Mid-Substance Achilles Tendinopathy.

Venugopal, Grice, et al.·Bone Joint J·2026·1 citations·Review article·Foot & Ankle

Purpose

This review provides a comprehensive overview of mid-substance Achilles tendinopathy (MAT), covering its aetiology, pathophysiology, diagnosis, and management strategies, both nonoperative and operative.

Methods

A detailed literature analysis was conducted, focusing on MAT's epidemiology, clinical presentation, imaging methods, and treatment options.
Key studies and meta-analyses were reviewed.
This review synthesizes the current evidence on the assessment and management of MAT.
It details the pathophysiology, epidemiology, and diagnostic process, including clinical evaluation, specific provocation tests, and the role of imaging.
A comprehensive analysis of both conservative and surgical treatment options is presented, evaluating their efficacy based on the available literature.

Results

MAT presents bimodally, with a male predominance.
Diagnosis is primarily clinical, supported by ultrasound and tools such as the Victorian Institute of Sport Assessment-Achilles score.
Nonoperative management is the cornerstone, with eccentric exercise rehabilitation standing as the most evidence-based and effective intervention.
For recalcitrant cases, high-volume image-guided injection (HVIGI) is a promising second-line option with a favourable safety profile.
Extracorporeal shockwave therapy (ESWT) may be considered as an adjunct.
Evidence for other adjuncts such as platelet-rich plasma and corticosteroids is weak, and their use is not recommended.
Surgical intervention is reserved for the approximately 20% to 29% of patients who fail conservative treatment.
Options include gastrocnemius recession, plantaris excision, and open or minimally invasive/endoscopic debridement, with tendon transfer indicated for large defects.
While most techniques report high success rates, a lack of high-level comparative evidence precludes a definitive surgical algorithm.

Conclusions

The management of MAT is fundamentally staged, beginning with a prolonged trial of eccentric exercises. HVIGI and ESWT are valuable next-step options. Surgery is considered for refractory cases, with a trend towards minimally invasive techniques owing to their lower complication profile. However, there is a paucity of randomized controlled trials, making surgeon preference and expertise a significant factor in choice of procedure. An evidence-based treatment algorithm is proposed to guide clinical decision-making.

Published abstract, Bone Joint J 2026. Copyright remains with the authors and publisher.

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