REF-1380 · de Vos et al., 2021 · British Journal of Sports Medicine · Paper · PubMed · Free full text
My Achilles hurts in the morning — can I keep running?
Only within a pain limit: the guideline first swaps out what provokes it, rebuilds under a pain scale and adds 12+ weeks of calf work. Takes months; mostly expert opinion.
Main caveat: Low and very-low certainty throughout. No GRADE conclusion above "low".
The Dutch Association of Sports Medicine led a three-year national guideline process on Achilles tendinopathy (midportion and insertional; adults, active and sedentary; ruptures excluded), with a multidisciplinary working group of sports physicians, an orthopaedic surgeon, a radiologist, a general practitioner, a rheumatology physician assistant and a sports physiotherapist, supported by the Knowledge Institute of the Federation of Medical Specialists, and with patients involved in every phase (a panel of 9, a national survey answered by 97, a focus group).
Six modules answer six questions patients prioritised: risk factors and primary prevention, diagnosis, imaging, treatment, long-term prognosis and recurrence.
Diagnosis is clinical — four findings (site, pain on loading, local thickening, pain on palpation) — and no imaging is needed when all four are present; imaging has no prognostic value and should not be used to predict the course or monitor treatment.
Treatment is active, not wait-and-see: start with patient education (the condition, the prognosis, pain education), loading advice (temporarily stop pain-provoking activities, temporarily replace them with non-provoking ones, increase load gradually, steer by a pain scale) and progressive calf strengthening for at least 12 weeks; if there is no improvement after 3 months, discuss add-ons (shockwave, passive modalities, injections, acupuncture), be cautious with NSAIDs and corticosteroid injections, and consider surgery only after at least six months of active treatment.
Most patients recover but 23-37% may still have symptoms up to 10 years, 85% of athletes return to sport, no long-term prognostic factor is known, a full symptom-free return takes "a few months" of active treatment at a minimum, and a return within days goes with more recurrence.
The supplementary modules show how little of this is graded evidence: active treatment beating wait-and-see at 3 months is very low certainty (a network meta-analysis whose estimates for different treatments largely overlap); the effect of education and of loading advice "have not been studied in RCTs" and is recommended "based on clinical expertise"; the lifestyle, work and sports-loading question was "impossible to answer this question using the GRADE methodology" and "mainly answered based on expert opinion"; recurrence had no studies at all.
Our reading: this is the best single statement of how Achilles tendinopathy is managed, and it settles the order of the base's Achilles default — the provoking load is swapped out first and brought back gradually under a pain scale — but its specific numbers are experienced clinicians' practice, not trial results.
Protocol
Process: Dutch Federation of Medical Specialists "Medical Specialist Guidelines 2.0" method, based on AGREE II; KNMG code on conflicts of interest followed; development, commentary and authorisation phases; sounding-board group of nine associations, including the Royal Dutch Athletics Union and the Dutch Patient Federation.
Patients: a patient panel of nine set the six practice challenges; a national survey through the Netherlands Patient Federation was answered by 97 patients with Achilles tendinopathy (85 gave treatment aims: sport participation without mentioning pain status 36%, pain-free sport 27%, pain-free daily activity 22%); a focus group interview and an invitational conference added stakeholders.
Evidence: multiple databases and existing guidelines searched to May 2019; eligibility per module; risk of bias and GRADE "where applicable"; recommendations combine the evidence with patient values and preferences, costs, acceptability and feasibility. Crucial outcomes: VISA-A score, return-to-sport rate, patient satisfaction and subjective recovery, all patient-reported.
Scope: n = not applicable (guideline). Adults (18 and over) with midportion (symptoms more than 2 cm above the insertion) or insertional (within the first 2 cm) Achilles tendinopathy; active and sedentary; systemic causes (spondyloarthritis, familial hypercholesterolaemia) flagged for referral; ruptures excluded. A subclassification by symptom duration (reactive under 6 weeks, chronic 3 months or more) was dropped for lack of literature and agreement.
Funding and interests: a grant from the Dutch Association of Medical Specialists (main text; the abstract and the process supplement name the Quality Foundation of the Dutch Federation of Medical Specialists, SKMS); the Netherlands Patient Federation helped with the survey and, as printed, "is not involved in the planning, conduct or reporting of this project".Competing interests are in supplementary Table 1 for the seven working-group members: none declares a personal financial interest and every row reads "None needed" for action; under other potential conflicts J.Zwerver lists "Firm UTC Imaging paid for 2 visits to international conferences", and under external research funding R.J. de Vos lists research projects with personal funding from ReumaNederland, Annafonds, ZonMw, Maria Sklodowska-Curie, GE Healthcare and the National Basketball Association, stating these bodies have no potential gains from the guideline; several members list team and clinical roles (football clubs, a ballet company).The other authors (methodologists, the coordinator, the translator) are not in that table.
Key Results
How each recommendation is supported, as the guideline's own modules grade it (main text = recommendation; supplement = GRADE conclusion or the stated basis):
| Module: recommendation | What the guideline says it rests on |
|---|---|
| Prevention: inform people with a previous lower-limb tendinopathy who start or increase training of their higher risk | Low GRADE: a previous lower-limb tendinopathy "seems to infer a 3 to 4 times higher risk" |
| Prevention: gradual training build-up (type, frequency, size, intensity) | Working group's consideration: load increase "has not been explicitly investigated as a risk factor"; low GRADE that a volume-progression running programme was no better than an intensity one |
| Prevention: calf strengthening before the season, dose tailored | Working group's consideration, against the graded conclusion: calf strengthening (eccentric, body weight, in season, professional footballers), shock-absorbing shoes and warm-up/stretching "do not seem to be effective" (low GRADE); a higher isokinetic plantar-flexor force "may protect" (very low) |
| Prevention: warm clothing for winter training | Very low GRADE: winter training "seems to give a 2 to 3 times higher risk" |
| Prevention: avoid fluoroquinolones if an alternative exists | Very low GRADE: ofloxacin "a 10-times increased risk"; the guideline judges the absolute risk very low |
| Diagnosis by four clinical findings; no imaging if all four present | No data on the test characteristics of any criterion; the four are the criteria most used in randomised trials (working-group recommendation) |
| Imaging: none to predict prognosis or monitor treatment | Very low GRADE: ultrasound Doppler flow not associated with change in symptoms after non-surgical treatment; no studies for other imaging |
| Treatment: active treatment, not wait-and-see | Very low GRADE: wait-and-see for 16 weeks "does not appear to improve symptoms" (one study); exercise and several other categories beat wait-and-see after 3 months (very low, network meta-analysis, estimates largely overlapping) |
| Treatment: education + loading advice | "No evidence is available" for either; recommended "Based on clinical expertise" |
| Treatment: progressive calf strengthening for at least 12 weeks | Exercise therapy is among the categories beating wait-and-see (very low); the 12 weeks and the progression scheme are the working group's |
| Treatment: after 3 months without improvement, add shockwave, passive modalities, injections or acupuncture; be cautious with NSAIDs and corticosteroid injections | Very low certainty, overlapping estimates; insufficient evidence for insertional tendinopathy, return to sport or satisfaction; caution with NSAIDs because their short-term analgesia means "interference with load management", and the working group "advises avoiding corticosteroid injections" (considerations) |
| Surgery only after at least six months of active treatment | The only graded surgical conclusions compare one operation with another (very low); surgery against non-surgical treatment is not graded; the six months is the working group's caution |
| Lifestyle, work and sports-loading advice | "impossible to answer this question using the GRADE methodology"; "mainly answered based on expert opinion"; one trial (REF-628) shown, its conclusion left ungraded |
| Prognosis: 23-37% persistent symptoms up to 10 years; 85% of athletes return to sport; no long-term prognostic factor | Very low: 23 to 60% persistent at 2-5 years (midportion); low: 37% at 10 years (one cohort, midportion or insertional); low: at least 85% returned to their original level (one study, midportion); very low: age, sex, BMI, symptom duration, tendon thickening and Doppler flow without prognostic value |
| Recurrence: months of active treatment before provocative load; gradual build-up; consider continuing calf exercise | No study of recurrence prevention, so no conclusion; expert opinion, citing a cohort of professional footballers in which 53/194 Achilles tendinopathies were recurrences and a return within 0-10 days went with 31% recurrence vs 13% after more than 10 days |
The loading advice, in the guideline's own words (main text): "Temporary cessation of pain provoking (sports) activities. Temporary replacement of provocative (sports) activities with non-provocative (sports) activities. Gradual increase of the load of (sports) activities. Use a pain scale to monitor the level of complaints related to (sports) activities and adjust these activities based on the pain scale." The main text gives no pain threshold.
The pain limits (supplement, expert opinion): in the first stage only daily and sports loading that "does not provoke any or minimal pain"; the sports load "is ideally performed with a pain score of 0 to 5 on a scale of 0 to 10", with pain "significantly less" right after and the next morning; when daily activity stays within these limits the sports load can rise — existing running schedules to build "to 5 km in 6 to 8 weeks", speed set by the pain; fitness kept meanwhile with swimming, cycling, the cross-trainer and walking (midportion) or swimming and cycling (insertional, less provocative than walking or the cross-trainer).Load can then be expressed as an acute:chronic ratio (more than 1.5 = higher risk, from team and endurance sports; its effect on Achilles tendinopathy "is not yet known").
The exercise progression (supplement, Figure 4.5, expert opinion): start with a set of 15 isotonic calf exercises; if pain reaches "a score of 5 points or higher" or fatigue prevents a set, start with isometric forms; progress isotonic work and add external weight while "a pain score of 5 or less can be accepted"; plyometrics last if tendon-loading sport is the goal; insertional tendinopathy starts on a flat surface, not below a step.
The one sports-loading trial the guideline shows ([REF-628], ungraded): continuing sport with pain up to 5 of 10 during activity, back to baseline the next morning and not rising week to week, "seems to have no negative effect" on outcome at 6 to 52 weeks versus stopping sport for the first 6 weeks; both groups did eccentric exercise.
Short symptom duration (supplement): the evidence is from chronic tendinopathy (more than 8 to 12 weeks); with a short history and an obvious overload, "a short period of rest (avoiding pain-provoking activities) can be initiated", followed by active treatment.
Background figure: runners have "a 52% chance (cumulative incidence)" of an Achilles tendon injury in their lifetime (introduction, cited).
Mechanisms
Measured (in the studies graded): active treatments (exercise, injections, exercise plus shockwave and others) gave better VISA-A scores than wait-and-see at 3 months, with largely overlapping estimates between treatments; a previous lower-limb tendinopathy went with 3-4 times the risk; imaging findings did not predict the course.
Authors' interpretation: Achilles tendinopathy is a load-related condition in which the external load exceeds capacity (athletes) or capacity is very low (inactive people); education manages expectations and self-efficacy, loading advice keeps the patient active while avoiding a flare from too rapid progression, and calf strengthening raises load-bearing capacity; NSAIDs blunt the pain signal on which load management relies.
Practical Application
My Achilles hurts in the morning — can I keep running? Only within a pain limit: the guideline first swaps out what provokes it, rebuilds under a pain scale and adds 12+ weeks of calf work. Takes months; mostly expert opinion.
The order settles the base's Achilles default: the guideline's first step is to stop and replace the pain-provoking activity temporarily, then bring it back gradually, steered by a pain scale (A for the guideline; expert opinion for this advice).Running that stays within the limit is compatible with it — the working group shows REF-628 (continued sport up to 5/10 "seems to have no negative effect") — but replacement first is the default, not the exception. Not from this paper; the base's own practice: the ceiling the assistant gives is ≤3/10, "more conservative" than the trial's 5/10 (SYNTH-73).
Numbers to quote, labelled as practice: sports load ideally at 0-5 of 10 pain, clearly less afterwards and the next morning; calf exercises progressed while pain stays at 5 or less; running rebuilt towards 5 km over 6 to 8 weeks once daily activity is within the limits (the working group's expert opinion; supplement).
Keep fitness on a swap: swimming, cycling, the cross-trainer or walking for midportion pain; swimming or cycling for pain at the heel insertion (expert opinion).
Do not wait it out: wait-and-see is advised against; any active treatment beat it at 3 months (very low certainty). Reassess at 3 months; add-ons only then; surgery not before six months of active treatment.
Painkillers: be cautious with NSAIDs — they mask the pain that steers the load — and with corticosteroid injections (SYNTH-73: never mask pain to train).
Timeline and prognosis to give honestly: a return to full symptom-free loading "is only possible after a few months of active treatment at a minimum"; a return within days goes with more recurrence; 23-37% have symptoms years later; 85% of athletes return to sport, level unknown; no factor predicts who.
After recovery: a gradual rebuild after any break, and consider continuing single-leg calf strengthening about three times a week (expert opinion).
What it is good for as a source: the accepted clinical sequence and its components for Achilles tendinopathy, with the guideline's own statement of which parts are graded and which are opinion. What it does not show: that any specific pain number, rebuild schedule or return date is safe or effective; that education or loading advice works on its own (never tested in a trial); anything about runners specifically — no runner-only evidence was graded for treatment.
Limitations
Low and very-low certainty throughout. No GRADE conclusion above "low"; education, loading advice, lifestyle and sports-loading advice, return to sport and recurrence rest on expert opinion, as the guideline states.
Recommendations go beyond, and once against, the graded evidence. Pre-season calf strengthening is recommended although the graded conclusion (low certainty, an in-season eccentric programme in professional footballers) found no preventive effect; the working group explains why it still advises it.
Numbers that do not line up: the prognosis recommendation says "23-37%" persistent up to 10 years, while the graded conclusions give "From 23 to 60%" at 2-5 years and 37% at 10 years; the recommendation says it is "unknown whether this is at original (performance) level" for the 85%, while the graded conclusion reads "At least 85%" returned "to their original level of sports" (one study).
Midportion-heavy. Treatment evidence is mostly midportion; insertional advice is extrapolated.
Not a runner guideline. Runners are one group among active and sedentary adults; the running-specific steps (5 km in 6 to 8 weeks, acute:chronic ratio) are the working group's suggestions, and the acute:chronic ratio is contested elsewhere in the base (SYNTH-73: describe load change with it, never a risk score).
Dutch health system. Referral routes, availability and cost judgements are Dutch.
Funding and interests: a grant from the Dutch Association of Medical Specialists (Quality Foundation, SKMS); working-group members' interests are listed in supplementary Table 1 (one member's conference visits paid by an imaging firm; the chair's external research funding includes GE Healthcare and the NBA). No device maker, data platform or sports federation funded the guideline; the funder is the medical specialists' own quality foundation.
How this entry was checked and changed
Why this level
a major national guideline built on systematic review with patients in every phase (rubric: major consensus / position statement). The level is the document's; most of what it recommends on load is not graded evidence: its GRADE conclusions are low or very low, and education and the loading advice rest on clinical expertise, the pain-scale numbers on expert opinion and the return and recurrence advice on no studies, as the guideline itself states; the 12-week exercise period is the working group's choice, not a graded conclusion. Read from the full text and the online supplementary module files (Europe PMC, CC BY-NC 4.0)
Full text (checked 2026-10-28)
Start treatment of midportion and insertional Achilles tendinopathy with patient education, loading advice (temporary cessation of pain provoking (sports) activities; temporary replacement with non-provocative activities; gradual increase; a pain scale) and progressive calf muscle strengthening exercises for at least 12 weeks (full text)
After 3 months of patient education, structural exercise therapy and following loading advice, if there is still no improvement discuss additional treatment options (full text)
Consider surgery only in patients who do not recover after at least six months of active treatment (full text)
Symptoms may persist in the long term (at least up to 10 years with 23-37% having persistent symptoms); the majority of athletes return to sports (85%) (full text)
A return to full symptom-free (sports) loading is only possible after a few months of active treatment at a minimum; a return to sports within days is associated with a greater likelihood of recurrence (full text)
The effectiveness of patient education and load management advice have not been studied in RCTs for Achilles tendinopathy; based on clinical expertise, the working group recommends considering them as the basis of the treatment (supplement, Module 4; full text)
Sub-module 4.6 was "mainly answered based on expert opinion"; the (sports) load is ideally performed with a pain score of 0 to 5 on a scale of 0 to 10; running schedules to 5 km in 6 to 8 weeks (supplement; full text)
Exercise progression: if the pain level reaches a score of 5 points or higher, start with isometric forms; a pain score of 5 or less can be accepted during progression (supplement; full text)
A previous lower limb tendinopathy seems to infer a 3 to 4 times higher risk (Low GRADE); calf muscle strengthening exercises do not seem to be effective for preventing Achilles tendinopathy (Low GRADE) (supplement, Module 1; full text)
Recurrence: 53/194 professional footballers; recovery time of 0 to 10 days 31% chance of recurrence vs 13% after more than 10 days (supplement, Module 6; full text)
From 23 to 60% persistent symptoms after 2 to 5 years (Very low); 37% at 10 years (Low); At least 85% return to their original level (Low) (supplement, Module 5; full text)
Zwerver: Firm UTC Imaging paid for 2 visits to international conferences; de Vos: research funding including GE Healthcare and the NBA (supplement, Table 1; full text)