Dutch multidisciplinary guideline on Achilles tendinopathy

Overview

Achilles tendinopathy is a common cause of heel and lower leg pain in athletes and in physically less active adults. This Dutch multidisciplinary guideline was developed with orthopaedic surgeons, sports physicians, physiotherapists, radiologists and other specialists. Its aim is to standardise care for both the midportion and the insertional forms of the condition, and it covers diagnosis, conservative treatment, invasive options and return to activity.

Diagnosis

The guideline treats Achilles tendinopathy primarily as a clinical diagnosis. It is based on a typical history of load-related pain, morning stiffness and localised tenderness of the tendon. Imaging is not needed routinely to confirm the diagnosis. It is reserved for uncertain cases, suspected alternative pathology, or planning before invasive treatment.

Treatment

Exercise therapy, particularly progressive tendon loading, is the cornerstone of management and is recommended as first-line treatment. Patient education and load management are essential: patients should understand the condition, the expected gradual course of recovery and how to adjust their activity. The guideline takes a cautious view of injection therapies and several passive treatments, because evidence of meaningful benefit is limited. It advises against their routine use. Surgery is considered only for patients who remain symptomatic despite an adequate period of well-conducted conservative treatment.

Clinical implications

For clinicians, the guideline supports an active, exercise-based approach and discourages reliance on imaging and passive or invasive treatments in early management. It also addresses realistic expectations and the gradual return to sport and work. It points to research priorities, including better comparisons of treatment strategies for insertional tendinopathy.