Keywords: Insertional Achilles tendinopathy, exercise therapy, tendon compression
This blog is a summary of a recently published randomised clinical trial (1)
Why is this study important?
Insertional Achilles tendinopathy is a stubborn and painful injury at the point where the Achilles tendon attaches to the heel bone. It’s especially common in sport-active individuals and can be difficult to treat. Conventional exercise therapy that works well for mid-portion Achilles tendinopathy often falls short here, with up to 50% of patients ultimately opting for surgery (2,3). One theory is that compressive loads on the tendon—especially during deep ankle bending (dorsiflexion)—might provoke symptoms during rehabilitation (4). Until now, however, no study had rigorously tested whether reducing that compression during rehab could actually help.
How did the study go about this?
In this randomized controlled trial, 42 sport-active patients with chronic insertional Achilles tendinopathy were randomly assigned into two groups. One group followed a low tendon compression rehab program (LTCR), which included exercise therapy that limited ankle dorsiflexion, specific education about compressive loading, avoidance of stretching, and the use of heel lifts. The other group followed a high tendon compression rehab program (HTCR) that included exercise therapy with end-range dorsiflexion, standard education, daily calf stretching, and no heel lifts.
Both groups completed an 8–12 week progressive tendon-loading program with supervision and home exercises. The main outcome was the VISA-A score, a tool that measures Achilles tendon pain and function. Researchers also evaluated patient satisfaction, return to sport, pain during activities, and changes in tendon thickness using ultrasound.
What did the study find?
The LTCR group significantly outperformed the HTCR group. At both 12 and 24 weeks, they showed greater improvements in VISA-A scores—enough to be considered clinically meaningful. More participants in the LTCR group reported being satisfied (95% vs. 58%), returned to their desired sport (95% vs. 74%), and experienced less pain during daily activities and hopping tests. Importantly, only the LTCR group showed a significant reduction in tendon thickness over time—suggesting a real improvement in tendon structure, not just symptoms.
What are the key take-home points?
- Reducing Achilles tendon compression is simple. It can be achieved by limiting ankle dorsiflexion during exercise therapy, avoiding excessive stretching, and using heel lifts during daily or sports activities throughout rehabilitation.
- Low tendon compression rehabilitation works better. It leads to greater improvements in pain, function, and return to sport for patients with insertional Achilles tendinopathy compared to conventional rehab.
- LTCR doesn’t just change symptoms—it changes structure. LTCR reduces tendon swelling, which may help interrupt the vicious cycle of swelling, increased compressive load, and ongoing pain.
- It’s time to rethink the rehab playbook. This study supports a shift in strategy: don’t just focus on loading more—focus on loading smarter, starting with less compression. However, because compressive load is a naturally occurring force on the tendon insertion during sports, it should be gradually reintroduced as symptoms improve.
Authors:
Lauren Pringels, Aäron Van den Abeele, Arne Burssens, Guillaume Planckaert, Evi Wezenbeek, Luc Vanden Bossche
References:
- Pringels L, Capelleman R, Van den Abeele A, et al. Effectiveness of reducing tendon compression in the rehabilitation of insertional Achilles tendinopathy: a randomised clinical trial. Br J Sports Med. 2025;59(9):640-650. doi:10.1136/BJSPORTS-2024-109138
- Fahlström M, Jonsson P, Lorentzon R, Alfredson H. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc. 2003;11(5):327-333.
- Nicholson CW, Berlet GC, Lee TH. Prediction of the success of nonoperative treatment of insertional Achilles tendinosis based on MRI. Foot Ankle Int. 2007;28(4):472-477. doi:10.3113/FAI.2007.0472
- Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy? Br J Sports Med. 2012;46(3):163-168.
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