An update on current concepts and management of mid-substance Achilles tendinopathy

Aims: 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. Conclusion: 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.