Surgery is the exception, not the rule — here is when it applies

Achilles tendinopathy is common — around 24% of athletes encounter it at some point in their lifetime — yet the vast majority never reach an operating table. Surgery is a genuine last resort, triggered not by a diagnosis or a scan result alone, but by the failure of a full, structured course of conservative care.

The practical bar has two components. The first is functional: pain that continues to limit everyday activities — walking, working, sleeping — despite at least three to six months of supervised physiotherapy, eccentric-loading programmes, orthotics, and activity modification. The second is structural: imaging evidence of significant tissue damage, which may include greater than 50% fibre disruption, a tendon exceeding 6.1 mm in thickness, an intratendinous degenerative ratio above 48.8%, substantial calcification, or Haglund's deformity with corresponding MRI changes. These structural findings carry clinical weight only when the patient has also failed the functional threshold — a scan finding alone is never sufficient to justify a surgical decision, and that principle applies throughout the management pathway.

Neither criterion operates independently. A tendon that looks severely degenerated on MRI but causes manageable symptoms points toward further conservative optimisation, not theatre. A patient in significant daily pain who has not yet completed a proper eccentric-loading programme is similarly not yet a surgical candidate.

That framing matters because it keeps surgery proportionate — reserved for the minority in whom structured non-surgical care has genuinely run its course.

Insertional versus midportion tendinopathy — why location changes the pathway

Location determines pathway. The tendon has two distinct vulnerable zones, and the distinction shapes every subsequent decision.

Insertional Achilles tendinopathy (IAT) affects the point where the tendon meets the heel bone. Pain is felt at the very back of the heel, often worsened by shoes pressing on the attachment site. This variant is frequently accompanied by Haglund's deformity — a bony prominence on the posterior calcaneus — and by calcific deposits within the tendon or bursa. Both features can narrow how far conservative care alone can go, because no amount of loading programme addresses underlying bone geometry.

Midportion tendinopathy sits roughly 2–6 cm above the heel, in the tendon body itself. Pain here tends to be provoked by running or jumping rather than static pressure. In some patients, the plantaris tendon — a slender structure running alongside — becomes independently inflamed, and this combination may require a different approach if conservative care eventually fails.

Acute rupture is a separate presentation: sudden pain, often with an audible crack, immediate loss of push-off strength, and a palpable gap. Unlike chronic tendinopathy, rupture may warrant early surgical discussion without first attempting months of physiotherapy.

Imaging — ultrasound or MRI — helps characterise the tendon's condition and identify structural features such as intratendinous signal change or calcification. Signal change alone, however, is common in asymptomatic tendons and is not a surgical trigger in itself; it is one input into a clinical picture, not a verdict.

What structured conservative care actually involves

"Conservative care" often sounds passive — rest, wait, hope. In practice, a genuine trial looks quite different.

The cornerstone is progressive eccentric loading: a structured exercise programme that places the tendon under controlled load as it lengthens. Two established protocols are widely used — the Alfredson protocol, which centres on heavy, slow calf drops, and the Silbernagel protocol, which incorporates a broader progression of loading tasks and functional activities. Both are graduated variants rather than interchangeable prescriptions; a physiotherapist selects and adapts the approach based on location, severity, and what the patient can tolerably load at the outset. Neither is simply a stretching routine.

Physical therapy extends beyond the exercises themselves. A well-designed programme addresses load management — how much running, stair-climbing, or prolonged standing is currently appropriate — alongside gait, footwear, and contributing biomechanical factors such as calf tightness or altered foot mechanics.

Activity modification means reducing provocative loading, not stopping altogether. Supervised, graded activity is preferred to complete rest, which allows pain to settle temporarily without rebuilding the tendon's tolerance to load.

For insertional tendinopathy specifically, heel raises or custom insoles can help offload the attachment point and reduce friction from shoe counters pressing on the heel.

The 3–6 month window is an active commitment, not a waiting period. Patients who feel conservative care has not worked have often not completed a supervised, consistently adhered-to programme — and that distinction matters when escalation is being considered.

When conservative care is incomplete — bridging options before surgery

Not every patient who completes a structured conservative programme reaches a clear binary outcome. Some experience meaningful improvement but not enough to restore acceptable function — persistent pain on return to sport, continuing difficulty with stairs or prolonged walking, or activity levels still well below their baseline. This partial-response group warrants a second phase of non-surgical management before surgical referral is considered.

Platelet-rich plasma (PRP) injection is the best-evidenced option at this stage. A 2025 systematic review and meta-analysis found that PRP, used as a second-line intervention after failed conservative care, produced statistically significant pain reduction compared with control at both six months (mean difference −0.83) and twelve months (mean difference −1.11). For some patients, this may delay or avoid surgery altogether — though it does not work for everyone, and the evidence does not allow prediction of who will respond.

Critically, PRP is additive to a loading programme, not a replacement for it. It is considered alongside physiotherapy, not instead of it.

Suitability is assessed at specialist review. If this phase also fails to restore acceptable function, the clinical picture shifts toward surgical assessment.

What surgery involves and what the evidence shows about outcomes

Surgical technique depends on tendon location and the specific structural problem identified at assessment.

For insertional Achilles tendinopathy (IAT), the procedure typically involves partial tendon detachment, debridement of degenerate tissue and calcific deposits, removal of the Haglund bony prominence, retrocalcaneal bursectomy, and reattachment using a bone-anchor system. Both open and endoscopic approaches are evidence-supported. A 2025 prospective multicentre study of 89 patients found that the endoscopic SpeedBridge technique produced significantly better functional scores at three months compared with open surgery — and a separate calcaneoplasty study reported that 41.6% of endoscopic patients had returned to sport at three months versus 20.6% in the open group. By twelve months, however, outcomes in both studies had converged, with no statistically significant difference between approaches. Endoscopic surgery may therefore be the better option for competitive athletes with an earlier return-to-sport priority, but it is not demonstrably superior over the long term.

For non-insertional (midportion) AT that has failed conservative management, both open and endoscopic debridement carry a broadly similar evidence profile. Around 80% of patients return to sport by six months — but only approximately one-third do so at their previous performance level. This ceiling is clinically important and worth understanding before committing to surgery.

Where midportion tendinopathy co-exists with plantaris tendinopathy, a minimally invasive option is available: ultrasound-guided WALANT surgery (Achilles scraping and plantaris removal under local anaesthetic). A 2025 study of 34 patients reported a mean VISA-A improvement from 34 to 93, with 32 of 34 patients satisfied and back to their pre-injury activity level at one year — though this was a single-centre series without a comparator group.

Across all surgical pathways, return to sport is criteria-based rather than calendar-based: graded load tolerance, functional symmetry, and progressive return-to-running protocols guide the timeline, not a fixed number of weeks post-operation.

Why getting the first surgical decision right matters — and what to do next

One outcome figure from the surgical literature carries particular weight for anyone still weighing their options. When surgery for insertional Achilles tendinopathy fails and revision is required, only around one-third of patients reach functional scores comparable to a healthy reference population — and no preoperative factor reliably predicts who will do so. The point is not that surgery should be feared, but that the first surgical decision carries consequences that are genuinely difficult to undo.

That places real weight on the decisions that precede it. Optimising the conservative pathway — ensuring eccentric loading, physiotherapy, and any indicated injection support have been given a proper trial before surgical referral — is not a formality. Choosing the primary surgical technique with the specific anatomy and activity demands in mind matters equally. Both decisions are better made carefully, with specialist input, than under time pressure or with incomplete assessment.

For patients whose symptoms persist despite a properly structured programme, specialist assessment that takes clinical history, symptom duration, and imaging together is the appropriate next step; Achilles tendinopathy assessment is available at London Cartilage Clinic on Harley Street, with consultations bookable at londoncartilage.com.

1. [1] Correlations between insertional Achilles tendinopathy and Haglund's deformity: MRI and radiographic findings. (2025). https://doi.org/10.1186/s13018-025-06036-z https://doi.org/10.1186/s13018-025-06036-z
2. [2] Combined Midportion Achilles and Plantaris Tendinopathy: 1-Year Follow-Up after WALANT Surgery. (2023). https://doi.org/10.3390/medicina59030438 https://doi.org/10.3390/medicina59030438
3. [3] Surgical treatment of non-insertional Achilles tendinopathy: Comparison of endoscopic and open approaches. (2025). https://doi.org/10.1016/j.otsr.2025.104215 https://doi.org/10.1016/j.otsr.2025.104215
4. [4] PRP injections as second-line treatment in tendinopathy with failure of conservative treatment: systematic review and meta-analysis. (2025). https://doi.org/10.1093/pm/pnaf022 https://doi.org/10.1093/pm/pnaf022
5. [5] Comparison of endoscopic and open Achilles SpeedBridge in insertional Achilles tendinopathy: prospective multicenter study (89 patients). (2025). https://doi.org/10.1016/j.otsr.2025.104220 https://doi.org/10.1016/j.otsr.2025.104220
6. [6] Outcomes of revision surgery for surgically treated insertional Achilles tendinopathy. (2024). https://doi.org/10.1007/s00402-024-05693-9 https://doi.org/10.1007/s00402-024-05693-9