What Is Achilles Tendinopathy?
Achilles tendinopathy is a degeneration of the Achilles tendon — the largest and strongest tendon in the human body, which connects the calf muscles (gastrocnemius and soleus) to the calcaneus. The tendon undergoes repetitive tensile overload that exceeds its repair capacity, leading to collagen degeneration (angiofibroblastosis) and loss of elasticity.
There are two main types: insertional tendinopathy (at the posterior pole of the calcaneus, more common in sedentary and obese individuals) and midportion tendinopathy (2 to 6 cm above the insertion, more common in runners and athletes). The second type is the most frequent and the one that benefits most from dry needling, since the midportion region is chronically hypovascular.
Pain typically presents as stiffness and Achilles pain on initiating walking in the morning, improving with warm-up and worsening after exercise or the following day.
Very Common in Runners
Affects 9% of recreational runners and up to 52% of elite athletes over the course of their sporting career.
Hypovascular Region
The midportion of the Achilles has a precarious blood supply — the reason why degeneration persists without adequate intervention.
Stimulus to Local Repair
Experimental studies suggest that dry needling can induce a controlled microlesion capable of stimulating local repair responses (including pro-angiogenic factors) — a plausible mechanism, still under clinical investigation.
Why Conventional Treatments Are Not Always Sufficient
NSAIDs offer temporary symptomatic relief but do not modify the degenerative process — which, as in other tendinopathies, is not classically inflammatory. Peritendinous corticosteroid is particularly contraindicated in the Achilles: it significantly increases the risk of tendon rupture, a serious complication that may require surgery.
Eccentric calf exercises (Alfredson protocol) are the conservative treatment with the strongest evidence, but they are painful in the early phases and have a high dropout rate. A heel-lift insole is a palliative measure. Dry needling offers the biological component that exercises alone cannot provide.
TREATMENTS FOR ACHILLES TENDINOPATHY
| TREATMENT | MECHANISM | MAIN RISK |
|---|---|---|
| NSAIDs | Symptomatic (pain) | Chronic GI; minimal modification of the degenerative process |
| Peritendinous corticosteroid | Anti-inflammatory | Increased risk of tendon rupture described in the literature |
| Eccentric exercises | Stimulus to collagen | High dropout rate (initial pain) |
| Dry needling | Biological (possible stimulus to angiogenesis) | Minimal (local hematoma, transient pain) |
| Needling + eccentric exercises | Biological + mechanical | Low risk profile; moderate evidence |
How Does Medical Acupuncture Work in Achilles Tendinopathy?
One of the most studied mechanistic hypotheses is the stimulus to local perfusion and repair in the hypovascular midportion of the Achilles. Needling produces a local microlesion that, according to experimental studies, can activate part of the repair cascade (growth factors, fibroblast recruitment, angiogenic response) — a plausible pathway in this chronically poorly vascularized zone.
In parallel, dry needling of trigger points in the gastrocnemius and soleus can reduce the tension transmitted to the Achilles tendon during gait. In hypertonic calf musculature, the load on the tendon tends to be greater; by modulating these trigger points, the local overload may decrease — complementing the role of training load modification and eccentric exercises.
Mechanism of Action in Achilles Tendinopathy
Needling of the Achilles midportion
Controlled microlesion in the angiofibroblastosis region activates the biological repair cascade (growth factors, platelets).
Local angiogenesis
Formation of new capillaries in the hypovascular region, providing oxygen and nutrients needed for collagen healing.
Needling of the gastrocnemius and soleus
Release of trigger points in the calf reduces the tension transmitted to the Achilles during gait and exercise.
Segmental neuromodulation S1-S2
Reduction of the nociceptive signal from the tendon at the spinal dorsal horn, relieving the pain that prevents exercise.
Stimulus to eccentric exercise
With less pain and less muscle tension, the patient is able to perform the eccentric exercise protocol more effectively.
What Do the Scientific Studies Say?
Studies on acupuncture and dry needling in Achilles tendinopathy show consistently positive results in pain, function, and quality of life. Combination with progressive eccentric exercises produces the best long-term outcomes.
What Is the Difference of the Modern Approach?
The medical acupuncturist performs a protocol that simultaneously addresses the tendon (needling of the midportion), the tension-generating musculature (gastrocnemius and soleus), and segmental neuromodulation for pain control. Low-frequency electroacupuncture (2 Hz) over the tendon enhances angiogenesis and collagen production.
Low-power laser therapy is a valuable complementary alternative: applied directly over the midportion of the Achilles, it accelerates the metabolism of tendinoblasts and has a local anti-inflammatory effect without the risks of corticosteroids. It is especially indicated for patients with intolerance to needling or in the phase of greatest sensitivity.
When to See a Physician?
Pain, stiffness, or thickening of the Achilles tendon — especially in the morning or after exercise — requires medical evaluation. Ultrasound and MRI are useful to confirm the diagnosis and rule out partial rupture, which completely changes management.
Frequently Asked Questions
It depends on the phase and intensity of pain. In general, training is modified: volume reduction by 50-70%, replacement of running with cycling or swimming on high-pain days, and gradual progression as improvement occurs. The physician will guide a "pain diary" — pain during exercise up to 3/10 is tolerable; above that, training should be reduced.
In chronic tendinopathy without rupture, complete conservative treatment (acupuncture + eccentric exercises + activity modification) frequently reduces the need for surgery. Surgery is generally reserved for cases with failure of 6 to 12 months of adequate conservative treatment or with significant structural rupture. The surgical decision belongs to the orthopedic surgeon.
Recovery is a biological process that takes time: even with optimal treatment, collagen takes 6 to 12 months to reach full maturity and resistance. Pain may improve much earlier (4 to 8 weeks), but the tendon is still reorganizing. For this reason, progressive return to sport is essential to avoid recurrence.
When performed by a trained physician, yes. Needling of the Achilles midportion is an established technique with an adequate safety profile. The professional uses fine-gauge needles, carefully assesses tendon thickening by palpation and, when available, ultrasound guidance. The absolute contraindication is in the presence of documented partial or total rupture.
Insertional tendinopathy (posterior pole of the calcaneus) responds less to direct dry needling and more to footwear modifications, insoles, and shock waves. Midportion tendinopathy (2-6 cm above the insertion) is where dry needling is most effective, since it is exactly in this hypovascular region that controlled microlesion promotes the angiogenesis needed for healing.