Achilles
Tendonitis

Tendinitis refers specifically to acute inflammation of the tendon, while tendinopathy is a broader term that encompasses the full spectrum of Achilles disorders — including chronic degenerative changes where the tendon fibers become disorganized, thickened, and weakened rather than simply inflamed. The distinction matters clinically because treatments that reduce inflammation (NSAIDs, cortisone) work well in acute tendinitis but can be counterproductive or even harmful in chronic tendinopathy, where the primary problem is failed tendon healing and collagen disarray rather than active inflammation. Dr. Katz uses diagnostic ultrasound to differentiate the two and tailor treatment accordingly. Most patients who have been suffering for months or years have tendinopathy rather than pure tendinitis, which is why regenerative treatments like shockwave therapy and PRP — which stimulate healing rather than suppress inflammation — tend to outperform anti-inflammatory approaches in chronic cases.

The Achilles tendon attaches at the back of the heel bone (calcaneus). Insertional tendinopathy affects the lowest 2 cm of the tendon at this bone attachment and is often associated with Haglund's deformity (a bony prominence on the heel), retrocalcaneal bursitis, and calcific deposits within the tendon. Patients typically report pain precisely at the back of the heel that worsens with low-heel shoes or direct pressure from shoe counters. Mid-substance tendinopathy affects the segment 2–6 cm above the heel bone insertion — an area of relative avascularity that is particularly vulnerable to degenerative change. It produces a painful, often visible and palpable thickening in the tendon body. The two conditions respond somewhat differently to treatment: insertional disease often requires addressing heel bone anatomy, while mid-substance disease responds especially well to eccentric loading programs, shockwave therapy, and ultrasound-guided PRP injection.

The answer depends entirely on the severity and stage of your condition. In mild, early-stage tendinitis, modified activity — reducing mileage, eliminating hills and speed work, switching temporarily to flatter terrain — is often appropriate while treatment begins. Continuing to run through pain, however, risks progressing an inflammatory condition into a more serious degenerative tendinopathy, or worse, causing a partial or complete rupture. Dr. Katz's standard recommendation is to use pain as a guide: activity producing pain above a 3–4 out of 10 during or after exercise should be reduced or paused. After a diagnostic ultrasound confirms there is no structural compromise (fiber tearing, high-grade degeneration), a structured return-to-run program is developed as part of your treatment plan. Most patients are back to full training within 6–12 weeks under this monitored approach.

Extracorporeal shockwave therapy (ESWT) delivers calibrated acoustic pressure waves into the degenerated tendon tissue. The waves produce micro-trauma at the cellular level that triggers the body's own healing cascade — stimulating tenocyte activity, collagen synthesis, and neovascularization (new blood vessel formation). This is particularly valuable in chronic Achilles tendinopathy, where the tendon has essentially failed to heal on its own due to poor local blood supply and disrupted cellular signaling. In addition, shockwave therapy breaks up calcific deposits that accumulate in insertional tendinopathy and desensitizes the local pain receptors, providing both structural repair and pain relief. Multiple randomized controlled trials show ESWT achieving 60–80% long-term success in chronic Achilles tendinopathy, outperforming cortisone injection, which carries a documented risk of tendon weakening and rupture with repeated use.

Platelet-rich plasma (PRP) is derived from a small sample of your own blood, which is centrifuged to concentrate the platelets — the cells that carry growth factors responsible for tissue repair. When injected under real-time ultrasound guidance directly into the degenerated portion of the Achilles tendon, these growth factors (including PDGF, TGF-β, VEGF, and EGF) stimulate tenocyte proliferation, collagen synthesis, and angiogenesis. PRP is particularly effective in mid-substance tendinopathy where there is high-grade disorganization of tendon fibers identified on ultrasound. At Katz Regenerative Foot & Ankle, ultrasound guidance is used for every PRP injection to ensure precise delivery into the target tissue rather than the surrounding paratenon. PRP is often combined with shockwave therapy for additive effect — shockwave prepares the tissue by disrupting pathological scar matrix, then PRP floods the area with healing growth factors.

Surgery for Achilles tendinopathy is genuinely a last resort, reserved for a minority of patients who have failed an extended course (typically 6+ months) of well-executed conservative and regenerative care. Surgical indications include complete tendon rupture (though even partial ruptures are often managed non-surgically), large calcific deposits that haven't responded to shockwave therapy, severe Haglund's deformity causing mechanical impingement, or irreversible high-grade tendon degeneration confirmed on MRI. When surgery is necessary, modern techniques including minimally invasive tendon debridement, gastrocnemius recession, and calcaneal ostectomy offer good outcomes. That said, the majority of Achilles tendinopathy patients — including those who have suffered for years — can achieve excellent results without surgery through the combination of advanced diagnostic imaging, shockwave therapy, PRP, and a structured rehabilitation program supervised by Dr. Katz.