To the Editor: I read with interest the recent article on heel pain.1 It provides a helpful overview for family physicians; however, I would like to offer clarification regarding nonoperative management options for Achilles tendon pathology, particularly injection and biologic therapies.
The article states that for patients with compromised wound-healing capabilities, nonoperative options such as corticosteroid injections, platelet-rich plasma, extracorporeal shock wave therapy, radiofrequency microtenotomy, and biologic membranes are recommended.1 Although these interventions may be considered in select cases in sports medicine, the cited evidence does not support their routine use, and they are not typically used in primary care.
A randomized controlled trial that compared nonoperative functional rehabilitation with open and minimally invasive surgical repair for acute Achilles tendon rupture found no meaningful differences in patient-reported or functional outcomes at 12 months. Importantly, this study did not evaluate injection or biologic therapies; therefore, their inclusion as nonoperative treatment options is not supported.2
Similarly, a Cochrane review of platelet-rich therapies for musculoskeletal soft tissue injuries concluded that the evidence is very low quality and insufficient to support their use, including for Achilles tendinopathy and rupture.3 Achilles tendon–specific analyses were limited to one small randomized trial for tendinopathy and one for surgical augmentation, and neither demonstrated clinically meaningful benefit.3
Another Cochrane review of injection therapies for Achilles tendinopathy found no clinically relevant improvement in function at short-, medium-, or long-term follow-up and concluded that evidence is insufficient to support their routine use. Notably, one trial reported Achilles tendon rupture following corticosteroid injection.4
Presenting these advanced interventions as recommended nonoperative options may unintentionally overstate the strength of evidence and their applicability in primary care. Emphasizing progressive tendon-loading programs, activity modification, and appropriate referral better aligns with current evidence and the scope of family medicine practice.
In Reply: On behalf of myself and my coauthors, I thank Dr. Wojda for the careful, meticulous appraisal of the evidence we summarized. In our article, we aimed to present recommendations that are feasible in primary care settings while acknowledging emerging therapies that may shape future clinical decision-making.
As Dr. Wojda notes, management of Achilles tendon pathology should be individualized through shared decision-making, with transparent discussion of the strengths and limitations of the supporting literature. We agree that no intervention should be portrayed as more effective than the evidence demonstrates.
Our grouping of nonsurgical interventions in the Achilles tendon rupture section, rather than delineating the evidence for specific Achilles pathologies, may be interpreted as insufficiently granular. For example, an approach most consistent with the literature should specify that high-volume injections (normal saline with local anesthetic, with or without a corticosteroid), particularly when performed with ultrasound guidance, have demonstrated short- to medium-term improvement in pain and function in some patients with Achilles tendinopathy.5
It may be helpful to frame the current therapeutic landscape as comprising options with variable quality of evidence and durability of benefit. These include topical nitroglycerin, heel lifts, structured physical therapy, progressive high-load strength training, short-term immobilization when indicated, extracorporeal shock wave therapy, bipolar radiofrequency microtenotomy, judicious use of corticosteroid injection in select cases, and pain psychology. These treatments may offer symptomatic relief over differing durations, and selection should reflect patient goals, comorbidities, and clinician expertise.6–10
Although platelet-rich plasma and micronized dehydrated human amnion/chorion membrane have generated substantial clinical interest, current evidence remains inconclusive. This reinforces the need for well-designed comparative trials with standardized reporting of outcomes.
- 1.Morancie NA, Irvin L, Rayala BZ. Heel pain: diagnosis and management. Am Fam Physician. 2025;112(6):648-656.
- 2.Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or surgical treatment of acute Achilles' tendon rupture. N Engl J Med. 2022;386(15):1409-1420.
- 3.Moraes VY, Lenza M, Tamaoki MJ, et al. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2014(4):CD010071.
- 4.Kearney RS, Parsons N, Metcalfe D, et al. Injection therapies for Achilles tendinopathy. Cochrane Database Syst Rev. 2015(5):CD010960.
- 5.Hassan R, Poku D, Miah N, et al. High-volume injections in Achilles tendinopathy: a systematic review. Br Med Bull. 2024;152(1):35-47.
- 6.Abdelkader NA, Helmy MNK, Fayaz NA, et al. Short- and intermediate-term results of extracorporeal shockwave therapy for noninsertional Achilles tendinopathy. Foot Ankle Int. 2021;42(6):788-797.
- 7.Al-Ani Z, Meknas D, Kartus JT, et al. Radiofrequency microtenotomy or physical therapy for Achilles tendinopathy: results of a randomized clinical trial. Orthop J Sports Med. 2021;9(12) ): 23259671211062555.
- 8.Rabusin CL, Menz HB, McClelland JA, et al. Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (HEALTHY): a randomised trial. Br J Sports Med. 2021;55(9):486-492.
- 9.Chimenti RL, Post AA, Rio EK, et al. The effects of pain science education plus exercise on pain and function in chronic Achilles tendinopathy: a blinded, placebo-controlled, explanatory, randomized trial. Pain. 2023;164(1):e47-e65.
- 10.Hawks M, Clauson E, Hughes P, et al. Treatment of insertional Achilles tendinopathy using adjunct electroacupuncture therapy: a randomized controlled trial. Med Acupunct. 2023;35(2):76-81.
