Snapshot A 40-year-old elite runner presents to the physician’s office for pain in the Achilles tendon. For the past few weeks, he has had intermittent pain and swelling in his right Achilles tendon. He also reports some stiffness in the mornings after waking up. On physical exam, there is tenderness 2-6 cm proximal to the Achilles tendon insertion and limited dorsiflexion. His physician recommends rest and ice for the next few weeks. Introduction Clinical definition overuse injury of Achilles tendon characterized by pain insertional tendinopathy where the tendon inserts into the calcaneus (25% of cases) noninsertional tendinopathy at 2-6 cm proximal to the tendon insertion (75% of cases) Epidemiology demographics male > female 30-50 years of age professional runners risk factors obesity diabetes poor techniques during athletic training specific drugs corticosteroids fluoroquinolones Pathogenesis mechanical overload may cause tendinopathy three phases initial acute inflammatory phase (few days) proliferative phase with new collagen production and neovascularization (3 weeks) collagen remodeling phase (up to a year) Associated conditions seronegative arthropathies Presentation Symptoms intermittent pain in the Achilles tendon related to activity stiffness after prolonged sessions of immobility may have swelling Physical exam tenderness at the insertion of the Achilles tendon or 2-6 cm proximal to the insertion may have limited dorsiflexion range of motion calf squeeze test to assess for Achilles tendon rupture Studies Making the diagnosis most cases are clinically diagnosed Differential Achilles tendon rupture distinguishing factor positive calf squeeze test Ankle sprain distinguishing factor no focal tenderness of the Achilles tendon Treatment Conservative ice and rest indication for all patients stretching exercises indication for patients with limited range of motion from the tendinopathy Medical nonsteroidal anti-inflammatory drugs (NSAIDs) indication pain management Complications Achilles tendon rupture