Athletic development specialists dedicated to the art and science of excellence in movement

Achilles Tendon: Symptoms versus Pathology

Mind over matter?  In a recent study, Alfredson (2012) studied thirteen patients with bilateral Achilles tendon pain.  All subjects underwent unilateral surgery (only operated on one foot).  In 11 of 13 patients, there was postoperative improvement not only on the operative side but also on the non-operated side!  Yes, the side that didn’t get operated on also improved.  There are many theories behind this result, but it does raise more interesting questions on pain versus pathology. (for a detailed review of this study see this review at Runners' World

Literature has consistently shown that the low back, shoulder, and knee all exhibit poor correlations between pathology and pain.  In other words, some patients have pain but demonstrate no structural damage, while others have structural damage but have no pain.  It seems the Achilles may follow this same pattern, based not only on the Alfredson study, but also on previous work. 

Van Snellenberg (2007) examined Achilles tendons of sixty four varsity athletes using Doppler ultrasound.  It is believed that Achilles tendinopathy may be related to neovascularization in the tendon.  However, authors found no relationship between tendinopathy and neovascularization.  Further, neovascularization was present in both painful and non-painful tendons.

Emerson  (2012) studied elite gymnasts and a control group and found significantly greater thickness and irregularity in the gymnasts (both male and female) as compared to controls.  Most importantly though, among gymnasts there was no relationship between painful symptoms and structural irregularities   Authors concluded, “the poor correlation between signs and symptoms suggests pathology is not always symptomatic.”

Pathology has also been shown an unreliable predictor of injuries from the beginning of the season.  Boeson (2012) conducted a prospective study with Doppler imaging of Achilles tendons and anterior knee tendons of badminton players at the start and end of the season.   Their findings paralleled the other studies in showing no meaningful relationship between pain and pathology.

  • of the 37 painful tendons at the start of the season, 25 had abnormal flow (68%).
  • In contrast, 131 tendons (85%) with abnormal flow at the start of the season were pain free.
  • At the end of the season, 18 of the 51 painful tendons (35%) had abnormal flow.

As to the lack of predictive value, ninety-six of the 131 pain-free tendons (73%) with abnormal flow at the start of the season were normalized (no pain and normal flow) at the end of the season.


We’ve said it before and will say it again: imaging can be helpful but can also deceive.   Especially frustrating is dealing with athletes who wait for imaging to give them permission to feel more intense pain! (“My pain was only a 3 out of 10, but since the MRI detected swelling, my pain is now a 6…”)  Modern pain science has shown that pain is not always a structural matter.  There may be connections between pain and pathology in individual cases, but the predictive value on a population level is limited.   

The “definitive answers” that athletes often seek merely add to confusion.  Imaging is simply one aspect to evaluate in each individual case and is more effectively used to rule out more serious conditions rather than to give people reasons to overthink themselves into longer lasting pain.    

van Snellenberg W, Wiley JP, Brunet G.  Achilles tendon pain intensity and level of neovascularization in athletes as determined by color Doppler ultrasound.  Scand J Med Sci Sports.2007 Oct;17(5):530-4.

Boesen AP, Boesen MI, Torp-Pedersen S, Christensen R, Boesen L, Hölmich P, Nielsen MB, Koenig MJ, Hartkopp A, Ellegaard K, Bliddal H, Langberg H.  Associations between abnormal ultrasound color Doppler measures and tendon pain symptoms in badminton players during a season: a prospective cohort study.  Am J Sports Med.2012 Mar;40(3):548-55. doi: 10.1177/0363546511435478. Epub 2012 Feb 9.

Emerson C, Morrissey D, Perry M, Jalan R.  Ultrasonographically detected changes in Achilles tendons and self reported symptoms in elite gymnasts compared with controls--an observational study.Man Ther.2010 Feb;15(1):37-42. doi: 10.1016/j.math.2009.05.008. Epub 2009 Jul 29.

Alfredson H, Spang C, Forsgren S.  Unilateral surgical treatment for patients with midportion Achilles tendinopathy may result in bilateral recovery.  Br J Sports Med.2012 Nov 28. [Epub ahead of print]


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