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Achilles Tendinitis Treatment Science

Evidence-based guidelines for recovering as fast as possible

Paul Ingraham, updated

Achilles tendinitis is one of several common repetitive strain injuries (RSI). The giant tendon can be stressed until it becomes acutely irritated and then, in some people, it stubbornly refuses to heal — either because it keeps getting re-irritated, and/or because it’s just naturally difficult for tendon to recover, and that phenomenon is worse in some people.

All of the well-known RSIs have a lot in common. I provide more detailed information about the nature of the beast in a separate guide (see Repetitive Strain Injuries Tutorial). That article dives deep into questions like: are RSIs really inflamed? Do we get them because of things like biomechanical asymmetry, poor ergonomics, a wonky gait? And much more. This article is a brief guide to treatment and rehabilitation only.

Tendon never truly “heals,” it just gets patched (and you can’t rush it)

You cannot ever undo the damage done to connective tissue by overuse and inflammation. There is basically zero turnover of that tissue.1

Luckily, the body can lay down a fresh layer of connective tissue. So a cruddy old tendon can become a rotten core wrapped in a fresh and fully functional outer layer. “Healing”! So at least there’s that.

The first rule of tendinitis rehab is to just accept that there’s no known method of actually speeding or facilitating that process. Accelerated/regenerative healing are not serious options for Achilles tendinitis. (More about high-tech regenerative treatments below.)

Load management in principle

The basic template for all injury rehab is to “calm shit down” and then “build shit up,”2 also known as “load management.” That is, first you rest, soothe, comfort, reassure, protect … and then you gradually introduce easy, artificial challenges, and then more difficult functional ones, slowly “demonstrating” to your brain and tendons that painless function is possible and eventually required.

The challenge is to keep your tendons in the Goldilocks zone: stimulated enough to heal, but not so much that you re-irritate the tendon. It’s a challenge because the Goldilocks zone changes as you heal, and so you have to keep up with it… which is a bit error-prone. Many factors affect our vulnerability to load.3 This uncertainty is the main source of error in rehab: we can never be sure how much stimulation is enough or too much.

So bog standard rehab for tendinitis usually consists of:

Ten years after doing this kind of rehab, 76% of about a hundred patients were back to normal, with no sign of serious consequences of the steroid injections.4 But 24% were not — after a decade! Those numbers tell a clear story: most people are probably eventually going to be fine with standard therapy, but clearly not everyone.

Don’t underestimate the importance of rest

If there’s a “trick” to load management, it’s that the initial resting phase is important — probably more important than most people realize.5 And the build-shit-up phase is slower and more baby-steppy than most people realize. Especially with &*[email protected]# tendinitis.

It’s also largely just a matter of simply not interfering with natural healing by re-irritating it, so please really make sure you take it quite easy for a quite a while. Avoid spikes in tendon loading like the plague in the early stages.

But it’s not like you won’t use your tendons at all while taking it easy. There is work to do…

Stimulating new tendon growth: early mobilization

Exactly how to inspire the body to lay down that fresh layer is, of course, not totally clear. We know it’s possible, but it probably requires a just-right amount/kind of exercise stimulation that is impossible to be sure of.

In general it just means progressively loading the tendon, asking it to do its job a little more each week over many weeks: progressive training.

And what is it’s job? The major function of the Achilles tendon is that is a giant elastic that absorbs some energy during part of your stride, and gives some of it back during another part, kind of like regenerative braking in an electric car. Anything that doesn’t use that system won’t be very challenging/stressful to the tendon.

But you also can’t start out asking it to do its entire job, anymore than you send someone back to work the day after they’ve had a major surgery. One thing at a time. So you start out with easier, less functional challenges.

Initially, you focus on unloaded, pain free range of motion exercises or “mobilizations” — literally just flexing the foot up and down, or rolling the ankle around in circles, “pumping” the tendon and leg muscles gently, without straining it in the least. This is so easy it is compatible with rest. It is resting… but with gentle stimulation of the tissue while you rest. Use it or lose it!

After patiently doing plenty that, you transition to the first obvious functional challenge: heel raises. Lots and lots of heel raises over time. Not many and very easy at first, but more and more intense over many weeks and months, eventually working up to fairly high loads and more serious challenges like eccentric training (see below).

And, as you go, you start to mix in more functional challenges, which mostly means walking and jogging, but in quite small doses initially.

Isometric contractions for Achilles tendinitis

In 2017 study, a high profile study suggested that isometric contractions are an effective treatment for Achilles tendinitis.6

Iso-what? Isometric contractions are non-moving contractions, so basically clenching. Isometric loading of the Achilles tendon is easily achieved by simply standing on the edge of a step or curb, suspending the heel. Just stand there, with tension on your tendons.

concentric contraction = contraction while shortening
isometric contraction = contraction without changing length (“clenching”)
eccentric contraction = contraction while lengthening (“braking”)

So does calf clenching work? I doubt it. There’s now failed replication of Rio et al,7 plus other conflicting evidence,8 and so… meh.9

One could argue that isometric contractions are not a functional stimulus, and so they are unlikely to do much good, and the lack of consistent, persuasive results isn’t surprising.

Eccentric exercise for Achilles tendinitis (heel drops)

An eccentric contraction is a contraction while lengthening, also sometimes called a braking contraction. This type of contraction is more efficient than concentric (harder work for less energy), and causes more soreness. The canonical example of an eccentric contraction is the biceps while lowering a barbell: the muscle is lengthening, but clenching to control the rate at which it lengthens.

The eccentric contraction relevant to Achilles tendinitis is the calf muscle. When you stand up on your toes, the calf contracts concentrically to lift you up. If you hold the position, that’s an isometric contraction. And then as you lower your heels down the calf contracts eccentrically. So a standard heel raise (with a bit of a pause at the top) uses all three.

The high “efficiency” of eccentric contractions makes them potentially useful for rehab.10 Eccentric exercise (EE) is often prescribed for tendinopathy in particular, because it seems to “improve symptoms,”11 and could even be a rare example of truly evidence-based rehab.12

On the other hand, nothing is ever that tidy in sports medicine. Or science. Or life.

Even if it is helping symptoms, recent evidence shows that EE may not actually be changing the tendon,13 which is probably what most people would hope and assume — a novel stimulus, with an interesting and useful tissue response, would be of great interest.

Today, some experts are just not impressed by eccentric exercise therapy, despite the sprinkling of positive studies: “There is no convincing clinical evidence to demonstrate that isolated eccentric loading exercise improves clinical outcomes more than other loading therapies.”14

I bet “it depends.” If exercising eccentrically is actually useful in rehab, it is not clearly established yet.

Emphasizing the eccentric: the Alfredson protocol

The eccentric exercise craze for Achilles tendinitis started with the “Alfredson protocol,” proposed way back in 1998 by Alfredson et al, a Swedish research group.15 A bunch of mediocre follow-up studies encouraged people who probably should have known better than to get “excited” about it. In 2012, the first longer-term study was finally published, which didn’t establish much except that many people quickly moved on from the Alfredson therapy to try other treatment methods — so it clearly wasn’t working any miracles — but they generally did well over time (though clearly not necessarily because of the Alfredson protocol).16

But enough of my nay-saying! I’ve done lots of this myself, despite my skepticism. And this is how it’s done…

Summarized, the Alfredson protocol is basically “lots of heel drops, with both bent and straight knee” where by “lots” I mean one hundred and eighty of them per day. That’s really a lot.

A heel drop is extremely simple: you just stand on the edge of something and lower ("drop") your heel down below the level of your toes a bit. The key to heel dropping the eccentric way is not to raise yourself back up with the leg you are treating. You get back to the starting position with your other leg.17

And what if your other leg has Achilles tendinitis? Then you can’t really do this, or at least not easily. It’s technically possible to get back to the start of the exercise without using either calf, with the right equipment… but it’s tricky.

And seriously, 180 drops per day? For many weeks? Ain’t nobody got time for that, and in fact the dosage is probably not all that important. A 2014 trial of 28 people (yes, tiny — almost all trials in this field are tiny) which found no significant difference between the Alfredson protocol’s high volume and a lower-volume version.18 So if you want to try this, here’s my recommendation, the modified Alfredson protocol. Ingredson protocol?

Pain relief

Masking symptoms,” especially with medications, is often maligned. But sometimes symptoms need masking! If you need a little pain relief during activity you cannot avoid (and many of us have activities we cannot avoid, like childcare and careers that naturally involve some tendon loading):

Just bear in mind that pain-relief and load management are natural enemies. Pain is generally a useful warning that we’re pushing tissue too hard. If you mute that signal, it’s much easier to accidentally leave the Goldilocks zone.

And also beware of overusing Voltaren or any other non-steroidal anti-inflammatory drug (like ibuprofen): there is some evidence that these drugs can actually interfere with healing.20 Which really sucks.

Surgical repair of tendon rupture

Tendon rupture is mostly beyond the scope of this article for now, but a 2019 scientific review had such a surprising conclusion about this that it’s worth a mention. I think it has implications for all rehab, even of unruptured tendons.

Ochen et al looked at ten trials and determined that surgery only modestly reduces the risk of re-rupture of the tendon, while introducing about a 2.5 times greater risk of complications (mostly infections).21 In other words, all other things being equal, the average patient with a ruptured Achilles tendon does approximately as well with or without surgery. For patients who did good rehab with an emphasis on early mobilizations, there was no difference in re-rupture risk at all. All the surgery did for those patients was give them a risk of complications that they wouldn’t have had otherwise.

The surprising part here is not only that it’s possible to heal from tendon ruptures without surgery, but that it’s possible to do it well — potentially just as well as with surgery, and certainly not much worse. How do ruptured tendons heal on their own without being surgically reattached? I can’t really explain it. Something is obviously wrong with my mental model, because if tendon rupture works the way I imagine it, then healing without surgical fixation of the tendon seems impossible. Let’s chalk it up to a terrific example of the healing powers of the human body. Animals have to be able to heal from tendon ruptures without surgery, and we can.

It’s also a good example of how many orthopedic surgeries are surprisingly useless, even the ones where the need for “repair” seems “obvious” — this is something research has been exposing regularly since the mid-2000s.22

This evidence strongly validates conventional rehab in general, and especially suggests that getting going with pain free range of motion exercises ASAP is particularly valuable — even with a ruptured tendon! And if it’s helpful for a ruptured tendon, it’s probably good for any case of tendinopathy. Use it or lose it!

Regenerative medicine

There are some emerging high-tech treatments intended to stimulate/accelerate tendon tissue growth. These are exciting possibilities, but I think you should save your money for now.

This website has a salamander for a mascot/logo because that critter has genuinely amazing powers of regenerative healing. We know it’s possible because salamanders do it: the only macroscopic animal with that superpower.

But we certainly don’t have it yet. We’ll probably get some real regenerative medicine eventually, but it’s still early days. Meanwhile, there are several companies racing to market on this. Their value can only be based on hype, because none of them have been adequately tested yet. Tendoncel is the most prominent I know of, and by their own admission they are still testing their product.

There’s also platelet-rich plasma injection — basically, injecting a sauce of your own platelets — which is a poor man’s version of stem cell therapy, less new, and less promising. Despite widespread claims of efficacy, the evidence is extremely weak sauce. I cannot recommend PRP at this time. I review that topic in detail in a separate article: Does Platelet-Rich Plasma Injection Work? An interesting treatment idea for arthritis, tendinopathy, muscle strain and more.

So there’s just no basis for confidence about any regenerative therapy for tendons at this time. It’s implausible on its face, because there are extremely few precedents for clearly successful regenerative medicine in humans, and many conspicuous failures.

That doesn’t mean it won’t work, but it does mean that the bar for the evidence is very high, and even if we see evidence of efficacy soon, it will definitely still not be enough: it will have to be replicated independently.

So we’re ways off yet, probably another couple of years at least.

Orthotics for Achilles tendinitis

Orthotics are generally over-rated, and the industry that supplies that is pretty rotten with nonsense.23 Orthotics are often recommended for conditions remote from the feet, allegedly because foot biomechanics are relevant to the function of practically everything else in the body. People love this idea, and it sells, but it has not stood up to scrutiny, and is one of the best examples of the failed paradigm of “structuralism” in rehab and pain medicine. Structuralism is the excessive focus on causes of pain like crookedness and biomechanical problems.24

Practically every imaginable condition below the knee can supposedly be treated by orthotics. Some of them are undoubtedly legit. Not Achilles tendinitis. An excellent 2015 study slammed the door shut on this topic, a rare case of a study that was good enough to actually produce a persuasive answer, instead of just more low quality evidence that has to be taken with a huge grain of salt.25

This was a controlled test of customized orthotics for Achilles tendinitis, compared to a sham of off-the-shelf orthotics. The design and methodology were solid: straightforward and with plenty of statistical power (140 subjects in two groups). They checked up everyone at intervals for a year, and found … no difference at any point. Everyone improved somewhat, but the custom orthotics did not grant any advantage. The bottom line:

Customised foot orthoses… are no more effective than sham foot orthoses.

This is the kind of conclusion that orthotics makers really do not want anyone to know about. Achilles tendinitis is exactly the kind of condition that custom orthotics can supposedly work marvels with, and failing this test so completely is really damning for that industry. Unsurprisingly, the researchers have been harshly criticized, and they have responded to those criticisms at length — and I don’t think any of the criticisms hold up.

Do not spend your money on custom orthotics for Achilles tendinitis.

There’s not really much to it

Someday I will expand this guide into a book, and go on and on and on for 50x as long, delving into all the weird little details — but the bottom line won’t really differ much from what you’ve seen here. “Progressive loading” is mostly all there is to know. Shhhhh. Our little secret.

About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

What’s new in this article?

Six updates have been logged for this article since publication (May 15th, 2019). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more Like good footnotes, update logging sets PainScience.com apart from most other health websites and blogs. It’s fine print, but important fine print, in the same spirit of transparency as the editing history available for Wikipedia pages.

I log any change to articles that might be of interest to a keen reader. Complete update logging started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.

See the What’s New? page for updates to all recent site updates.

OctoberNew section, “Orthotics for Achilles tendinitis,” based mainly only Munteanu et al.

AugustMuch more detailed information, and more science, about heel drops and the Alfredson protocol.

JulyAdded section, “Surgical repair of tendon rupture,” and some more specific information about early mobilizations.

MayScience update: added some fresh evidence about the efficacy of standard rehab methods (not bad, not great either).

MayAdded section about eccentric exercise. Improved layout of embedded video of heel raises. Lots of editing. Added caveats about pain-killers.

MayAdded section about regenerative medicine.

MayPublication.

Notes

  1. Heinemeier KM, Schjerling P, Heinemeier J, Magnusson SP, Kjaer M. Lack of tissue renewal in human adult Achilles tendon is revealed by nuclear bomb (14)C. FASEB J. 2013 May;27(5):2074–9. PubMed #23401563.  PainSci #53171. 

    There is basically no turnover in tendon tissue in adults (as measured in the Achilles tendon in this experiment).

    And how do we know this? Because NUKULAR BOMBAS! The atomic signatures of the era of nuclear bomb testing are still written into the tendons of people who were alive at the time, trapped like bubbles of ancient air in an ice core.

    Incredible. Very cool science. Indeed, probably the coolest tendon study that has ever been or ever will be.

    BACK TO TEXT
  2. Tweet, Sep 24, 2014, Greg Lehman (@GregLehman), physical therapist and chiropractor. BACK TO TEXT
  3. Soligard T, Schwellnus M, Alonso JM, et al. How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. Br J Sports Med. 2016 Sep;50(17):1030–41. PubMed #27535989. 

    This is the first of a pair of papers (with Schwellnus) about the risks of athletic training and competition intensity (load). Is load a risk for injury and illness? How much is too much? Is too little a problem? These papers were prepared by a panel of experts for the International Olympic Committee, and both them use many words to say the same things formally — but they are good points. Here they are in plain English:

    • There’s not enough research, surprise surprise, and what we do know is mostly from limited data about a few specific sports. But there’s enough to be confident that “load management” overall is definitely important.
    • Both illness and injury seem to have a similar relationship to load — lots of overlap.
    • Too much and not enough load probably increase the risk of both injury and illness. You want to be in the goldilocks zone! But the devil is in the details …
    • Not everyone is vulnerable to high load, and elite athletes are the most notable exception: they are relatively immune to the risks of overload, probably because of genetic gifts. Everyone else gets weeded out!
    • Big load changes — dialing intensity up or down too fast — are much bigger risks than absolute load. If you methodically work your way up to a high load, it may even be protective.
    • “Load” can also refer to non-sport stressors and “internal” loads, which are legion. Psychology, for instance, probably does matter: anything from daily hassles to major emotional challenges, as well as stresses related to sport itself.

    BACK TO TEXT
  4. Johannsen F, Jensen S, Wetke E. 10-year follow-up after standardised treatment for Achilles tendinopathy. BMJ Open Sport Exerc Med. 2018;4(1):e000415. PubMed #30305926.  PainSci #52260.  BACK TO TEXT
  5. PS Ingraham. The Art of Rest: The finer points of resting strategy when recovering from injury and chronic pain (hint: it’s a bit trickier than you might think). PainScience.com. 5747 words. Resting “properly” is trickier and more critical part of injury rehabilitation than most people realize, and is often at odds with a culture tradition of aggressive therapeutic exercise (“no pain, no gain”). This article explores the rationale for resting, and tactical considerations like how to rest anatomy that you need to use for your job, and how to know how much rest is enough. BACK TO TEXT
  6. Rio E, van Ark M, Docking S, et al. Isometric Contractions Are More Analgesic Than Isotonic Contractions for Patellar Tendon Pain: An In-Season Randomized Clinical Trial. Clin J Sport Med. 2017 May;27(3):253–259. PubMed #27513733.  BACK TO TEXT
  7. Holden S, Lyng K, Graven-Nielsen T. The Acute Effect of Isometric Versus Isotonic Resistance Exercise in Patients With Patellar Tendinopathy—does contraction type matter? A randomised crossover trial. {Presented at the Scandinavian Sports Medicine Conference, Copenhagen, Denmark, 2019}. 2019. PainSci #52445.  BACK TO TEXT
  8. O'Neill S, Radia J, Bird K, et al. Acute sensory and motor response to 45-s heavy isometric holds for the plantar flexors in patients with Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc. 2018 Jul. PubMed #29974171.  BACK TO TEXT
  9. Gravare Silbernagel K, Vicenzino BT, Rathleff MS, Thorborg K. Isometric exercise for acute pain relief: is it relevant in tendinopathy management? Br J Sports Med. 2019 May. PubMed #31076398.  BACK TO TEXT
  10. Hessel et al: “The high force and low energy cost of eccentric contractions makes them particularly well suited for athletic training and rehabilitation. Eccentric exercise is commonly prescribed for treatment of a variety of conditions including sarcopenia, osteoporosis, and tendinosis.” BACK TO TEXT
  11. Frizziero A, Vittadini F, Fusco A, Giombini A, Masiero S. Efficacy of eccentric exercise in lower limb tendinopathies in athletes. J Sports Med Phys Fitness. 2016 Nov;56(11):1352–1358. PubMed #26609968.  “Eccentric exercise (EE) is considered a fundamental therapeutic resource, especially for the treatment of Achilles and patellar tendinopathies.” BACK TO TEXT
  12. Rees JD, Wolman RL, Wilson A. Eccentric exercises; why do they work, what are the problems and how can we improve them? Br J Sports Med. 2009 Apr;43(4):242–6. PubMed #18981040.  “Eccentric exercises (EE) have proved successful in the management of chronic tendinopathy, particularly of the Achilles and patellar tendons, where they have been shown to be effective in controlled trials.” BACK TO TEXT
  13. Drew BT, Smith TO, Littlewood C, Sturrock B. Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review. Br J Sports Med. 2014 Jun;48(12):966–72. PubMed #23118117.  “The available literature does not support observable structural change as an explanation for the response of therapeutic exercise except for some support from heavy-slow resistance training.” It’s conceivable that moderate intensity eccentric contractions are just somewhat closer to the real goal of “heavy-slow resistance training” — a shortcut. BACK TO TEXT
  14. Couppé C, Svensson RB, Silbernagel KG, Langberg H, Magnusson SP. Eccentric or Concentric Exercises for the Treatment of Tendinopathies? J Orthop Sports Phys Ther. 2015 Nov;45(11):853–63. PubMed #26471850.  BACK TO TEXT
  15. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360–6. PubMed #9617396.  BACK TO TEXT
  16. van der Plas A, de Jonge S, de Vos RJ, et al. A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med. 2012 Mar;46(3):214–8. PubMed #22075719.  PainSci #54410.  BACK TO TEXT
  17. The idea is to emphasize eccentric contraction, but normal heel raises include equal doses of concentric and eccentric contraction. What goes up must come down! So how do you separate them? You have to make a point of eliminating the concentric — which means that you just don’t do the “raise” part of heel raises. You stand on the edge, lower your heel, and then rather than lifting back up again, you just take the load off with your other leg, reset, and repeat. Just never raise with the calf you’re training. For whatever it’s worth. BACK TO TEXT
  18. Stevens M, Tan CW. Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial. J Orthop Sports Phys Ther. 2014 Feb;44(2):59–67. PubMed #24261927.  BACK TO TEXT
  19. Heinemeier KM, Øhlenschlæger TF, Mikkelsen UR, et al. Effects of anti-inflammatory (NSAID) treatment on human tendinopathic tissue. J Appl Physiol (1985). 2017 Nov;123(5):1397–1405. PubMed #28860166.  This study reported that “tendinopathic cells are not responsive to ibuprofen.” BACK TO TEXT
  20. Bittermann A, Gao S, Rezvani S, et al. Oral Ibuprofen Interferes with Cellular Healing Responses in a Murine Model of Achilles Tendinopathy. J Musculoskelet Disord Treat. 2018;4(2). PubMed #30687812.  PainSci #52446.  “We conclude that the use of Ibuprofen for pain relief during inflammatory phases of tendinopathy, might interfere with the normal processes of extracellular matrix remodeling and cellular control of expression of inflammatory and wound healing genes.” BACK TO TEXT
  21. Ochen Y, Beks RB, van Heijl M, et al. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019 Jan;364:k5120. PubMed #30617123.  PainSci #52396.  BACK TO TEXT
  22. Louw A, Diener I, Fernández-de-Las-Peñas C, Puentedura EJ. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Med. 2016 Jul. PubMed #27402957.  PainSci #53458. 

    A review of a half dozen high quality tests of four popular orthopedic (“carpentry”) surgeries, all showing a lack of efficacy compared to placebos. As of 2016, this review is the best single academic citation to support the claim that “sham surgery has shown to be just as effective as actual surgery in reducing pain and disability.” It’s also an eyebrow-raiser that Louw et al could find only six good (controlled) trials of orthopedic surgeries, and all of them were bad news.

    (See more detailed commentary on this paper.)

    BACK TO TEXT
  23. PS Ingraham. Are Orthotics Worth It? A consumer’s guide to the science and controversies of orthotics, special shoes, and other allegedly corrective foot devices. PainScience.com. 5163 words. BACK TO TEXT
  24. “Structuralism” is the excessive focus on crookedness and “mechanical” problems as causes of pain. It has been the dominant way of thinking about how pain works for decades, and yet it is source of much bogus diagnosis. Structuralism has been criticized by several experts, and many studies confirmed there are no clear connections between biomechanical problems and pain. Many fit, symmetrical people have severe pain problems! And many crooked people have little pain. Certainly there are some structural factors in pain, but they are generally much less important than messy physiology, neurology, psychology. Structuralism remains dominant because it offers comforting, marketable simplicity. For instance, “alignment” is the dubious goal of many major therapy methods, especially chiropractic adjustment and Rolfing. See Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain. BACK TO TEXT
  25. Munteanu SE, Scott LA, Bonanno DR, et al. Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial. Br J Sports Med. 2015 Aug;49(15):989–94. PubMed #25246441.  BACK TO TEXT