The Achilles Problem in Running: What Recent Sports Injury Research Means for Podiatry and Rehab Outcomes | Critical Review | Find Your Stride | Edinburgh Podiatrist

Introduction

The 2025 narrative review Dilemma in the Treatment of Sports Injuries in Athletes tackles three of the most consequential injury categories seen in sports podiatry and sports medicine: tendinopathy, acute muscle strain, and tendon rupture. While not foot-specific by title, the paper is highly relevant to Achilles tendinopathy, calf muscle injury, plantarflexor weakness, and return-to-running decision-making. For podiatrists, this paper is valuable not because it offers new protocols, but because it highlights why outcomes remain disappointing despite “best practice” rehabilitation.

How can we keep athletes injury free and lacing up those shoes? The 2025 narrative review Dilemma in the Treatment of Sports Injuries in Athletes tackles three of the most consequential injury categories seen in sports podiatry and sports medicine: tendinopathy, acute muscle strain, and tendon rupture.

Strengths of the paper

1. Honest appraisal of treatment limitations

One of the paper’s strongest contributions is its refusal to oversell current interventions. Across all three injury types, the authors repeatedly show that:

• Evidence-based treatments improve symptoms but rarely restore full performance

• Re-injury rates remain high

• Structural and functional deficits often persist long-term

For clinicians managing runners frustrated by “doing everything right” yet failing to return to previous capacity, this framing is refreshingly honest.

2. Achilles tendinopathy: confirming what podiatrists already see

The authors strongly reinforce that progressive loading remains the cornerstone of Achilles tendinopathy management, with eccentric and heavy slow resistance training outperforming passive modalities. This aligns closely with contemporary podiatric and sports medicine practice.

Importantly for clinicians:

• PRP, NSAIDs, and biologics show little to no additive benefit

• Corticosteroid injections may improve short-term symptoms but remain controversial

• Shockwave therapy appears condition-specific rather than universally effective

For runners seeking “quick fixes,” this paper supports a clinician’s evidence-based resistance to overtreatment.

Critical gap:

While load management is discussed extensively, there is minimal exploration of foot biomechanics, footwear, or running-specific load distribution—an omission particularly relevant to podiatry.

3. Muscle strain injury: relevance for calf and soleus pathology

Although much of the muscle strain discussion focuses on hamstrings, the findings translate well to calf strains in runners, particularly soleus injuries.

Key takeaways:

• Early vs delayed loading shows less difference than commonly assumed

• Longer rehabilitation reduces reinjury risk by approximately 1.5% per day delayed

• MRI findings do not always correlate with readiness to return to sport

This reinforces a principle podiatrists managing running injuries know well: return-to-run decisions cannot rely on imaging alone.

4. Achilles rupture: sobering but clinically crucial

The section on Achilles tendon rupture is arguably the most important for sports podiatrists.

Key points with direct clinical relevance:

• Both operative and non-operative care can result in permanent strength deficits

• Tendon elongation is strongly correlated with reduced push-off strength and heel-rise height

• Soleus dysfunction may be under-recognised in standard rehab models

For runners, this explains why “successful” rehabilitation can feel like failure when sprinting, climbing hills, or racing.

Clinical implication:

Podiatrists involved in long-term rehabilitation may be better placed shifting expectations from 'full recovery' to 'functional optimisation'.

Limitations and missed opportunities

1. Limited running-specific context

Despite the high prevalence of Achilles injuries in runners, the paper offers little discussion on:

• Running biomechanics

• Cadence or stride modifications

• Footwear or orthotic interventions

• Progressive return-to-run frameworks

This narrows its direct applicability for clinicians treating endurance athletes.

2. Narrative review = expert opinion, not new evidence

While authored by leaders in tendon research, this is a narrative review, not a systematic review or meta-analysis. As such:

• Selection bias is possible

• Quantitative comparisons are limited

• Clinical recommendations remain broad

For clinicians, this paper should guide clinical reasoning, not dictate protocol.

What this means for podiatrists and other pratitioners working with runners

Key clinical takeaways:

• Progressive loading remains essential but not curative

• Structural deficits often persist despite symptom resolution

• Return-to-run decisions should prioritise function, not imaging

• Athlete education and expectation management are as important as exercise prescription

For podiatrists, the paper reinforces the need for long-term, performance-oriented management, rather than short rehabilitation windows.

Bottom line

This paper does not provide new tools but it does give some clarity.

For podiatrists treating runners with Achilles tendinopathy, calf strains, or post-rupture deficits, the paper suggests that modern sports injury treatments reduce pain, but rarely restore pre-injury performance. However, we think this may be the result of inadequate, shortened rehab programmes.

The papers greatest value possibly lies in reframing success not as complete recovery, but as maximising function within biological limits. A standpoint that could be seen as contentious as many runners won't like the idea of being 'limited'.

Citation

Kjær M, Petersen J, Dünweber MR, Andersen JL, Engebretsen L, Magnusson SP. Dilemma in the Treatment of Sports Injuries in Athletes: Tendon Overuse, Muscle Strain, and Tendon Rupture. Scandinavian Journal of Medicine & Science in Sports. 2025;35:e70026.

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