In midportion Achilles tendinopathy, what currently shows the strongest short-term effect on pain and function: heavy slow resistance, eccentric-only loading, ESWT, or leukocyte-poor PRP? Recent trials and meta-analyses through 2023 point to loading (HSR ≈ eccentric) with about 15–20 VISA-A points gained by 12 weeks, while PRP underperforms; has anyone seen contrary data in high-mileage runners?
Seen ‘15–20 VISA-A’ with HSR; add 8–12mm heel lifts early, taper by week 12.
If speed’s the goal, pair HSR with targeted ESWT in the first 4–6 weeks — data show a small additive effect over exercise, sometimes pulling people to that “15–20 VISA-A by 12 weeks” sooner… I’ve had best luck with 2–3 ESWT sessions while keeping HSR 3x/week; PRP still underperforms, and @mstevens77 we’ve seen an extra about 5–7 VISA-A over loading alone.
Fastest wins I see come from biasing the soleus: heavy bent‑knee calf raises (3–4 s down, 2 s up) 3x/wk while keeping pain in the “acceptable” range so you can keep loading — the soleus is the Achilles’ workhorse. HSR vs eccentric looks equivalent, and this RCT backs that up: https://bjsm.bmj.com/content/49/6/406; are you already pushing bent‑knee loads to about 0–2 reps in reserve?
Loading wins, but I’d make it brain-friendly: metronome-paced HSR (60–70 bpm) under the “pain ≤4/10 and not worse next morning” rule for the full 12 weeks, while avoiding deep dorsiflexion early; PRP still lags (de Vos NEJM 2010: https://www.nejm.org/doi/full/10.1056/NEJMoa0905420). @OP, are you letting them keep easy running on flats if they meet those criteria?