Factors associated with midportion and insertional Achilles tendinopathy: a systematic review with meta-analysis and meta-regression
Related Experiment Video
Updated: Nov 3, 2026
Murine Hind Limb Explant Model for Studying the Mechanobiology of Achilles Tendon Impingement
Published on: December 8, 2023
Sven A Weerkamp1, Marc A Paantjens2, Faridi S van Etten-Jamaludin3
1Department of Science and Data-analysis, Podiatric Primary Care Center, Rondom Podotherapeuten, Utrecht, The Netherlands.
Objective:
To identify and evaluate factors associated with midportion Achilles tendinopathy (mid-AT) and insertional Achilles tendinopathy (ins-AT).
Design:
Systematic review with meta-analysis.
Data Sources:
The databases MEDLINE Ovid, Embase, Web of Science, Cochrane Library and grey literature sources were searched up to 4 August 2025.
Eligibility Criteria For Selecting Studies:
Cohort and case-control studies investigating factors associated with mid-AT and ins-AT separately were included.
Results:
19 primary studies (11 prospective cohort studies and 8 case-control studies) were included in this systematic review. For mid-AT, high-quality evidence was found for a previous episode of Achilles tendinopathy and very low-quality evidence for 17 other factors including: older age, adverse lipid profile, being registered as a marathon runner, decreased calf muscle strength, winter training, ultrasound parameters, decreased forward progression force during running and limited first metatarsophalangeal joint dorsiflexion. No associations were found between 48 other factors and mid-AT, including a previous running-related injury, body mass index and foot posture. For ins-AT, moderate-quality evidence was found for a previous episode of Achilles tendinopathy and very low-quality evidence for younger age as associated factors. No associations were found between 17 other factors and ins-AT, including Haglund's deformity and weight.
Conclusion:
A wide range of non-modifiable, modifiable, imaging and biomechanical factors associated with mid-AT and ins-AT were identified, although most were supported by very low-quality evidence. High risk of bias and heterogeneity in the available evidence make the identification of factors associated with Achilles tendinopathy challenging.
Prospero Registration Number:
CRD42024539362.
