Management & Decision Making: Healthy Achilles Tendon

“Could we harm the individual or athlete by being too focused on a specific intervention?” -Jarred Boyd

In everyday clinical practice, there is no shortage of complicating factors feeding into our decision-making process. This complexity weighs heavily in performance realms where margins are thin and the consequences of miscalculations are drastic.

Jarred Boyd does an outstanding job covering many facets of athlete management in performance settings. Not only does he explain how he evaluates and acts on the factors shaping strength qualities, but he also shows how he fits those decisions within real‑world constraints.

We will not cover every aspect of his talk here, but we do want to zoom in on one interesting input to his decisions: avoiding downside.

Solving for Unwanted Problems

In Scot Morrison’s introductory presentation at the Tendon Summit, he talks about the ignorance many unknowingly embrace. If we do not seek out whether we are right or wrong, we can “go through an entire career feeling right about everything (we) did.”

Jarred does not allow this to become an issue.

He employs the idea of inversion to his framework to ensure few stones are left unturned. In this concept, you start with the end in mind and work backward. But, instead of a typical reverse engineering process, you instead attempt to ‘solve’ the opposite of the problem you’re concerned with.

To provide examples: If we’re concerned with maximizing an athlete’s performance, we could invert that goal to answer the following questions:

How could I hinder my athlete’s on-court time?
How could I negatively impact the reactive strength capabilities of my athlete?
How could I set my athlete up for future problems?

In ‘solving’ these questions, we help expose areas that require further consideration. Exaggerating our thought process helps define the boundaries of the decisions we can realistically make.

Choices have consequences. There is always a cost to doing business.

This entire summit is based around a relatively narrow aspect of health and performance: Achilles tendons. We obviously consider the topic worthy of deep thought and action. However, it would be wise to employ inversion and begin considering what happens if we allow our priorities to drift and we over-invest in a singular structure.

Reactive Strength Paradox

Jarred highlights a non‑intuitive reality of tendon training: the very movements that determine sport success, short‑duration, high‑impulse, high‑rate contractions, impose substantial strain on tendons but do not allow sufficient time for uniform load distribution. They are essential for performance, yet they are a poor stimulus for tendon adaptation. As a result, athletes accumulate high tendon stress without accruing the structural benefits typically associated with tendon‑focused loading.

Because these high‑impulse exposures are non‑negotiable for sport athletes, they consume a large portion of the tendon’s weekly strain budget. Any additional tendon‑specific loading (especially if applied without regard to tendon condition) can easily push the structure into supraphysiological territory. This is where well‑intended preventative work becomes a liability rather than a safeguard.

Unintended Consequences

“A person often meets their destiny on the road they took to avoid it.”
-Jean de La Fontaine

We spent a considerable amount of time outlining the current literature regarding tendinopathy prevention in the Summit Insider. Within, we discuss how the studies surrounding the topic often fail to employ preventative efforts aligned with our current understanding of tendon adaptability.  As such, any confidence we have regarding the topic should be tempered. In the years to follow, we expect our knowledge base (and subsequent narratives) to shift dramatically as more accurate frameworks are investigated.

Yet, as clinicians responsible for managing health and performance, we must make decisions with the information available now. We do not have the luxury of waiting for future trials.

Wang’s 2023 systematic review would be enough to give anyone pause [1]. In it, the authors state: “prophylactic programs still cannot significantly reduce the risk of patellar tendinopathy (PT) in the population. In the subgroup analysis, for recruits, the prophylactic program may even increase the risk of PT occurrence”.

This concern is largely driven by the included Fredberg Danish Super league study [2]. The group administered a prophylactic intervention of stretching and eccentric loading three times per week for the duration of a competitive season (we’ll discuss the loading parameters shortly).

They observed no measurable changes in Achilles tendon structure or injury risk, regardless of the individual's starting condition. However, they saw divergent responses in patellar tendons based on the integrity of the structure at the start of the season.

Players with normal patellar tendons tended to show mildly reduced risk of tendinopathy, whereas players with abnormal patellar tendons experienced a significant increase in symptoms when exposed to the same intervention. In other words, the very strategy intended to prevent tendinopathy appeared to accelerate it in tendons already showing early structural compromise [2].

Inverting the Problem

If our goal is to mitigate injury risk, we must ask: How might we unintentionally make our athletes more vulnerable?

One answer lies in ignoring tendon condition and applying uniform interventions across heterogeneous structures. Scot’s concept of satisficing is useful here. In complex systems, we rarely optimize. We choose what seems “good enough” under the constraints we face. But “good enough” for a healthy tendon may be excessive for a compromised one. When tendon condition is misjudged, added loading can shift from preventative to provocative [1,2].

A second answer comes from what Scot describes as “lying” to our tissues. Tendons adapt to the exposures they repeatedly encounter, and those exposures are never isolated. They occur within coordinated, multi‑system actions that reflect the true demands of sport. If we over‑prioritize the prevention of tendinopathy by reducing on‑court work or diverting time toward additional tendon‑focused training, we alter the pattern of stress the body expects to withstand. In doing so, we teach the system that high‑impulse, high‑rate demands will be less frequent than they actually are. A system trained under a false stress profile is less prepared for the realities of competition and more vulnerable when those demands inevitably return.

Inversion sharpens our understanding of where preventative strategies can drift off course. When we over‑invest in a single structure, misjudge tendon condition, or misrepresent the stress environment our athletes must withstand, we shift the system away from the demands it is meant to meet. Effective prevention requires alignment with both tendon state and sport‑specific realities.

Hedging Our Bets

This article is not meant to inspire fear in those working with athletes. Its purpose is to highlight the importance of recognizing the range of possible outcomes and the decisions that shape them.

There is still room for optimism. Our understanding of tendon behavior is advancing, and the questions we are asking now are more precise than those that guided earlier preventative work. As the field continues to refine how tendons respond to different inputs, future studies will offer clearer guidance and a stronger basis for clinical decision making.

Jarred’s position does not close off the possibility of using tendon‑focused training methodologies. What he does is weigh those interventions within the broader demands placed on the individual and consider how they fit alongside everything else an athlete must absorb.

As he explains, “We are trying to be robust. We try to diversify our inputs, hedge our bets, so we can tolerate the error that is inherent in complex systems.”

His point reinforces the importance of keeping our decisions broad enough to support real‑world demands rather than drifting toward narrow priorities that can create avoidable problems.

In essence, we never want to narrow our focus so much that we lose important training inputs. Often, the most effective strategy is simply to minimize avoidable negatives. Provide a sufficient stimulus to ensure athletes are not underprepared for the demands placed upon them, allow them to direct their efforts toward higher‑order action capabilities, and keep the cost‑benefit ratio in our favor.

The goal is not to avoid action but to act with clarity. Healthy Achilles tendons tolerate a wide range of loading inputs, and well‑designed training plans rarely create problems when they respect tendon condition and the realities of sport.

The task is to maintain perspective: understand the downside, account for it, and continue to make decisions that support robust performance.

In the final installment for this series, we review the lecture from Jarrod Antflick - decision making and management for the pathological Achilles tendon.

Debrief written by: Jason Eure, PT, DPT, OCS, CSCS

REFERENCES

1) Wang S, Lyu B. Are Current Prophylactic Programs Effective in Preventing Patellar Tendinopathy in Athletes and Recruits? A Meta-Analysis and Trial Sequential Analysis. Sports Health. 2023 May;15(3):382-385. doi: 10.1177/19417381221121808. Epub 2022 Sep 22. PMID: 36146934; PMCID: PMC10170222.

2) Fredberg U, Bolvig L, Andersen NT. Prophylactic training in asymptomatic soccer players with ultrasonographic abnormalities in Achilles and patellar tendons: the Danish Super League Study. Am J Sports Med. 2008 Mar;36(3):451-60. doi: 10.1177/0363546507310073. Epub 2007 Dec 13. PMID: 18079558.