Diagnosis of chronic Achilles tendinopathy in athletes and its treatment with prolotherapy and paratenon stripping

Chronic Achilles tendinopathy is a frequent cause of pain and functional limitation in athletes. Although progressive loading programs remain the first-line therapy, a substantial proportion of patients continue to have symptoms and seek additional options. Ultrasound is central for diagnosis and treatment guidance, allowing detailed assessment of tendon structure, peritendinous involvement, and neovascularization. Several ultrasound-guided interventions have been proposed for recalcitrant cases, including needle tenotomy, high-volume injections, and platelet-rich plasma. Among these, hyperosmolar dextrose prolotherapy and paratenon stripping using local anesthetic have emerged as potential adjunctive techniques. While preliminary prospective series have reported encouraging reductions in pain and neovascularization, the current level of evidence remains limited by small cohorts and a lack of large-scale randomized controlled trials. This review summarizes current concepts regarding the pathophysiology and imaging of chronic Achilles tendinopathy, emphasizing the role of neovascularization and neoinnervation as potential pain generators. We outline a practical approach to diagnosis using ultrasound and complementary modalities. We then describe the technical aspects of ultrasound-guided paratenon stripping and intratendinous dextrose prolotherapy, including positioning, injection targets, and post-procedural care. Finally, we appraise the clinical evidence, discuss safety, and highlight priorities for future research. Overall, ultrasound-guided prolotherapy combined with paratenon stripping represents a biologically plausible and technically feasible adjunctive option for refractory cases; however, its definitive role within clinical practice remains to be established through higher-quality comparative studies.