Introduction. Chronic Achilles tendinopathy is a common overuse injury. There are several modalities of treatment, reflecting difficulties in its management. In particular, due to the well-recognised morbidity associated with surgical decompression, treatment has steered towards a less invasive route. Dry needling has been efficacious in managing other tendinopathies. This study therefore assessed dry needling and percutaneous hydrostatic decompression of the Achilles tendon as a novel treatment for this condition. Methods. Twenty-two patients with 27 sonographically-confirmed chronic Achilles tendinopathy were prospectively enrolled. All were symptomatic for >6 months and have failed alternative conservative treatments. Ultrasound-guided dry needling of neovascular areas and paratenon hydrostatic decompression was performed by a dedicated musculoskeletal radiologist on a 6-weekly basis until symptomatic resolution or no improvement was evident. Sonographic assessment of the tendon's thickness and neovascularity was undertaken. Following treatment, a standardized physiotherapy regime was adopted. At baseline and 6 weeks post-final procedure, visual analogue scores (VAS) at rest and during activity were obtained. Telephonic interviews were carried out 12 and 24 months post-treatment. Results. 24 tendons (in 19 patients) were successfully treated - 1 patient had spontaneous symptomatic resolution and 2 progressed to surgical intervention. The mean number of treatment sessions was 2. There was no significant change in neovascularity or tendon thickness after treatment. Therapeutic intervention led to a significant improvement in VAS at rest (42 v 18.4, p=0.0005) and during activity (74 v 33.7, p< 0.0001). At 12 months, 77% of patients were >80% satisfied with their outcome of the procedure, with 85% of patients able to return to their sporting interests. At 24 months, 90% of patients were >80% satisfied with their outcome, with nearly half having complete symptomatic resolution. Conclusion. Dry needling and percutaneous paratenon decompression under ultrasound guidance shows promise as an alternative treatment for this chronic condition