Achilles Tendinopathy

Achilles Tendinopathy

Article by J.Miller, Z.Russell

What is Achilles Tendinopathy?

(Aliases: Achilles tendonitis, Achilles tendonitis, Achilles tendon pain, Achilles tendinosis, Achilles tendinopathy)

Most health experts now use Achilles tendinopathy to include both inflammation (tendonitis) and other Achilles tendon pathologies.

But many people may still use the term tendonitis out of habit.

Achilles Tendinopathy is usually an overuse injury common especially to joggers and jumpers, due to the repetitive action and so may occur in other activities requiring repetitive work.

What Causes Tendon Pain?

Tendons are the tough fibres that connect muscle to bone. Most tendon injuries occur near joints, such as the shoulder, elbow, knee, and ankle. A tendon injury may seem to happen suddenly, but usually, it results from many tiny tears to the tendon that have occurred over time. Health professionals may use different terms to describe a tendon injury. You may hear:

Tendonitis (or Tendinitis): This means “inflammation of the tendon,” but inflammation is rarely the cause of your tendon pain.

Tendinosis: This refers to tiny tears in the tissue in and around the tendon caused by overuse.

What Causes Achilles Tendinopathy?

Achilles tendinopathy is an overuse injury common especially to joggers and jumpers due to the repetitive action and so may occur in other activities requiring repetitive work.

Most tendon injuries are the result of gradual wear and tear to the tendon from overuse or ageing. Anyone can have a tendon injury, but people who make the same motions repeatedly in their jobs, sports, or daily activities are more likely to damage a tendon.

A tendon injury can happen suddenly or little by little. You are more likely to have a sudden injury if the tendon has weakened over time.

Common Causes of Achilles Tendonitis include:

  • Over-training or unaccustomed use – “too much too soon.”
  • An excessive intensity or distance increase
  • Change in training surface – e.g. grass to bitumen
  • Lack of training variation
  • Poorly supportive footwear.
  • Hill running.

Achilles Tendinopathy Risk Factors

  • Gender: Men > Women
  • Age: >30 most common
  • Weight: Higher body weight increases the risk
  • Diabetes
  • Calf Muscle: weakness, poor endurance &/or tightness
  • Poor Lower Limb Muscle Control: e.g. Poor hip and knee muscle control
  • Stiff Ankle/Foot Joints

What are the Symptoms of Achilles Tendinopathy?

Achilles tendinopathy may commence as a burning pain at the beginning of an activity, which gets less during the event and then worsens following the event. The tendon may feel stiffness first thing in the morning or at the beginning of some exercise.

  • Achilles tendinopathy usually causes pain, stiffness, and loss of strength in the affected area.
  • The pain may get worse when you use your Achilles tendon.
  • You may have more pain and stiffness during the night or when you get up in the morning.
  • Your Achilles may be tender, red, warm, or have a swollen lump on your Achilles tendon.
  • Variable pain. Achilles pain can vary significantly depending upon your exercise load.

How is Achilles Tendinopathy Diagnosed?

Achilles tendinopathy is one of many causes of lower calf or heel pain. The correct diagnosis is vital to your treatment plan and recovery! Would you please seek the professional opinion of your trusted physiotherapist or sports doctor? They will base their determination on your history, symptom behaviour and clinical tests. You will rarely require diagnostic imaging in most cases of Achilles tendinopathy. In some cases, your health practitioner may recommend an MRI or diagnostic ultrasound in refractory cases. Achilles tendons will often have a painful and prominent lump within the tendon.

Tendinopathy Phases

Tendinopathy is a continuum of pathological processes. Your treatment plan progresses by correct identification of the current phase of injury and the application of appropriate exercise in the rehabilitation of your injury. Inappropriate loading may delay your recovery and your return to sport.

Identifying the phase helps identify an entry point for your rehabilitation and how much you can perform in your recovery and balance your activity levels in your rehabilitation plan.

It is crucial to have your tendinopathy professionally assessed to identify your injury phase. Identifying your tendinopathy phase is also vital to direct your most effective treatment since specific modalities or exercises should only be applied or undertaken in distinct tendon healing phases.

Please seek the advice of your trusted physiotherapist with a particular interest in Achilles tendinopathy.

Achilles Tendinopathy Treatment

Achilles tendinopathy treatment varies significantly from how we treated the condition just a few years ago. Researchers are continually updating their treatment recommendations. Based upon that, our Achilles tendinopathy treatment protocols we regularly upgrade to the latest research-supported versions.

Achilles tendinopathy treatment can become complicated due to the high level of recurrence and patient variables. Achilles treatment varies depending on where you are within the tendon injury phase continuum, as outlined above. The secret to a quick path to success is correctly assessing what phase you are currently in and prescribe the appropriate exercises and advice suitable for that phase. That’s exactly where the support of an up-to-date Achilles physiotherapist can fast-track your rehabilitation success.

How is Your Rehabilitation Progress Monitored?

Your physiotherapist is highly skilled in the management of Achilles tendinopathy. They aim to guide you towards a return to sport safely. Among other tests, your physiotherapist will use your pain provocation tests, strength measures, and functional activities as a valuable tool to monitor your pain, function and when to progress exercises or return to sport.

They’ll also be happy to discuss your injury rehabilitation with your coach.

How Do You Treat Achilles Tendinopathy?

Achilles tendinopathy treatment has progressed significantly in recent years. It is essential to ensure that an up-to-date Achilles tendinopathy physiotherapist treats you.


There is increasing importance in exercise in the management of tendinopathy. Isometric exercise, or exercise in the joint angle and muscle length that does not change during use, have proven pain relief effects for athletes suffering from tendinopathy.

How Does Your Physiotherapist Progress Your Treatment?

Tendinopathy treatment is progressed based on your tendon’s ability to withstand your exercises load. For most athletes, the traffic light system defines how much training is too much clearly.

Red will indicate that you need to reduce your exercise load. Amber suggests that you can exercise at your current limitations. Green indicates that you can safely increase your exercise loads.

Your physiotherapist will explain how to interpret your symptoms and plan your exercise loads based upon their assessment and your symptoms.

Managing Your Activity Load is a Priority!

Exercise load monitoring is crucial to the success of your Achilles tendinopathy. Mild load increases will stimulate new tendon growth. In contrast, overload leads to tendinopathy deterioration.

Reduce the load to a level that allows the tendon to recover. This may mean total rest from your sport or modifying training depending on tendinopathy severity in severe cases. Discuss your activity load with your physiotherapist, who will plan and adjust your program accordingly, based upon your pain provocation tests, traffic light response to activity and other symptoms.

When managing load, you should be guided by how the tendon responds immediately and 24 hours later. Tendons are known to have a latent response to loading. This latency means they can take 24 hours or more to react. It is essential to modify your activity to remain pain-free during and after 24 to 48 hours.

For more specific information, please discuss your Achilles tendinopathy with your physiotherapist.

How Long Does it take for Achilles Tendinopathy to Heal?

If you identify your Achilles tendon injury in the early stages, load management and reduction will allow the tendon time to adapt and quickly recover. The reactive stage can be relatively short. Pain may settle in 5 to 10 days, but the tendon will still be sensitive to high loads, and training needs gradual progression to prevent relapse. It mustn’t progress into late-stage two or stage 3 tendinopathy. These tendinopathies require additional time and rehabilitation.

A likely return to sport is in the order of 12 weeks. However, everyone is very different!

There is no specific time frame for when to progress from each stage to the next. Many factors will determine your Achilles tendonitis rehabilitation status during your physiotherapist’s clinical assessment and reviews. In most cases, you’ll find that your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improves.

It is also important to note that each progression requires carefully monitored as attempting to progress too soon to the next level can lead to re-injury and frustration. The severity of your tendon injury, your compliance with treatment, and the workload you need to return will ultimately determine how long your injury takes to rehabilitate successfully.

When Will Your Achilles Tendinopathy Heal?

Some practitioners suggest that the tendinopathy phase can sum up the prognosis with guided treatment:

  • Phase I: days
  • Phase II: weeks
  • Phase III: months
  • Phase IV: years

Achilles Tendinopathy – What Exercises to Avoid!

Avoid exercises that provoke your pain, such as running up hills or stairs, sprinting, jumping, hopping and deep squats until advised otherwise by your physiotherapist.

Massage, Foam Rollers & Stretches

Massage or foam rollers can release your calves, shins, quadriceps, ITB, and hamstrings, which may assist in cases of Achilles tendinopathy. You can perform these in positions that avoid ankle hyperdorsiflexion. Ask your physiotherapist for specific advice.

Eccentric Strengthening

Eccentric exercises were, for many years, the “go-to” exercises for tendinopathy rehabilitation. While important, premature or overloaded eccentric exercises can delay your recovery. Your physiotherapist will guide you when appropriate. They aim to commence strengthening that does not aggravate your Achilles tendinopathy. They may start you with isometrics to avoid tendon compression and progress from there towards a basic and then advanced eccentric exercise program.

Adjacent Joints & Lower Limb Biomechanics

Researchers have identified several lower limb biomechanical issues that may predispose you to Achilles tendinopathy. Tests may include your ankle dorsiflexion, single-leg squat alignment and control, gluteal control, hip/knee bend ratio and running and landing technique. Your physiotherapist will individually assess you. They’ll advise you if you require some treatment to address any deficiencies.

Other Treatments

Novel therapies such as the injection of sclerosing agents, platelet-derived growth factor (PDGF), and autologous blood into diseased tendons have shown potentially promising results. However, more clinical trials are needed, so it is still considered experimental at this time. Your physiotherapist is happy to discuss these options with you when they find an appropriate treatment option.

Remember, all tendinopathies are different. Please seek the advice of your Achilles tendinopathy physiotherapist. They will assist you in determining the best rehabilitation appropriate to your tendinopathy.

Can Your Achilles Tendon Rupture?

The worst-case scenario is a total rupture of your Achilles tendon, which occurs when tendon cell death occurs, and the tendon strength is insufficient. Treatment, in this case, may require surgery, plaster or a wedged walking boot for at least six weeks. Most of these injuries take six months or more to rehabilitate adequately, so avoiding Achilles tendon rupture remains the best option.

The best advice is to seek early advice from your physiotherapist to do all you can to avoid this nasty rupture happening in the first place.

More info: Achilles tendon rupture.