Achilles Tendinopathy: Causes, Symptoms and Treatment

At a Glance

Achilles tendinopathy is one of the most common overuse injuries in active people, affecting 4 to 7% of the general population and up to 43% of elite athletes. It causes pain and stiffness in the Achilles tendon, typically after periods of rest and during or after exercise. A structured, progressive exercise programme is the most effective treatment and is the starting point for most people regardless of severity.

What is Achilles Tendinopathy?

The Achilles tendon is the strongest and largest tendon in the body. It connects your calf muscles (gastrocnemius and soleus) to your heel bone (calcaneus) and is essential for walking, running, and jumping. Achilles tendinopathy occurs when the tendon becomes painful and its normal tissue structure is disrupted, usually as a result of repetitive overloading.

The term "tendinopathy" is preferred to older terms like "tendinitis" (which implies acute inflammation) or "tendinosis" (which implies degeneration), because the actual tissue changes are more complex and this distinction helps guide treatment.

There are two main types:

• Midportion tendinopathy: Pain in the mid-section of the tendon, 2 to 6 centimetres above the heel bone. This is the most common type.
• Insertional tendinopathy: Pain at the point where the tendon attaches to the heel bone. This type is somewhat different in how it behaves and responds to treatment.

Who Does It Affect?

Achilles tendinopathy is particularly common in:

• Runners (especially middle-distance and long-distance)
• People who have recently increased their training load, intensity, or changed their running surface
• Those who participate in jumping sports (basketball, volleyball, court sports)
• People over 35, as tendons become stiffer and less resilient with age
• Those with tight calf muscles, flat feet, or biomechanical factors that increase Achilles loading
• People who have recently changed their footwear or started wearing minimalist running shoes without adequate transition

It is more common in men than women, and obesity, diabetes, and certain medications (particularly fluoroquinolone antibiotics) are known risk factors.

Symptoms

The characteristic pattern of Achilles tendinopathy is:

• Morning stiffness or pain with the first steps after getting out of bed
• Start-up pain that improves after a few minutes of activity — the tendon "warms up"
• Pain during or after exercise that may worsen as activity continues or with increased intensity
• Tenderness when you press on the tendon, particularly at a specific point
• Occasional swelling or thickening of the tendon that can be felt or seen

If you feel or hear a sudden snap or pop in the back of your leg during activity, and cannot stand on tiptoe or walk normally, stop all activity and seek urgent assessment. This may indicate a tendon rupture, which requires prompt treatment.

How Is It Diagnosed?

Your podiatrist will diagnose Achilles tendinopathy through:

• History: When the pain started, your activity levels and training history, footwear, and any changes in routine
• Physical examination: Palpating the tendon to find the precise location of tenderness, assessing calf muscle flexibility and strength, checking ankle range of motion, and observing your walking pattern
• VISA-A questionnaire: A validated tool that measures the severity of Achilles symptoms and tracks progress over time

Ultrasound imaging is often used to confirm the diagnosis, measure tendon thickness, and rule out a partial tear. MRI provides more detail if the diagnosis is uncertain or a tear is suspected.

Treatment Options

Treatment of Achilles tendinopathy centres on progressive tendon loading — gradually increasing the demands on the tendon to stimulate tissue adaptation and recovery. This is quite different from simply resting, which tends to weaken the tendon further.

First-line treatment — exercise rehabilitation:

A structured exercise programme is the most evidence-based treatment for Achilles tendinopathy. Your podiatrist or physiotherapist will design a programme tailored to your stage of recovery. This typically includes:

• Isometric exercises (holding contractions without movement) — useful in early, painful stages to provide pain relief and maintain muscle function
• Eccentric exercises (slowly lowering from tiptoe) — strong evidence, particularly for midportion tendinopathy
• Heavy slow resistance (HSR) training — equally effective to eccentric and often more practical; involves slowly raising and lowering on your toes under load

The programme progresses over 12 to 16 weeks. It is normal to experience some discomfort during exercise, but pain levels should not significantly increase, and any post-exercise soreness should settle within 24 hours.

Adjunct treatments:

• Heel raises: Temporary use during early stages can reduce pain by offloading the tendon (particularly helpful for insertional tendinopathy)
• Manual therapy: Joint mobilisation around the ankle and foot can reduce pain and complement exercise
• Dry needling: Can be helpful for associated calf muscle tightness

Second-line treatments (if exercise alone is insufficient after 3 months):

• Shockwave therapy (ESWT) — good evidence for midportion tendinopathy that has not responded adequately to exercise
• Low-level laser therapy

Third-line (for chronic, refractory cases):

• Ultrasound-guided PRP (platelet-rich plasma) injection — emerging evidence
• Surgery (tendon debridement or repair) — reserved for cases unresponsive to 12 months of structured treatment

What does NOT work:

• Rest alone — the tendon needs graduated loading to recover
• Corticosteroid injections — provide short-term pain relief but are associated with tendon weakening and increased rupture risk; not recommended for Achilles tendinopathy
• Therapeutic ultrasound alone — not effective in isolation

Self-Care and Home Management

• Follow your prescribed exercise programme consistently — adherence is the single most important factor in recovery
• Modify activity rather than stopping completely. Replace high-impact activity (running) with lower-impact alternatives (swimming, cycling) to maintain fitness during rehabilitation
• Wear supportive footwear with a mild heel raise, particularly in the early stages
• Avoid walking barefoot on hard floors, especially in the mornings when the tendon is at its stiffest
• Stretch your calves gently after activity, not before
• Monitor your pain levels using the VISA-A or a 0 to 10 pain scale and use this to guide loading decisions

When to See a Podiatrist

See a podiatrist promptly if:

• You experience a sudden snap or pop in the Achilles area — this may indicate a rupture
• Tendon pain has not improved after 4 to 6 weeks of appropriate self-management
• Pain is affecting your ability to walk normally
• You have swelling, heat, or tenderness that is worsening rather than improving
• You have diabetes, peripheral neuropathy, or are taking fluoroquinolone antibiotics

Prognosis and Recovery

Recovery from Achilles tendinopathy takes longer than most people expect:

• Mild to moderate cases: Meaningful improvement in 8 to 12 weeks with a structured programme
• Chronic or severe cases: Full recovery can take 6 to 12 months or longer
• Re-injury risk is significant if rehabilitation is incomplete or return to sport is too rapid

The key message is that consistency with loading exercises, even when the tendon is sore, produces better outcomes than repeated periods of rest. Progress should be monitored using a validated tool (VISA-A) and loading adjusted accordingly.

Prevention

• Increase training load gradually — the 10% rule (increase weekly mileage by no more than 10% per week) provides a guide, though individual tolerance varies
• Incorporate calf strength and flexibility work into your regular training
• Ensure your footwear is appropriate for your foot type and activity
• Transition slowly to minimalist or lower-drop footwear
• Include adequate recovery time between high-intensity sessions

Further Reading

• Achilles Tendinopathy — Better Health Channel (Victoria)
• Achilles Tendon Pain — OrthoInfo (AAOS)
• VISA-A Questionnaire — University of Melbourne