What is Achilles Tendinopathy?
Achilles tendinopathy is a common, painful overuse injury of the Achilles tendon. It causes pain, stiffness and swelling, often worse after rest or activity, due to microtrauma and failed collagen healing. Treatment involves rest, physical therapy, and occasionally anti-inflammatories.
Achilles tendonitis seems to occur more often in men, and knowing a person’s medical history can help identify those at higher risk, based on various risk factors. Running with Achilles tendinopathy is a frequent concern for athletes and other active people. It can also affect less active individuals, causing ankle pain and pain in the back of the heel.
Thankfully, there are management strategies available for Achilles tendinopathy from expertly trained physiotherapists, like those at HelloPhysio.
Quick facts: About 1 in 4 athletes will deal with this at some point, usually between the ages of 30 and 50. It peaks around 40-44 years old. Sports that involve a lot of running or jumping, such as basketball, tennis and football, have the highest rates and are risk factors.
Anatomy of the Achilles Tendon
The Achilles tendon is the strongest tendon in your body, connecting your calf muscles to your heel bone. This tendon connects the muscles to the heel and is essential for things we do every day, like walking, running and jumping. Unfortunately, it doesn’t receive a good blood supply, so once it’s damaged, healing can be slow and frustrating.
Different Types of Achilles Tendinopathy
Symptoms of Achilles tendinopathy presentation vary by type.
Mid-portion (non insertional achilles) tendinopathy occurs 2 to 7cm above the heel in the lower leg. Achilles tendinopathy symptoms include discomfort during or after activity, which may temporarily ease with warm-up but worsen with continued activity, leading to pain throughout the Achilles tendon.
Insertional Achilles tendinopathy occurs where the tendon attaches to the heel bone at the back of the heel, rather than higher up. This condition is often sensitive to shoe pressure, compression, or uphill walking and requires load modification. Bone spurs can be associated with this type of problem.
Treatment is slightly different for each type of Achilles tendinopathy, as the amount of stress and the load the Achilles tendon can handle vary.
Symptoms of Achilles Tendinopathy
Achilles tendinopathy symptoms are often worse first thing in the morning or after you’ve been active, and you might notice some swelling or thickening in that spot. Weakness, burning sensation, heel ache, stiffness and soreness are common symptoms of Achilles tendinopathy.
However, if you get a sudden, sharp sensation, hear a ‘pop,’ or experience immediate swelling or weakness, that could mean an Achilles tendon rupture, and you need to get medical help right away. Tendon rupture is a serious concern.
How Severe Is It?
Not all Achilles pain is the same. Here’s a simple way to think about severity:
| Degree | What It Feels Like | Can You Still . . . | What Helps |
| Mild | Hurts during or right after activity | Finish your workout (with some discomfort) | Backing off a bit, stretching, gentle strengthening |
| Moderate | Swelling sticks around; you might feel a lump; mornings are rough | Do some things, but performance suffers | Structured Achilles tendinopathy exercises, hands-on therapy, and possibly advanced treatments |
| Severe | Even walking hurts | Forget about sports; daily life is hard | Intensive Achilles tendinopathy rehab, maybe Achilles tendinopathy surgery if nothing else works |
Watch out for a rupture. In the worst cases, an Achilles tendon rupture can completely tear. You’ll know it. It feels like someone kicked you hard in the back of the heel, and suddenly you can’t push up on your toes. That’s a medical emergency.
What Causes Achilles Tendinopathy?
Primary Causes
Doing too much, too fast: This is the main reason. Maybe you had a sudden increase in running distance, or you’re one of those “weekend warriors” who sit all week then go hard on Saturday. Your tendon simply can’t keep up with the sudden demand and starts causing pain.
Foot mechanics that aren’t ideal: If you have flat feet, your arch collapse pulls on your calf muscles, which keeps your Achilles under constant tension. High arches or tight calf muscles can cause problems, too, or anything that puts extra strain on the tendon during normal movement.
Your shoes: Worn-out shoes are a real issue. This includes wearing beat-up sneakers (replace them every 400-500 miles), suddenly switching to minimalist shoes, or wearing high heels regularly. If you wear high heels a lot, especially anything over 5 cm, you’re shortening your calf muscles and making your Achilles tendons stiff. That sets you up for injury. Stretch daily with calf stretches if heels are part of your work wardrobe.
Getting older: Between 30 and 50, your tendons just don’t bounce back as well as they used to. If you’re in this age range, you need to be more careful about addressing risk factors early to prevent Achilles tendinitis.
Medication and Systemic Risks
Certain antibiotics: Fluoroquinolone antibiotics (such as Cipro, Levaquin, and Avelox) can significantly increase the risk of Achilles tendon problems, including ruptures. The risk is highest if you’re over 60, taking steroids, or have had an organ transplant. If you’re on one of these antibiotics and your Achilles starts hurting, call your doctor right away and stop taking it.
Inflammatory arthritis: Conditions such as ankylosing spondylitis, psoriatic arthritis, or reactive arthritis can trigger Achilles tendon problems. The pattern is different: both Achilles tendons usually hurt, morning stiffness lasts more than an hour, and you might also have back pain or skin issues. This needs a rheumatologist, not just local treatment.
The Difference Between Achilles Tendinopathy and Tendonitis
Another related issue, Achilles tendinitis, can also cause heel and ankle pain and is both related to and sometimes confused with Achilles tendinopathy. Understanding Achilles tendinopathy vs tendonitis is essential for proper treatment of Achilles issues.
Think of Achilles tendinitis as the initial stage, that sharp, painful inflammation and swelling, the acute problem. Tendinopathy, on the other hand, is the bigger, often long-term issue where chronic Achilles tendinopathy develops, and the tissue itself has started to break down and become disorganized, sometimes progressing to Achilles tendinosis.
The main distinction is simple: inflammation versus structural wear and tear. Because of this, the treatments are completely different: anti-inflammatory meds help with tendinitis, but they can actually harm the chronic tendinopathy, which really needs targeted, progressive Achilles tendinopathy exercises to rebuild load and strength.
When Should You See a Physiotherapist?
See a physiotherapist if:
- Pain’s been hanging on for more than two weeks
- Mornings are getting worse instead of better
- It’s messing with your daily life or keeping you from exercise
- You think you might have a tendon rupture (heard or felt a “pop,” can’t stand on your toes)
The sooner you get help, the shorter your recovery will be. Putting it off just makes everything take longer and raises your chances of needing surgery.
Diagnosing Achilles Tendinopathy
Our physiotherapist will likely start with a thorough check of the sore area. They will pinpoint the source of the discomfort, feel for any thickening, and test the strength of your calf muscles. They will also assess how well your ankle moves and its range of motion. Sometimes they might ask you to do functional tests, such as standing on one leg and raising your heel.
If issues are severe, haven’t improved with standard treatment, or if there’s concern about a tear, you might need imaging tests like an ultrasound or MRI.
Treating Achilles Tendinopathy
At HelloPhysio, we treat Achilles tendonitis with a combination of targeted exercises, manual physical therapy, and advanced treatments, including Shockwave Therapy and INDIBA®. This comprehensive, all-around Achilles tendinopathy treatment strategy is designed to speed recovery, reduce pain effectively, and help prevent recurrence, covering every step of the healing process.
At Home PEACE & LOVE
Forget the old RICE method. Modern Achilles tendonitis treatment has shifted to PEACE & LOVE
PEACE (first few days):
- Protect: but don’t stop moving completely
- Elevate your foot when you can
- Anti-inflammatories: Inflammation is actually part of the healing, so skip the NSAIDs
- Compress: with an elastic bandage
- Educate yourself about what’s happening
LOVE (ongoing):
- Load: gradually as pain allows; mild cases can still do some activity, severe cases need complete rest from what’s aggravating it
- Optimistic: your mindset matters
- Vascularization: Get your blood flowing with pain-free cardio like swimming or cycling to promote healing
- Exercise is key. Progressive loading is what fixes chronic Achilles tendinopathy
Prescribed Exercise Progression
Managing this common issue comes down to carefully adjusting the load you put on the area and reducing strain. This is key to starting the healing process while making sure you don’t lose strength. You need to gradually introduce specific rehabilitation exercises, especially those heavy-slow resistance ones. These exercises are crucial for encouraging tissue remodeling and strengthening it against future strain.
The secret is finding exercises that your body can handle and keeping them well within a comfortable range. This approach helps heal properly without causing painful flare-ups.
While temporarily cutting back on activity helps ease discomfort, truly recovering means sticking to a prescribed strengthening program and physical therapy to rebuild strength and capacity. Achilles tendinopathy recovery time depends on the level of consistency. Hands-on manual therapy can also be beneficial for improving your ankle’s range of motion and the way the tissue glides. A little bit of discomfort during this process is normal, but it should never be unbearable.
Adjunct Modalities
When you have chronic Achilles tendinopathy, you can speed up recovery with some advanced modalities:
- Extracorporeal Shockwave Therapy for Achilles tendonitis stimulates cellular repair and gets the blood flowing to reduce discomfort and promote healing
- INDIBA radiofrequency increases the circulation for vasodilatation to get the healing started
- Dry Needling targets the calf muscles and leg muscles, tension that might be putting too much load on the area
- Extracorporeal Magnetic Transduction Therapy (EMTT) stimulates deep tissue regeneration in particularly stubborn cases
Using a heel lift while recovering can help decrease the load. Steroid injections may be considered but are generally avoided. A walking boot may help in severe cases.
Footwear & Orthoses
Footwear matters more than you’d think. Picking the right footwear is one of the most crucial steps to preventing or managing Achilles tendinopathy. You want good-quality, supportive shoes with a 1.2 to 2.5 cm heel-to-toe drop, good arch support, a firm heel cup, and decent cushioning. You need to wear supportive, comfortable, good-quality shoes that provide proper support and cushioning to help reduce strain.
Make sure to toss out any worn-out shoes, as they do not provide the support you need and could lead to problems like retrocalcaneal bursitis or Haglund’s deformity. Even for walking around or light exercise, supportive shoes can make a significant difference and reduce strain on your lower legs.
If you are already feeling issues, adding heel lifts or orthotics can provide extra relief and support for your foot. Arch supports help too. Aim for a heel gradient of about 3.8 cm; that level of lift is usually enough to take the pressure off your Achilles tendon.
Steroid Injections
Avoid steroid injections for Achilles tendinopathy. They significantly raise rupture risk, offer poor long-term benefit, and weaken the tendon. Steroid shots into the Achilles tendon are generally a bad idea. They significantly increase your risk of rupture, don’t help much in the long term, and can weaken the tendon. The Achilles tendon is different from other tendons in this way. Alternatives like PRP or ACP injections exist for chronic cases, but the evidence is weak. Exercise remains the most effective treatment.
Surgical Intervention
If conservative treatments have not helped, considering Achilles tendinopathy surgery might be the next step. The goal of surgery is to relieve ongoing issues by repairing or removing damaged tissue, thereby helping the area heal. The choice of surgery depends on the extent of the damage, with options ranging from minimally invasive procedures to grafting for more complex cases to restore function.
Achilles Tendinopathy Rehab & the Return to Sport
Getting over this condition typically takes weeks to months for full Achilles tendon recovery, so you need to be patient. It’s a marathon, not a sprint. Once discomfort and swelling have begun to settle, you can slowly reintroduce more demanding activities.
A critical part of this recovery is strengthening your calves through physical therapy. However, to ensure you move correctly, you also need to build up strength in your hips and core.
Pay attention to your walking and make sure your footwear is supportive enough to prevent unnecessary strain as you work your way back to full fitness. It’s normal for issues to wax and wane as you increase your load, but running in particular should be reintroduced very gradually. Sticking with a structured physical therapy program is the best path to recovery, even though you should expect some initial discomfort as you progress.
How Long Does Recovery Take?
Recovery from an Achilles tendinopathy injury takes time. Be patient. This takes time:
- Mild cases: 6-12 weeks if you manage things properly, with a gradual return over 3 months
- Moderate cases: 3-6 months of structured rehab, possibly with advanced treatments, returning to sport around 4-6 months
- Severe/chronic cases: 6-12 months of comprehensive care; if things aren’t better by 6 months, surgery might come up; after surgery, figure 10 weeks to normal activities, 3-6 months to competitive sports
To speed recovery, prioritize early intervention, regular exercise, fixing biomechanical issues, supportive footwear, and lower-impact fitness. What speeds recovery: Catching it early, doing your exercises religiously, fixing biomechanical issues, wearing proper shoes, and staying fit through other activities. Recovery is significantly delayed by pushing through pain (the biggest mistake), skipping treatment, rushing back, and ignoring the underlying problem, which also increases rupture risk.
Critical point: Working through pain doesn’t make you tough. It makes recovery take way longer and raises your rupture risk dramatically.
Risk & Complications
Untreated Achilles problems can spiral:
- The tendon degenerates further (tendinosis)
- Complete rupture becomes more likely and is at a higher risk
- Chronic pain that won’t quit
- It comes back. 20-30% of people see it return if they don’t fix the root causes (poor mechanics, skipping maintenance exercises, wrong shoes, training errors)
People with psoriatic arthritis or similar conditions need to be extra careful, as their risk is already higher.
Lifestyle Modifications and Home Care
Simple life changes make a big difference. Some simple changes make a big difference:
- Switch activities: Swap running for swimming, cycling, or water jogging while healing. Gradually increase activity. Don’t make sudden jumps. If something hurts, stop.
- Stretch regularly: Daily calf and ankle stretches help. Do them after warming up, never on cold muscles. Hold each stretch for at least 30 seconds. Stretch daily to prevent issues.
- Wear supportive shoes: All day, not just for exercise. Replace athletic shoes regularly. That 1.2 to 2.5 cm heel drop matters. If you’re wearing heels regularly, keep them under 2 inches and stretch daily.
- Watch your weight: Extra pounds mean extra strain on the tendon. Even modest weight loss can improve symptoms of Achilles tendinopathy.
The “Weekend Warrior” Problem
If you’re inactive all week, then go hard on weekends, you’re asking for trouble. Your tendons need consistent stimulus to adapt. A better approach is to walk or cycle for 20-30 minutes 3-4 times during the week, warm up for 10-15 minutes before weekend activities, increase intensity gradually, and stick with low-impact alternatives during recovery.
Preventing Recurrence
To prevent issues from recurring, you will need to focus on building your strength and on how much load your ankle can handle. Preventing Achilles tendinopathy is key, whether you’re an athlete or not. Whether you’re an athlete or just want to stay pain-free, prevention matters.
Maintain lower body flexibility and strength. Increase training gradually, following the 10% rule (no more than 10% weekly increase). Don’t jump up more than 10% per week. Always warm up and cool down, replace worn shoes, and maintain a healthy weight. Most importantly, address stiffness or minor pain immediately.
Don’t ignore early warning signs. A little stiffness or minor pain is much easier to fix than full-blown tendinopathy. Early symptoms are far easier to treat than severe tendinopathy.
How HelloPhysio Can Help
If your tendon pain lasts longer than 2 weeks, or if you notice your morning stiffness worsening, please get in touch with our physiotherapy clinic. If these issues are seriously interfering with your daily life, if you want to play sports, or if you are worried you might have a tear or a complete Achilles tendon rupture, it’s crucial to get it looked at right away.
Getting an early start with physical therapy can significantly cut down your recovery time and lessen the chance of needing surgery.
HelloPhysio provides personalized Achilles tendinopathy physiotherapy, utilizing the best available technology alongside expert rehabilitation to tackle your condition and the root causes of the problem. Schedule your appointment today for comprehensive treatment for Achilles tendinopathy.