Achilles Tendinopathy: Education and Treatment

Imagine this: you’ve been grappling with relentless Achilles tendon pain, keeping you away from your runs or playing on the court. Your doctor labels it as the usual Achilles tendinitis, prescribing the standard pain relief treatment of ice packs, anti-inflammatory medication, and rest. But as time ticks on, you’re still left with persistent pain, and you’re left wondering if it could be chronic Achilles tendon issues. Here’s the twist — your diagnosis and the prescribed treatment plan might not be hitting the mark. Contrary to the catchy term ‘Achilles tendinitis,’ which hints at inflammation as the main culprit, your discomfort might have a broader story to tell, known as ‘Achilles tendinopathy.’ This term ditches the inflammation focus and embraces a wider range of tendon issues, including degenerative changes in the tendon, which calls for a different treatment approach. In this article, we’re lifting the curtain on these terms, helping you grasp the essence of Achilles tendinopathy management, and giving you the tools to guide your journey towards effective recovery and rehabilitation.


What It Is and How to Treat It

Achilles tendinopathy is a common lower leg issue that affects both athletes and people who are not very active. Historically known as Achilles tendinitis, this condition can cause long-lasting discomfort and frustration. In this article, we’ll explain what Achilles tendinopathy is and offer effective ways to manage it.


Achilles tendon

What Is the Achilles Tendon?

The Achilles tendon is a remarkable part of the lower leg. It starts from the calf muscles in your lower leg and foot, including the gastrocnemius and Soleus. These muscles are crucial for walking and running. The Achilles tendon is the body’s largest and strongest tendon, can handle up to 12 times your body weight when you run. (Source: Komi PV, Fukashiro S, Järvinen M. Biomechanical loading of Achilles tendon during normal locomotion. Clin Sports Med. 1992;11:521-531)

How Does the Achilles Tendon Work?

Picture the Achilles tendon like a big rubber band that connects your foot to your lower leg. It acts as an elastic power source. When your foot hits the ground, the Achilles must stay firm, like a spring, to provide stability for your calf muscles to push you forward. For this to work well, the Achilles needs a solid “truss” (the foot) to attach to. Without a stable foot, the Achilles can experience abnormal stress, leading to strain and eventually tendinopathy.

Causes of Achilles Tendinopathy

One primary cause of Achilles tendinopathy is overloading the tendon. For instance, if someone starts running for exercise and increases their distance or speed too quickly, the tendon can become strained. Tendons are designed to stretch and contract throughout the day, storing and releasing energy. However, they don’t handle twisting or torquing well while doing so. This happens when the front and rear of the foot are unstable and twist against each other. This instability affects the Achilles tendon, putting it under strain and leading to tendinopathy.

The lack of foot control isn’t solely the foot’s fault. Issues in the lower back, hips, and knees can contribute to poor foot stability. A 2011 study by Munteneau et al found  that individuals with Achilles tendinopathy often have delayed muscle activation in the lower leg, improper timing of hip muscle contractions, and reduced knee bending upon foot impact. All these problems add up, making the foot unstable for efficient movement.

Who Is at Risk for Achilles Tendinopathy?

Achilles tendinopathy can affect both active individuals and those who are less active. Athletes can develop it due to excessive training, while less active people might experience it due to weak calf and upper leg muscles. Other factors that increase the risk include hill running, speed work, poor recovery, limited ankle mobility, and weakness in the Gastrocnemius and Soleus muscles.

Considering the stress the Achilles tendon endures during daily activities and sports, it’s no wonder this injury is common. A study in 2021 by De vos et al. revealed that 2-3 people out of 1000 experience Achilles tendon symptoms. Another study by Kujala et al. found that runners have a 52% chance of encountering an Achilles injury in their lifetime. Although middle-aged male distance runners are more susceptible, sedentary individuals can also be affected.

Factors that can increase the likelihood of Achilles tendinopathy include genetics, certain medications (like Fluoroquinolones), and age.

Types of Achilles Tendinopathy

There are two main types of Achilles tendinopathy, categorized based on the location of symptoms within the tendon: 

There are two main types of Achilles tendinopathy, categorized based on the location of symptoms within the tendon.
  • Mid-portion: Pain is localized 2-7cm above the Achilles tendon’s connection to the heel bone (calcaneus).
  • Insertional: Pain is localized where the tendon attaches to the calcaneus.

Symptoms of Achilles Tendinopathy

Recognizing Achilles tendinopathy involves understanding its symptoms:

  • Pain and stiffness when getting out of bed in the morning.
  • Pain that eases as you move around.
  • Pain when squeezing the tendon (mid-portion) or pressing on the heel bone (insertional).
  • Pain during activities like running, hopping, or jumping.
  • Reduced strength, endurance, and performance.
  • Swelling and thickening of the tendon at the painful site.

Effective Treatments for Achilles Tendinopathy

There are various treatment options for Achilles tendinopathy, but not all are equally effective. It’s important to know that tendinopathies take time to heal, and patience is key. There’s no quick fix, but increasing research suggests that exercise is a powerful tool for managing Achilles tendinopathy.

Research indicates that therapeutic exercise is one of the most effective treatments for overcoming Achilles tendinopathy. Exercise has strong evidence to support its role in optimal management and should be the primary treatment for at least three months before considering other options.

Additional treatments for Achilles tendinopathy include Platelet-Rich Plasma (PRP) injections, corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs), sclerosing injections, and shockwave therapy. However, a study in 2012 by Sussmilch et al. showed that none of these treatments, when used alone, were as effective as exercise therapy.

Non-Exercise Tips for Alleviating Achilles Tendinopathy Pain

If you’re dealing with Achilles tendinopathy, consider these non-exercise strategies to reduce pain:

  • Temporarily stop activities that worsen the condition, such as running, jumping, or hopping.
  • Use a heel lift or shoes with thicker heels (e.g., Hoka) for added support.

Best Exercises for Achilles Tendinopathy

While it’s natural to want to rest when something hurts, tendons actually benefit from being loaded and gradually worked. Extended rest can weaken the tendon and increase the risk of further injury. When it comes to Achilles tendon exercises, it’s okay to feel mild discomfort, rating it between 0 (no pain) and 4/10 (mild pain) on a pain scale.

However, it’s crucial to monitor your symptoms for 24 hours after exercising. If you experience pain greater than 4/10 and increased stiffness, you may have pushed too hard. Don’t worry! This just means your previous workout was a bit excessive. Instead of quitting, simply decrease the repetitions or sets in your next session.

Phase 1: Isometric Exercises

Isometric exercises are an excellent way to start strengthening an irritated Achilles tendon. These exercises help manage pain while gradually loading the tendon.

Standing Calf Raise Holds:

  • 5-10 repetitions, hold for 10-30 seconds
  • Rest for 30 seconds between each repetition
  • Perform every other day

Wall Sit with Elevated Heel:

  • Keep knees at a 45-degree angle with your back supported against the wall
  • 5-10 repetitions, hold for 10-30 seconds
  • Rest for 30 seconds between each repetition

Phase 2: Isotonic Exercises

During this stage, you’ll introduce movement while building strength and capacity in the tendon.

Calf Raise Off the Ground:

  • Raise your heels for 3 seconds and lower them for 3 seconds

Calf Raise Off a Step:

  • Perform calf raises on a step, lifting your heels for 3 seconds and lowering them for 3 seconds

Phase 3: Building Tendon Capacity

This phase is crucial to prepare the tendon for the forces it experiences when your foot hits the ground while running. Remember, when you run, almost 3 times your body weight is transmitted through your body upon each foot impact. These exercises help the tendon adapt to these demands.

High-Load Calf Raises:

  • Perform 3 sets of 6-8 repetitions with a moderate to heavy load
  • Ideal with a Smith machine


Achilles tendinopathy is a common condition that affects both active individuals and those who are less active. Understanding the causes, symptoms, and effective treatments can help manage this issue and prevent it from interfering with your daily life. Remember, exercise is a key player in the management of Achilles tendinopathy, so stay patient, consistent, and consult a healthcare professional for personalized guidance.

Frustrated by achilles stiffness and pain holding you back from your daily run? Sick and tired of letting your tennis partner know you cant make  the match, AGAIN because your achilles is on fire?

If this sounds like you, then take the first step to getting to back to the active lifestyle you desire, by taking advantage of our Discovery Session! It’s a Free 20 minute call with one of our specialist physical therapists to determine if we are the right solution of your pain.

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