Achilles tendinopathy is a common overuse injury that affects the Achilles tendon – the thick, fibrous band that connects the calf muscles to the heel bone. This condition typically presents as pain, stiffness, and reduced function in the back of the lower leg, especially with activity. It is often seen in runners, athletes, or anyone who increases their physical activity too quickly.

Achilles tendinopathy can be acute (short-term) or chronic (long-term). It is generally classified as:

• Mid-portion tendinopathy: pain 2-6 cm above the heel bone
• Insertional tendinopathy: pain at the point where the tendon attaches to the heel

The Achilles tendon is the largest and strongest tendon in the body. It connects the calf muscles to the heel bone. It allows you to walk, it allows running, jumping , and helps you rise onto your toes by transmitting force from your calf muscles to your foot. Despite its strength, the Achilles tendon is prone to overuse injuries due to the high loads it experiences during activity (Contreras-Hernandez et al., 2022).

Common signs and symptoms of Achilles tendinopathy include:

• Gradual onset of pain and stiffness in the back of the heel or lower calf
• Pain that worsens with activity, especially running, jumping, or climbing stairs
• Morning stiffness or pain after periods of rest
• Tenderness when pressing on the tendon
• Swelling or thickening of the tendon
• Reduced strength and performance in the affected leg

Achilles tendinopathy typically develops due to repetitive stress or overuse of the tendon. Common causes and risk factors include:

Intrinsic Factors (related to the individual):

• Poor ankle or foot biomechanics (e.g., flat feet, high arches)
• Calf muscle weakness or tightness
• Decreased ankle joint mobility
• Age (more common in people over 30)
• Previous Achilles tendon injuries

Extrinsic Factors (related to external influences):

• Sudden increase in training volume or intensity (load)
• Inadequate warm-up or poor recovery
• Running on hard or uneven surfaces
• Inappropriate or worn-out footwear
• Poor training technique

While not all cases can be prevented, there are several steps you can take to reduce your risk:

• Gradually increase training load to allow the tendon to adapt (Beyer et al., 2015)
• Include calf strengthening and stretching exercises in your routine (Springer Open, 2022)
• Maintain good ankle and foot biomechanics (orthotics may be helpful in some cases)
• Use supportive footwear appropriate for your activity
• Warm up properly and include rest or recovery days
• Address any muscle imbalances or mobility restrictions

Several other soft tissue injuries can present with similar symptoms to Achilles tendinopathy, making an accurate diagnosis essential:

• Achilles Tendon Rupture: A sudden and severe injury that causes the tendon to tear completely.
• Plantar Fasciitis: Inflammation of the plantar fascia, causing heel pain.
• Retrocalcaneal Bursitis: Inflammation of the bursa located between the Achilles tendon and the heel bone.
• Calf Muscle Strain: Injury to the calf muscles, causing pain in the back of the leg.

Physiotherapy plays a key role in the effective management of Achilles tendinopathy. Treatment is typically tailored to your individual needs and stage of injury. A physiotherapy program may include:

• Load Management: Modifying activities to reduce strain on the tendon without complete rest. Gradually reintroducing higher-load activities as tolerated (Contreras-Hernandez et al., 2022)
• Exercise Therapy: Stretching the calf and associated muscles. Heavy, slow resistance training (e.g., calf raises) to strengthen the tendon and stimulate healing (Springer Open, 2022). Eccentric loading exercises are particularly effective for mid-portion tendinopathy (Rompe et al., 2008). Isometric exercises to reduce pain in the early stages (BMJ Open protocol, 2022)
• Manual Therapy: Soft tissue massage or mobilisations to address tightness and improve range of motion (Contreras-Hernandez et al., 2022)
• Biomechanical Correction: Addressing foot posture, gait abnormalities, or poor running technique (Contreras-Hernandez et al., 2022). Possible recommendation of orthotics or footwear adjustments
• Pain Management: Use of ice, non-steroidal anti-inflammatory medications (if advised by a doctor), or taping to help manage symptoms (Contreras-Hernandez et al., 2022).
• In some chronic or persistent cases, adjunct therapies such as shockwave therapy may be considered; adding shockwave to eccentric training improved outcomes versus eccentric alone (Rompe et al., 2008)
• Education: Helping you understand your condition, how to monitor symptoms, and how to avoid recurrence (Contreras-Hernandez et al., 2022)

If you experience ongoing Achilles pain that interferes with your activity levels or doesn’t settle with rest, it’s best to consult a physiotherapist. Early assessment and intervention can lead to faster recovery and reduce the risk of long-term issues.

Achilles tendinopathy can be frustrating, especially for active individuals. However, with the right treatment plan, most people return to their normal activities successfully. Physiotherapy can help guide you through recovery by addressing the root causes, improving strength and flexibility, and ensuring a safe return to sport or exercise.

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Reference List

Beyer, R., Kongsgaard, M., Hougs Kjær, B., Øhlenschlæger, T., Kjær, M. & Magnusson, S.P. (2015) ‘Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: A randomized controlled trial’, The American Journal of Sports Medicine, 43(7), pp. 1704–1711. doi:10.1177/0363546515584760.

Contreras-Hernandez, I., Falla, D. & Schneebeli, A. (2022) ‘Neuromechanical changes in Achilles tendinopathy and the effects of exercise-induced mechanical tendon loading: a protocol for a systematic review’, BMJ Open, 12(2), e050186.

Rompe, J.D., Furia, J. & Maffulli, N. (2008) ‘Eccentric loading versus eccentric loading plus shock-wave treatment for midportion Achilles tendinopathy: a randomized controlled trial’, The American Journal of Sports Medicine, 37(3), pp. 463–470. doi:10.1177/0363546508326983.

Springer Open (2022) ‘Effectiveness of kinesiotherapy in the treatment of Achilles tendinopathy’, Sports, 12(8).

Additional systematic evidence: Evidence-Based Management of Achilles Tendinopathy in the Athletic… (2024) notes heavy slow resistance as effective as eccentric, with higher patient satisfaction.