Achilles Tendinopathy

Overview

The Achilles is the largest tendon in the body, connecting the calf muscles to the heel bone. Achilles tendinopathy is a gradual overload condition in which the tendon becomes painful, stiff and often thickened. It is common in runners and in people who have recently increased their walking or started a new sport, but it also affects people in their 40s to 60s who are not especially active.

There are two types, and the distinction matters for treatment. Mid-portion tendinopathy affects the tendon 2–6 cm above the heel bone and is the more common form. Insertional tendinopathy affects the point where the tendon attaches to the heel and is often aggravated by stretching or by shoes that press on the heel. The treatments overlap, but insertional cases need loading that avoids stretching the tendon over the heel bone.

The typical pattern is stiffness and pain for the first few steps in the morning, pain at the start of a run that eases as you warm up, and a tendon that is tender and sometimes visibly thickened. Tendons adapt slowly, so recovery is measured in months rather than weeks and depends on consistent, progressive loading.

Causes and risk factors

• A sudden jump in running mileage, speed work or hill training
• Changing to flatter or minimalist shoes without building up gradually
• Tight or weak calf muscles
• Reduced ankle flexibility
• Being over 40 — tendon elasticity reduces with age
• Flat feet or excessive pronation
• Certain medical conditions, such as diabetes or high cholesterol, and some medications — your GP can advise

How we may be able to help

Assessment first: we locate exactly which part of the tendon is involved, test calf strength and endurance, check ankle mobility and foot posture, and review your training history. This tells us why the tendon has been overloaded and which type of loading programme is appropriate.

Physiotherapy centres on a progressive tendon-loading programme. It generally starts with isometric holds for pain relief, progresses to slow heavy calf raises (modified for insertional cases so the heel is not dropped below the step), and later includes faster, spring-like movements to prepare the tendon for running or jumping. Manual therapy or dry needling for the calf, and mobilisation of a stiff ankle, may help with flexibility and comfort.

For tendons that have been painful for more than three months and have not responded to loading alone, focused shockwave therapy may be added after assessment. Evidence suggests it may help reduce pain in chronic Achilles tendinopathy, and it is typically delivered as a course of three to six sessions alongside the exercise programme.

Kinesiology taping may offload the tendon during activity. If your foot posture is contributing, a 3D foot scan and custom orthotics may reduce the twisting load on the tendon, and a small heel raise is sometimes used in the short term for insertional cases.

What you can do at home

• Reduce running volume and avoid hills and speed work until morning stiffness settles, but keep walking
• Start calf raises: slow up and slow down, twice daily, adding weight as they become comfortable
• For insertional pain, do calf raises from flat ground rather than off a step
• Avoid shoes with a hard heel counter that presses on the back of the heel
• Use a wrapped ice pack for 10–15 minutes after activity if the tendon is sore
• Avoid aggressive stretching if your pain is at the heel attachment