Achilles Tendinopathy / Tendinitis
Achilles tendon pain, both insertional and mid-portion
Overview
The Science of Achilles Tendinopathy / Tendinitis
Link copiedAchilles is a failed healing response characterized by changes rather than acute inflammation. The condition involves disorganized , increased ground substance, and within the tendon. This represents a chronic overuse injury where the cumulative load on the tendon exceeds its adaptive capacity.
Two distinct types require different treatment approaches: Mid-portion Achilles tendinopathy (MAT) occurs 2-7 cm from the heel insertion and is primarily a tensile overload condition. Insertional Achilles tendinopathy (IAT) affects the tendon's attachment to the and involves both tensile and compressive forces, as the tendon can be compressed against the heel bone during movements.
The involves a breakdown in the normal collagen structure, leading to painful, thickened tissue with reduced mechanical properties. Unlike acute inflammation (), this degenerative process (tendinosis) requires specific loading strategies to stimulate proper tissue remodeling rather than anti-inflammatory treatments.
Overview
Contributing Factors
Link copiedAchilles typically develops from a combination of training load mismanagement and poor . Your Achilles tendon has to handle forces up to 8-12 times your body weight during activities like running and jumping, making it incredibly sensitive to changes in load. The classic pattern I see is someone who increases their training volume or intensity too quickly, or returns to activity after a break without gradually building up their tendon capacity.
Running mechanics significantly influence Achilles tendon loading. A or midfoot strike pattern generally loads the Achilles more than heel striking, which can be problematic if your tendon isn't adapted to higher loads. (excessive foot flattening) creates a whipping action in the tendon that can contribute to overload, particularly at the insertion point. Tight calf muscles or poor ankle flexibility force your Achilles to work harder during push-off and limit your ability to absorb impact forces effectively.
Footwear and training surface changes can trigger Achilles problems even in experienced athletes. Switching to more minimalist shoes or zero-drop footwear significantly increases the load on your Achilles. Running on hills, particularly uphill running which requires more power, or sudden increases in or jumping activities can overload the tendon. Age compounds these factors because the tendon naturally becomes less elastic and has reduced blood supply, making it more vulnerable to developing the changes characteristic of tendinopathy rather than healing normally from micro-damage.
Symptoms
Clinical Presentation
Link copiedPrimary Symptoms
Associated Symptoms
Typical pattern
Gradual onset. Morning stiffness prominent. Pain at beginning of activity that may improve with warming up but worse after.
Symptoms
Differential Diagnosis
Link copiedConditions with similar presentations:
Insertional vs Mid-portion Achilles Tendinopathy
Key differences: Insertional pain sits right at the heel bone and often flares with deep or uphill running because the tendon gets compressed against the . Mid-portion pain sits 2 to 6 cm above the heel in the soft part of the tendon. The distinction matters because insertional cases tolerate less dorsiflexion range during loading, and heel drops below a step are typically avoided early on.
Partial or Complete Achilles Rupture
Key differences: A rupture is usually a sudden event with an audible snap or a sense of being kicked in the back of the ankle, immediate weakness pushing off, and a positive Thompson test where squeezing the calf produces no ankle . builds over weeks, responds to warm-up, and preserves push-off strength.
Retrocalcaneal Bursitis or Haglund's Deformity
Key differences: Pain sits at the back of the heel itself rather than in the tendon substance. A visible bony bump at the upper edge of the , pain reproduced by squeezing either side of the tendon just above the heel rather than the tendon itself, and strong aggravation from shoe counters pressing on the heel all point away from a primary tendon problem.
Posterior Ankle Impingement
Key differences: Pain is deep and posterior rather than along the tendon, and it peaks with forced such as during a calf raise to full height, ballet en pointe, or the push-off phase of a sprint. Calf-raise holds do not reliably reproduce symptoms, while full-range plantarflexion testing does.
Posterior Tibial Tendinopathy
Key differences: Pain and swelling track behind and below the medial ankle bone rather than at the Achilles, the arch often feels more fatigued or collapsed, and single-leg heel raise reveals the heel failing to . A classically painful Achilles on resisted is often comfortable here, and vice versa.
Sural Nerve Irritation
Key differences: Sharp, burning, or tingling pain following the outer border of the Achilles down into the foot, often with a reproducible tender spot over the nerve rather than the tendon. Calf-raise loading typically does not provoke the pain; light percussion or direct nerve tension does.
When to seek professional help
Research
Key Research & Evidence
Peer-reviewed studies supporting the treatment approach.
Murphy MC, Travers MJ, Chivers P, et al. · 2019
Efficacy of heavy eccentric calf training for treating mid-portion Achilles tendinopathy: a systematic review and meta-analysis
British Journal of Sports Medicine · n=7 randomised controlled trials
Key findings
Heavy eccentric calf training appeared superior to natural history and to traditional physiotherapy for pain and function on the VISA-A scale, but was not clearly superior to other exercise interventions, with any difference unlikely to be clinically meaningful. The authors emphasise that the small sample sizes and methodological limitations of the included trials mean these estimates remain uncertain.
Clinical relevance
Supports loaded exercise as a first-line approach for mid-portion Achilles tendinopathy while indicating that no single loading protocol is clearly superior, allowing exercise prescription to be individualised
Murphy MC, Travers MJ, Chivers P, et al. Efficacy of heavy eccentric calf training for treating mid-portion Achilles tendinopathy: a systematic review and meta-analysis. Br J Sports Med. 2019;53(17):1070-1077.
Beyer R, Kongsgaard M, Hougs Kjær B, et al. · 2015
Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial
American Journal of Sports Medicine · n=58 participants
Key findings
Heavy slow resistance training showed equivalent outcomes to traditional eccentric exercises at 52-week follow-up. Both groups demonstrated significant, lasting improvements in VISA-A scores and activity pain, with heavy slow resistance tending toward greater patient satisfaction at 12 weeks and higher training compliance across the programme.
Clinical relevance
Provides evidence that multiple loading strategies are effective, allowing clinicians to individualize exercise prescription based on patient preference and adherence factors
Beyer R, Kongsgaard M, Hougs Kjær B, et al. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2015;43(7):1704-1711.
Färnqvist K, Morrissey D, Malliaras P. · 2021
Factors associated with outcome following exercise interventions for Achilles tendinopathy: A systematic review
Physiotherapy Research International · n=6 studies, 11 factors
Key findings
Across six low-quality studies examining eleven possible factors, no factor consistently predicted outcome after exercise for Achilles tendinopathy. Symptom duration and age were not associated with change in VISA-A, while baseline pain and function, sex, BMI and imaging measures showed only inconsistent associations. The authors caution that the poor quality of evidence prevents firm prognostic conclusions.
Clinical relevance
Tempers expectations about predicting who will respond to exercise, reinforcing that loading should be trialled rather than withheld based on baseline characteristics or imaging
Färnqvist K, Morrissey D, Malliaras P. Factors associated with outcome following exercise interventions for Achilles tendinopathy: a systematic review. Physiother Res Int. 2021;26(2):e1889.
Murphy M, Travers M, Gibson W, et al. · 2018
Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis
Sports Medicine · n=24 studies
Key findings
Pain and function improved gradually over the course of loading programmes, with meaningful change accruing over months rather than weeks. The pooled data showed VISA-A scores continuing to improve well beyond the early weeks of treatment, underscoring that recovery from mid-portion Achilles tendinopathy with exercise is slow.
Clinical relevance
Sets realistic expectations for recovery timelines, helping patients understand that loaded rehabilitation works gradually and that persistence over months is part of the treatment
Murphy M, Travers M, Gibson W, et al. Rate of improvement of pain and function in mid-portion Achilles tendinopathy with loading protocols: a systematic review and longitudinal meta-analysis. Sports Med. 2018;48(8):1875-1891.
Management
Evidence-Based Management
Treatment strategies with the strongest support in the current literature.
Primary approach
Exercise therapy including and heavy-slow resistance training achieves pain reduction and functional improvement in 60-90% of cases, with no clear superiority between methods for mid-portion
Complementary
therapy provides effective adjunct treatment for recalcitrant cases, with evidence supporting improved pain relief and function when combined with exercise programs
Prevention & long-term
Load management and biomechanical assessment address the training errors that underlie most cases, while addressing risk factors like calf weakness and ankle stiffness significantly reduces recurrence
Detailed management strategies
Progressive Loading
Stimulates tendon remodeling
Important precautions
- Pain during exercise acceptable, increasing pain after is not
Activity Modification
Manages load while maintaining fitness
Important precautions
- Don't completely rest
Management
Treatment Techniques
Evidence-based manual therapy and intervention approaches.
Treatment approaches supported by current research and clinical guidelines
Recommended treatment approaches
Treatment approaches are individualized to each patient's needs and goals. All interventions require explicit informed consent, and treatment plans are collaboratively modified based on your preferences and response to care.
Sports Rehabilitation & Return to Sport
Evidence-based recovery programs for athletes to safely return to sport after injury.
Dry Needling
Precise needle therapy targeting trigger points for effective pain relief and improved muscle function.
Soft Tissue & Myofascial Therapy
Targeted hands-on techniques to address muscle tension, pain, and movement restrictions.
Cupping Therapy
Technique using controlled suction to address muscle tension and localized pain.
IASTM (Instrument Assisted Soft Tissue Mobilization)
Instrument-assisted techniques to address soft tissue restrictions and pain.
Post-Surgical Rehabilitation
Evidence-based recovery programs following surgery to restore function and strength.
Rehabilitation
A Typical Rehabilitation Progression
Three phases, from settling symptoms to returning to full activity.
Recovery from Achilles Tendinopathy is usually staged: calm the symptoms first, then rebuild the strength and capacity of the area, then return to your full activities. The three phases below show the kind of progression the evidence supports and that I commonly work through in clinic. They are here to show you what the road can look like, not to act as a personal program.
- Phase 1
Pain Control and Isometric Loading (Weeks 1 to 4)
Bring morning stiffness and first-step pain down to a workable level, and introduce predictable tendon load without aggravation. calf holds load the tendon heavily without the repetitive length changes that often provoke early-stage Achilles pain. The Silbernagel pain-monitoring model guides dosage: symptoms during and after loading can sit up to 5 out of 10 provided they settle within 24 hours and do not rise week over week.
Examples, not a prescription
- Double-leg calf raise isometric hold at roughly two-thirds of full height, 5 sets of 45 seconds, once daily
- Seated calf raise isometric hold, 5 sets of 30 to 45 seconds, useful when standing holds flare insertional pain
- Slow double-leg calf raises on flat ground, 3 sets of 15, 3 seconds up and 3 seconds down
- Soleus-focused seated calf raise with the knee bent to roughly 90 degrees, 3 sets of 15
- Running volume reduced by 30 to 50 percent, with steepest uphill or speed work paused
Ready to progress when
Morning stiffness under 15 minutes for 7 consecutive days, pain during isometric holds at or below 3 out of 10, and no symptom rise 24 hours after loading sessions.
- Phase 2
Heavy Slow Resistance or Eccentric Loading (Weeks 4 to 12)
Rebuild tendon structural capacity. For mid-portion the choice is between Alfredson's heel-drop protocol (3 sets of 15 twice daily off a step, straight-knee and bent-knee versions, seven days a week) and the heavy slow resistance approach that Beyer and colleagues tested in AJSM 2015 (3 sets, 3 times per week, 3 seconds up and 3 seconds down, progressing from 15RM toward 6RM across the block). Outcomes at 52 weeks were equivalent in their trial. For insertional cases the heel stays on flat ground or a slight lift rather than dropping below level, consistent with the JOSPT 2018 guideline's caution about compressive loading at the insertion.
Examples, not a prescription
- Mid-portion: Alfredson heel drops off a step, straight-knee and bent-knee, 3 sets of 15 twice daily
- Alternative: Heavy slow resistance standing calf raise in a Smith machine or with a barbell, 3 sets of 6 to 15 reps, 3 times per week on non-consecutive days
- Seated heavy slow resistance calf raise for the soleus, 3 sets of 6 to 15 reps
- Insertional: floor-level or slightly elevated calf raises only, same tempo and sets, avoiding end-range
- Running maintained or gradually rebuilt using the 24-hour symptom rule as the gatekeeper
Ready to progress when
Full-range single-leg calf raises at 3 out of 10 pain or less, at least 20 consecutive single-leg raises possible on the affected side, and two weeks of loading sessions tolerated without a 24-hour flare.
- Phase 3
Energy Storage and Return to Sport (Months 3 to 6+)
Restore the spring-like, stretch-shortening behaviour the Achilles needs for running, cutting, and jumping. This follows the later stages of the Silbernagel and Crossley 2015 return-to-sport framework: only progress to once heavy resistance is comfortable, and rebuild running and sport volume gradually rather than in a single jump.
Examples, not a prescription
- Pogo-style bilateral hops on soft surface, 3 sets of 20, progressing to firm ground
- Single-leg hops in place, then for distance, then with change of direction
- A-skips, bounding, and controlled accelerations
- Running volume rebuild using a 10 percent weekly cap, with hills and speed work reintroduced last
- Sport-specific demands such as cutting for soccer, repeated sprints, or jump-intensive training reintroduced in graded blocks
Ready to progress when
VISA-A score trending upward and above 80 when used, single-leg hop symmetry within 10 percent of the unaffected side, and two consecutive weeks of full training or running volume without a 24-hour symptom flare.
Management
Prognosis & Recovery
What outcomes and recovery factors typically look like.
Expected timeline
Recovery is slow and requires patience. Improvements in pain and function can occur within 4 weeks, with peak improvement around 9-12 weeks, but full recovery often takes a year or longer. Only a minority achieve complete return to asymptomatic function, though most can return to desired activity levels
Natural history
Conservative treatment fails in 25-30% of patients requiring surgical consideration after 6 months of dedicated conservative care. Surgery success rates 70-90% but involves lengthy recovery and risks. Long-term studies show up to 40% may have ongoing mild symptoms despite good functional outcomes
Factors affecting recovery
Management
Measuring Progress
How to track the recovery arc week to week.
Day-to-day tracking
I track morning stiffness duration, pain levels, and single leg heel raise capacity
Assessment tools
VISA-A questionnaire for Achilles function
Activity targets
Return to running or desired activities without limitation
Management
Frequently Asked Questions
Common concerns and answers about this condition.
How long does Achilles tendinopathy take to get better?
How long does Achilles tendinopathy take to get better?
Meaningful change usually takes 3 months of consistent loading, and full return to running or jumping often sits in the 6 to 12 month range depending on how long symptoms were present before starting rehab. The Silbernagel and Crossley JOSPT 2015 framework and the JOSPT 2018 Achilles clinical practice guideline both set expectations around months, not weeks, because tendon remodels slowly. Patience is part of the treatment.
Should I stop running with Achilles tendinopathy?
Should I stop running with Achilles tendinopathy?
Usually no. Complete rest tends to detrain the tendon further and symptoms return as soon as running resumes. The Silbernagel pain-monitoring model allows continued running provided pain stays at or below about 5 out of 10 during the run, settles within 24 hours, and does not creep up week over week. If all three conditions hold, running is serving the rehab rather than undermining it.
Do eccentric heel drops still work, or is heavy slow resistance better?
Do eccentric heel drops still work, or is heavy slow resistance better?
Both work. Alfredson's 1998 protocol of 3 sets of 15 heel drops twice daily for 12 weeks produced results strong enough to reshape tendon rehab globally. Beyer and colleagues (AJSM 2015) compared heavy slow resistance against training at 12 and 52 weeks and found equivalent outcomes with higher patient satisfaction in the heavy slow resistance group at 12 weeks. I typically pick based on equipment access, schedule, and what the person will actually do three times a week.
Why is my Achilles worst in the morning?
Why is my Achilles worst in the morning?
Morning stiffness is one of the most reliable features of . During sleep the tendon sits in a shortened, unloaded position, and the first weight-bearing steps reload tissue that has not been primed. Stiffness that eases within 10 to 15 minutes, and a warm-up period where the tendon feels better during activity, are classic. Stiffness lasting over 30 minutes or worsening through the day signals that loading needs to be dialled back.
What is the difference between insertional and mid-portion Achilles tendinopathy?
What is the difference between insertional and mid-portion Achilles tendinopathy?
Mid-portion pain sits in the soft belly of the tendon 2 to 6 cm above the heel. Insertional pain sits right where the tendon meets the heel bone. The distinction matters because insertional tendons get pinched against the when the ankle dorsiflexes deeply, so heel drops off a step are typically avoided early on and flat-ground or slightly-raised calf raises are used instead. Mid-portion cases tolerate and often benefit from the decline heel drop position.
Are cortisone injections a good idea for Achilles tendinopathy?
Are cortisone injections a good idea for Achilles tendinopathy?
I steer people away from peritendinous cortisone for the Achilles. Pain relief is short-lived, and there is a real concern about tendon weakening and rupture risk with injection into or around a tendon. The JOSPT 2018 guideline and most current reviews do not support corticosteroid injection as a primary treatment. Progressive loading remains the cornerstone.
When should I worry about an Achilles rupture versus tendinopathy?
When should I worry about an Achilles rupture versus tendinopathy?
A rupture is almost always a sudden event, often with a pop or a sensation of being struck in the calf, followed by immediate difficulty pushing off or rising onto the toes. Inability to perform even a small single-leg heel raise, or a positive Thompson test (squeezing the calf while lying face-down fails to move the foot), warrants urgent assessment rather than rehab planning. , by contrast, builds gradually and preserves most strength.
Does ultrasound or MRI change the treatment plan for Achilles pain?
Does ultrasound or MRI change the treatment plan for Achilles pain?
In most cases, no. Imaging often shows tendon thickening, , or focal changes that correlate poorly with symptoms and with prognosis. Two Achilles tendons that look identical on ultrasound can behave completely differently. I order imaging when a partial tear, , or bone is genuinely on the differential, not as a routine confirmation of .
Related Conditions
Conditions I commonly see alongside, or confused with, this one.
- Biomechanically linked
Plantar Fasciitis & Heel Spurs
Both involve posterior chain; Achilles stiffness is major risk factor for plantar fasciitis
- Anatomically related
Sever's Disease
Both involve Achilles tendon attachment issues, though in different age groups
- Common co-occurrence
Shin Splints
Both are common running injuries; Achilles dysfunction can contribute to shin splints
Get Expert Treatment
Professional physiotherapy for achilles tendinopathy / tendinitis