Achilles Tendinopathy

It is estimated that Achilles tendinopathy accounts for around 11% of all running injuries. The Achilles tendon is the large tendon at the back of the ankle. It connects the large calf muscles (Gastrocnemius and Soleus) to the heel bone (calcaneus) and provides the power in the push off phase of the gait cycle (walking and running).

anklepainAchilles tendinopathy is no longer thought to be an inflammatory condition. On investigation, the main finding is usually degenerated tissue with a loss of normal fibre structure.

Achilles pain can be either acute; occurring over a period of a few days following an increase in training, or chronic which persists over a longer period of time. In addition to being either chronic or acute, the condition can also be either at the attachment point to the heel or in the mid-portion of the tendon (typically around 4cm above the heel).

Symptoms of Achilles Tendinopathy

One of the most likely reasons for a persistent condition is weakness in the area. Therefore it is essential that strengthening is incorporated into rehabilitation and any intervention. It is important you rehabilitate the tendon properly or the injury can return.

Don’t be satisfied with just local treatment of the area; massage, frictions, and expensive gadgets like shockwave etc. – although these can help with pain management, they do not strengthen and therefore without this component it is unlikely that you will make a full recovery.

It is unusual for you to get pain in the Achilles area unless there is a reason, this may be an unusual activity / increase in activity levels, but if you want to push yourself, and haven’t prepared enough then don’t forget to make sure you fully rehabilitate to prevent future recurrence.

  • Reactive tendinopathy / early tendon dysrepair

    • Acute overload
    • Pain
    • General swelling


    • Reduce frequency +/- tendon load
    • medication

  • Late tendon dysrepair / degeneration

    • Chronic overload
    • Pain is “grumbly” in nature
    • Specific swelling


    • Soft tissue treatment

Causes of Achilles Pain

“Too much too soon” is the typical cause of Achilles pain, however other factors may contribute to developing pain;

  • Increase in activity (distance, speed or hills).
  • Less recovery time between activities.
  • Change of footwear or training surface.
  • Calf weakness.
  • Decreased range of motion at the ankle joint.
  • Running up hills if unconditioned.
  • Altered foot mechanics
  • Altered tibial / femoral mechanics
  • Genetic, male, menopause, type 2 diabetes.

Some of these can be addressed, others not.

It is also important to determine where the issue lies. For example if the mid portion of the Achilles is affected then this responds well to a particular exercise regime, however if it is an insertional tendinopathy, then the programme needs to be adapted to reduce compressive load, and stretches may exacerbate the condition.

Treatment of Achilles Tendinopathy

What can the athlete do?

The most sensible thing you can do is manage the situation well.  Don’t be frightened by the pain.  A heap of research has been done with low back pain showing that pain is not relative to tissue damage – so don’t panic!

Yes – its important to manage the pain – but don’t over react. Tendons do not like a change in activity – so the worst thing you can do is rest until the pain goes away, then return to your activity.  Most likely the pain will come right back – you rest, and its a vicious circle.

Ideally get an assessment, so you are confident on what is wrong, then graduate your activities but don’t boom / bust….


  • Identify the contributing factors.
  • Local tissue techniques?
  • Agree a rehabilitation programme.
  • Refer on if necessary.

Isometric exercise

Even physios have niggles! Here’s Phil performing a few isometric calf exercises before we went for a team run. Just a few reps of holding this position resulted in enough pain relief for his run.

Don’t take my word for it – there’s evidence out there suggesting this kind of strategy really works.

Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy

OK – so as with all research, you can question the study size etc. etc., however if you’ve ever had a grumbly tendon then you may like to see if it works for you.

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If you have a recurrent / long term problem, why not consider a body screen

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