Achilles Tendinopathy: Why Your Achilles Hurts and How Physiotherapy Helps You Recover

Achilles pain is one of the most common issues we see in runners, weekend warriors, gym-goers, and people who suddenly increase their activity. If you’ve noticed a stiff, achy, or sharp pain at the back of your heel—especially first thing in the morning—you may be dealing with Achilles tendinopathy.

What Is Achilles Tendinopathy?

In simple terms, Achilles tendinopathy is irritation, overload, or degeneration of the Achilles tendon—the thick tendon that connects your calf muscles (gastrocnemius and soleus) to your heel bone (calcaneus).

In technical language: Achilles tendinopathy is a mechanical loading dysfunction involving disorganisation of collagen fibres, increased tendon thickness, neovascularisation, and reduced tendon capacity. It is not typically an “inflammation,” but a tendinopathy spectrum disorder, involving either mid-portion (2–6 cm above the heel) or insertional (directly at the heel) pathology.

How Do People Get Achilles Tendinopathy?

Achilles tendinopathy usually develops when the tendon is asked to do more work than it is currently capable of handling. This may happen gradually or after a sudden spike in load.

Common Everyday Causes:

• A sudden increase in running distance or intensity

• Beginning a new exercise routine too quickly

• Switching to flat shoes, minimal shoes, or worn-out runners

• Poor calf flexibility or weakness

• Lots of uphill running

• Standing or walking for long periods

• Reduced rest and recovery

  
  

More Clinical Contributing Factors:

• Rapid load progression or poor load management

• Reduced ankle dorsiflexion (DTF restriction)

• High BMI increasing tendon load

• Biomechanical patterns such as increased pronation

• Weak soleus (common in runners)

• Over-striding during running

• Tendon compression at end-range dorsiflexion (common in insertional tendinopathy)

Common Signs and Symptoms

Typical Symptoms:

• Stiffness and pain in the Achilles first thing in the morning

• Soreness when you begin activity that “warms up” as you move

• Pain after running or exercising

• Swelling or a thickened feeling along the tendon

• Tenderness when you pinch or press the tendon

• Pain when walking uphill or climbing stairs

  
  

Clinical Signs Physiotherapists Look For:

• Localised pain at the mid-portion or insertion

• Thickening/swelling of the tendon

• Pain on tendon loading tests (calf raises, hopping, decline calf raises)

• Reduced plantarflexor strength (soleus in particular)

• Positive Royal London Hospital Test (reduced tenderness under tension)

• Stiffness during the first few repetitions of calf raises

Physiotherapy Treatment for Achilles Tendinopathy

Physiotherapy is the gold-standard treatment for Achilles tendinopathy. Tendons recover best with progressive loading, not rest alone.

1. Load Management (The Key Starting Point)

We identify what movements or training loads are irritating your tendon and adjust them—not to stop activity, but to keep you moving while allowing the tendon to heal.

This may include:

• Temporarily reducing running distance

• Avoiding speed sessions or hills

• Changing from calf-stretching positions if insertional

• Short-term cross-training options (bike, pool running)

  
  

2. Progressive Strengthening Program

This is the backbone of tendinopathy rehab. The goal is to increase the tendon’s capacity to handle load again.

A well-structured program will target:

• Soleus strengthening (key for runners; most load goes through soleus)

• Gastrocnemius strengthening

• Isometric exercises early for pain

• Heavy slow resistance (HSR) for tendon adaptation

• Plyometrics later (skips, hops) for return to running or sport

Example exercise phases:

• Phase 1: Isometrics (calf hold) for pain control

• Phase 2: Slow, heavy calf raises

• Phase 3: Loaded decline calf raises (mid-portion)

• Phase 4: Running-specific plyometrics and return-to-sport loading

  
  

3. Manual Therapy

Used to support mobility and pain relief:

• Soft tissue release for calf tightness

• Ankle joint mobilisation (talocrural joint)

• Local tendon techniques if appropriate

  
  

While manual therapy doesn’t “fix” the tendon alone, it supports better loading and movement.

4. Footwear and Running Technique Review

Many people improve quickly with:

• Slight heel lift or supportive shoes

• Reduced forefoot striking for runners

• Shorter stride length

• Increased cadence

  
  

These reduce peak tendon load during activity.

5. Shockwave Therapy

Extracorporeal shockwave therapy can help stimulate tendon healing and reduce pain.

6. Graded Return to Running and Sport

Your physio will guide you through:

• Run-walk intervals

• Gradual progression in distance

• Controlled reintroduction of speed and hills

• Sport-specific plyometric progressions

Differential Diagnosis: What Else Could Achilles Pain Be?

Not all pain around the Achilles tendon is true tendinopathy. Physiotherapists also consider:

1. Achilles Tendon Rupture (Partial or Complete)

• Sudden sharp pain

• Feeling of being “kicked” in the calf

• Weakness and difficulty pushing off

• Requires urgent assessment

  
  

2. Retrocalcaneal Bursitis

• Pain at the back of the heel

• Worse with shoes rubbing

• Swelling around the Haglund’s region

• More compressive than tensile pain

  
  

3. Plantaris Tendinopathy

• Pain slightly more medial

• Often mistaken for mid-portion Achilles tendinopathy

  
  

4. Peroneal Tendinopathy

• Pain more on the outside of the ankle

  
  

5. Posterior Tibial Tendinopathy

• Pain on the inside of the ankle, not the Achilles

• Often linked with flat feet

  
  

6. Deep Vein Thrombosis (Rare but Serious)

• Redness, swelling, warmth in the calf

• Needs immediate medical review

  
  

7. Referred Pain from the Lumbar Spine

• Nerve-related referral patterns can mimic Achilles pain

  
  

Achilles tendinopathy can be frustrating, especially if it stops you from running or training the way you want. The good news is that with the right diagnosis, load management, and a structured strengthening program, most people make a full recovery.

If you’ve been dealing with ongoing Achilles pain or morning stiffness, getting assessed early can save months of frustration and prevent the tendon from becoming more sensitive over time.