Achilles Tendinopathy

Achilles tendinopathy is a problem with the tendon that connects the calf muscles to the heel bone. It is the largest tendon in the body and absorbs an enormous amount of force every time you walk, run, or push off the ground. When the demands on it outpace its capacity to recover, the tissue starts to change. Older language called this tendinitis, but the research over the last twenty years has shown that ongoing Achilles problems are rarely about active inflammation. The tendon structure itself has changed, and the treatment that follows from that distinction is different than the rest-and-ice approach that worked for the inflammation model. The broader picture of how this fits into tendon injuries generally is similar: the load on the tissue exceeded what it was prepared for.

There are two main locations and they behave differently. Mid-portion tendinopathy sits two to six centimetres above the heel bone, where the tendon is thinnest and the blood supply is poorest. Insertional tendinopathy sits right at the back of the heel where the tendon attaches to the bone, often with bony involvement. The two need different rehabilitation programs, which is one of the most common reasons people who are doing the right exercises in the wrong place are not getting better.

The classic pattern is morning stiffness in the back of the heel that eases once you start moving, then returns and worsens with running or impact. Some people can run through it for weeks before it stops them. Others get sidelined quickly. Either way, the tissue is asking for a change in how it is being loaded.

What Tips a Healthy Tendon Toward Trouble

Most cases trace back to a combination of these contributors:

Building the Tendon Back Up Through Loaded Work

Why Stretching and Rest Alone Will Not Fix It

The single most important thing in Achilles tendinopathy is graded loading. Tendons respond to mechanical stress, and progressive loading at the right level is what rebuilds the tissue’s capacity. Eccentric exercises, where the calf is loaded as it lengthens, have decades of research behind them and remain a cornerstone of rehabilitation. Heavy slow resistance training has caught up in the evidence base and is often easier to stick with. The exact progression depends on whether the problem is mid-portion or insertional, since insertional tendinopathy responds poorly to deep heel-drop exercises that work well for mid-portion cases. Our deeper write-up on eccentric loading goes into the protocol and reasoning in more detail.

Manual therapy plays a supporting role. Soft tissue work on the calf, work into the foot and ankle, and addressing whatever else is loading the tendon up the chain all help create the conditions for the loading work to take. Shockwave therapy has good evidence for Achilles tendinopathy, particularly in cases that have been stubborn for several months or where loading alone has plateaued.

The piece most people miss is that running and jumping have to be reintroduced as their own loading exercises late in the program. Walking around pain-free does not mean the tendon is ready to handle thirty minutes of impact, and a tendon that has been quiet for weeks can flare up again the first time it is asked to do something hard. You can’t go wrong with strong, and a stronger calf and Achilles is the most reliable predictor of staying out of trouble long term. Most people see meaningful improvement in eight to twelve weeks of consistent work, though stubborn cases can take longer.

Achilles Tendinopathy Questions We Get Asked Most

Most people who walk into the clinic with Achilles trouble have already tried stretching, rest, or googling exercises. The questions below are the ones that come up most once they are sitting in front of us.

Every Achilles is loaded differently and responds to a different progression. The patterns described here are the common ones, and the right plan for your tendon depends on what we find during the assessment.

Helping Burlington patients move better since 2005.