Achilles Tendinopathy

The Achilles is an important tendon in the lower leg, attaching the calf muscles to the heel bone. It is the biggest and strongest tendon of the body and as such can be very painful and debilitating when injured. One of the most common injuries to occur in the Achilles is a tendinopathy.

A tendinopathy often occurs when the tendon is put under more load or strain than it is able to cope with. This in turn causes some of the tendon fibres to become damaged causing micro-tears, leading to injury. Common causes of Achilles tendinopathy include over-training or starting exercise and doing “too much too soon”. Other causes include flat feet, high foot arches, unsupportive footwear or high heels, tight lower limb musculature, or uphill running.

Often, the first symptom of pain will arise during or after a bout of exercise. Normally the pain is localised to one spot but can be felt anywhere along the Achilles from below the calf muscle bulk to the bottom of the heel bone. The Achilles will also feel tender to touch and some swelling may occur initially. Other symptoms will include morning stiffness, pain that eases as the tendon warms up, and pain at the start of exercise that gets better during activity and worse afterwards or the next day.

Previously with Achilles tendinopathy we were told to rest from exercise and avoid loading the leg until the initial pain subsides. Current research into Achilles tendinopathy now shows that the tendon should continue to be loaded but that activities should be modified to a more manageable level. This means that an individual can still run or perform alternate exercise with Achilles tendinopathy if it is relatively pain free.

With manageable activity levels established, the tendon should be gradually loaded through eccentric activity to improve the tendon’s ability to handle more strain. Eccentric exercise is a type of strengthening exercise that loads the muscle and tendon while they are lengthening. This type of exercise is aimed to help the tendon fibres re-organise, stimulate healing and strengthen to withstand more load over time. A calf raise with the focus on a slow heel drop (returning the foot to the ground or below) is the best eccentric exercise to load the Achilles.

Achilles tendinopathy has a slow recovery time with symptoms often taking between 3 to 6 months to improve. Physiotherapy management of Achilles tendinopathy can also include soft tissue therapy, stretching, exercise technique correction including walking and running analysis, and advise on footwear and training load to aid a graduated return to normal exercise and activity.

Reid, H & Wood, S. (2015) Achilles Tendinopathy: Advice and Management. Information for Patients. Oxford University Hospitals NHS Foundation Trust; p1-15.
Magnussen, RA, Dunn WR, & Thomson, AB (2009) Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clinical Journal of Sport Medicine; 19(1): 54-64.
Wiegerinck, JI et al. (2013) Treatment for Insertional Achilles Tendinopathy: A Systematic Review. Knee Surgery Sports Traumatology Arthroscopy; 21(6): 1345-55.