A Simple Guide for Active and Everyday People
Achilles tendinopathy is one of the most common causes of pain at the back of the heel, and something we frequently see.
It affects runners, gym goers, field sport athletes, and also people who have recently increased their walking, training, or activity levels.
If you are experiencing pain or stiffness in your Achilles that worsens with walking, running, climbing stairs, or first thing in the morning, this guide will help you understand what is happening and how physiotherapy can help.
What Is Achilles Tendinopathy?
Achilles tendinopathy refers to pain and dysfunction in the Achilles tendon, which connects your calf muscles to your heel bone.
Despite often being described as “tendinitis”, research shows that this condition is usually not driven purely by inflammation. Instead, it reflects a tendon that has been overloaded beyond its current capacity.
In simple terms, the tendon is being asked to tolerate more load than it is currently conditioned for.
Achilles tendinopathy can occur in two main locations:
- Mid portion Achilles pain, typically 2 to 6 cm above the heel
- Insertional Achilles pain, located directly at the heel bone
Common Symptoms of Achilles Tendinopathy
People with Achilles tendinopathy often report the following symptoms:
- Pain at the back of the heel
- Morning stiffness that eases with movement
- Pain during or after running or walking
- Tenderness when squeezing the tendon
- Reduced calf strength or power
- Gradually worsening symptoms over time
Early assessment allows us to confirm the diagnosis and rule out more serious conditions such as partial tears or rupture.
What Causes Achilles Tendinopathy?
Achilles tendinopathy rarely develops because of one single event. It is usually the result of load exceeding tendon capacity over time.
Common contributing factors include:
- Sudden increases in training – Rapid changes in running distance, speed, hill work, or gym activity.
- Calf weakness – Reduced calf strength increases strain through the tendon.
- Poor load management – Returning to sport too quickly after time off.
- Reduced conditioning – Periods of inactivity lower tissue tolerance.
- Footwear or surface changes – New shoes or increased hard surface training can alter tendon load.
How Long Does Achilles Tendinopathy Take to Settle?
Recovery time depends on symptom duration and how well the tendon is rehabilitated.
As a general guide:
- Early stage symptoms: 6 to 12 weeks
- Longstanding symptoms: 3 to 6 months
Rest alone rarely resolves Achilles pain. Avoiding load often weakens the tendon further.
The key to recovery is progressive, targeted rehabilitation.
Why Graduated Loading Is the Most Effective Treatment
Research consistently shows that structured exercise based rehabilitation is the cornerstone of Achilles tendinopathy management.
Tendons need the right type of load to adapt and regain capacity.
Graduated loading works by:
- Improving tendon load tolerance
- Increasing calf strength and endurance
- Reducing pain sensitivity
- Restoring confidence in running and sport
Rehabilitation is structured in stages:
Early Stage
- Pain education and load modification
- Isometric calf strengthening
- Reducing excessive tendon compression
Mid Stage
- Progressive calf strengthening
- Heavy slow resistance or controlled heel raises
- Single leg loading progressions
Late Stage
- Energy storage exercises such as hopping
- Return to running drills
- Sport specific progressions
Loading is progressed based on objective criteria.
What About Shockwave Therapy?
For persistent or stubborn Achilles tendinopathy, Extracorporeal Shockwave Therapy may be used, often referred to as shockwave therapy.
Shockwave therapy delivers controlled acoustic energy to the tendon.
Research suggests that shockwave therapy can:
- Stimulate biological healing responses
- Improve blood flow
- Influence pain signalling pathways
- Support tendon remodelling
Shockwave therapy is not a replacement for strengthening. It works best when combined with a structured loading programme.
Why Combining Shockwave and Loading Works
Graduated loading builds long term tendon capacity.
Shockwave therapy may help reduce pain sensitivity and stimulate tissue level responses, allowing you to progress strengthening more effectively.
Together, they form a comprehensive, evidence informed treatment strategy for persistent Achilles pain.
What Does Achilles Rehabilitation Involve?
Your rehabilitation programme is tailored to your lifestyle and goals.
This may include:
- Objective calf strength testing
- Load monitoring strategies
- Progressive gym based strengthening
- Return to running plans
- Sport specific performance drills
Can Achilles Tendinopathy Be Prevented?
Recurrence is common if underlying strength and load management issues are not addressed.
Prevention strategies include:
- Maintaining calf strength
- Gradual increases in training volume
- Monitoring weekly load changes
- Incorporating strength training year round
When Should You See a Physiotherapist?
You should book an assessment if you:
- Have Achilles pain lasting more than two weeks
- Experience worsening morning stiffness
- Struggle to progress running
- Have pain that repeatedly returns
- Are unsure whether your pain is Achilles related
Early treatment leads to faster recovery and better long term outcomes.
References
Cook JL, Rio E, Purdam CR, Docking SI. (2016). Revisiting the continuum model of tendon pathology. British Journal of Sports Medicine.
Malliaras P, et al. (2013). Achilles and patellar tendinopathy loading programmes. British Journal of Sports Medicine.
Mani-Babu S, et al. (2015). The effectiveness of extracorporeal shockwave therapy in lower limb tendinopathy. American Journal of Sports Medicine.
Stania M, et al. (2023). Extracorporeal shockwave therapy for Achilles tendinopathy: systematic review and meta analysis.
National Institute for Health and Care Excellence. (2016). Extracorporeal shockwave therapy for refractory Achilles tendinopathy.
