Achilles Tendinopathy / Achilles Tendinitis

Achilles TendonThis article is about chronic Achilles tendinopathy / tendinitis that has been going on for weeks and months not just a few days. It is aimed at readers with knowledge of basic human anatomy and exercise. You may not be a musculoskeletal health professional, but you will know where your gastrocnemius is and you are probably trying to rehabilitate your own Achilles tendinopathy / tendinitis.

Stop saying Achilles tendinitis.

The term Achilles Tendinitis applied to ongoing Achilles pain demonstrates basic misunderstanding of the injury. The evidence is clear that any case of Achilles pain going on for more than a few days is unlikely to be a tendonitis. This is because cell studies have shown us that inflammation is rarely a significant factor in Achilles pain lasting more than a few days.  Acute Achilles tendinitis will either self-resolve or progress into a chronic tendinopathy. The term tendinopathy demonstrates we are not assuming inflammation is playing an active role in the presentation.

3 benefits of knowing the difference between Achilles tendinitis and tendinopathy

  • If you find yourself talking to a professional and they persistently use the term ‘tendinitis’ they are demonstrating that they’re not aware of the most recent research and best expert knowledge.
  • We reduce the chance we might resort to the use of anti-inflammatories which can have negative side effects.
  • We open up the possibility of considering a whole new, non-inflammation based, paradigm for treatment.

Technical bit for nerds. (You might not need this much detail!)

Pathos is Greek for diss-ease or suffering. Tendinopathy therefore literally means tendon that is suffering or at diss-ease. However, the cell studies have shown us that the cell states of painful tendons are abnormal not inflamed. The person looking down the microscope at the cell samples will therefore report on the presence of tendinosis because the -osis suffix translates as abnormal not tendinitis because there is no inflammation.

Now hold on to your hat, this is where we get super geeky.

Our friendly histologist (The person who looks at the cell sample) can’t know from the sample that the person has been experiencing pain or is in anyway feeling at diss-ease. The only way to know that is to ask the person. Therefore, it takes a clinician to put these two bits of information together and make a diagnostic decision to say the tendon is tendinopathic and it is completely wrong to diagnose tendonitis.

But first let’s make sure we are dealing with an Achilles Tendinopathy.

5 Common signs and symptoms of Achilles tendinopathy

Woman rubbing lower legIt is unnecessary to obtain and analyse a cell sample from everyone with Achilles pain. Instead we rely on interpretation of signs and symptoms. Typical signs and symptoms of achilles tendinopathy are:

  • Pain and or stiffness that reduces with gentle movement
  • Dull ache in achilles region after exercise
  • Pain on palpation. Squeezing the tendon between thumb and forefinger is often exquisitely painful
  • Swelling/thickening of the achilles tendon (Usually in chronic cases)
  • Ongoing pain in the achilles region. If the pain has been going on for several weeks/months then achilles tendinopathy is very likely.

5 Primary Risk Factors for Achilles Tendinopathy

It is worth knowing common risk factors for achilles tendinopathy. Identifying and dealing with these where possible will reduce the maintaining factors in the condition and to reduce the chance of it re-occurring in the future.

  • Deconditioning – Achilles tendinopathy is more common in people who are unfit, especially when work load increases. This is often either due to weight gain (carrying extra ballast is an increase in work load!) or, rather unfairly, starting new exercise to get fit.
  • Kinetic chain weakness. Weak Gluteals and quadriceps are known to predispose achilles tendinopathy
  • Local weakness. Weak toe flexors, tibialis posterior and ankle evertors predispose achilles tendinopathy.
  • Aged over 40 – Athletes aged over 40 need more rest and recovery time to avoid overload.
  • Menopause – Perimenopausal athletes are at risk due to the effect of hormonal changes on the connective tissues


Achilles tendinopathy and treatment in a nutshell

Because we know that the tendon is not inflamed but there is some mechanical degradation of the cells it is safe to think of achilles tendinopathy as an achilles tendon that was/is not strong enough, we might draw an analogy with a rope that is frayed because it has been over used. When looked at like this it becomes clear that we just need to make the tendon stronger. The clever bit is ‘how’ to make the tendon stronger without over loading it… remember nobody has ever got stronger with complete rest!

 7 Common causes of Achilles tendinopathy

  • Deconditioning. I’m afraid just being out of shape is is a common cause.
  • Sudden increase in training load. Specifically, increased pace or volume
  • Increase in hill running. Especially hill sprints.
  • Inadequate rest or recovery time, especially in older or deconditioned athletes
  • Sudden switch to forefoot running style. Forefoot running loads the Achilles much more than heel striking
  • Sudden change of running shoe. A large sudden change in load distribution which usually means the heel to toe drop height can be related to the onset of Achilles tendinopathy. Changes should therefore be managed gradually over time
  • Weight gain. If you gain weight, that extra ballast equals more work for your tendons to carry the load. If you add the unavoidable effect of age-related deconditioning and it’s a miracle that not every fat person over the age of 50 doesn’t have Achilles tendinopathy…. But, many do!

How to rehabilitate an Achilles Tendinopathy

So we’re definitely talking about Achilles tendinopathy. We know it’s been going on for a few weeks, months or even years, so we know this is going to be tricky. We know the reason it’s going to be tricky is because we need to make it stronger without overloading it. Let’s discuss how to fix it in 2 key steps.

Step 1. Reduce the maintaining factors

  • Avoid compression. All tendons hate compression. This means:
    • Avoid Tight shoes
    • Avoid Loading in a dorsiflexed (uphill) position. (When the foot is dorsiflexed the achilles tendon is compressed around the back of the calcaneus.)
  • Improve the general condition of your legs. Strengthen your glutes, quads, hamstrings and the intrinsic muscles of the lower leg.
  • It might be worth talking to a good Osteopath or Physiotherapist (The sort that gives you the time of day and doesn’t rush you through in short slots) about other ways of reducing the maintaining factors

4 Top Tips for runners to keep running whilst rehabbing an Achilles Tendinopathy

  • Reduce Hill Running to reduce the angle of loaded dorsiflexion
  • Reduce running intensity
  • Increase step rate/ shorten stride
  • Temporary use of a heel raise

Step 2. Strengthen the Achilles Tendon.

I’m afraid you don’t understand the basics of how to make your body stronger. If you did you wouldn’t be reading this.

Basic Principles of Rehab Strengthening

Female Athlete performing single leg calf raise for Achilles tendinopathy rehabilitation.The body adapts to what you do with it up to a point, no more no less. You need to apply enough stress(force) to make the body work. Not enough load and you won’t make any difference and too much you’ll to overload it. Nobody ever got strong sitting on the sofa with their foot up and like wise the benefits of trying to bench press a double decker bus are questionable. You must find the sweet spot of enough work but not too much. This is a simple principle, but transferring it into exercise can be tricky. Here’s some pointers that I give my clients.

Doing exercises slowly with long holds is a good way to apply significant loads whilst controlling the stress applied. Think about this:

Given the same resistance what is more stressful: doing 1 rep and holding it for 20 seconds or doing 20 reps each for 1 second? Hopefully you have an intuitive understanding that 1 long hold is less stressful than lots of fast ones even though the maths you tell us it is the same amount of weight shifted over time. TIP 1. You are going to start with long slow reps.

What is the right amount of sets, reps and duration?

Good question but unfortunately there is no magic prescription of sets, reps and duration for Achilles tendinopathy. Life is not like that. Your Achilles tendon is an integrated part of you. You can’t deal with the Achilles tendon in Isolation.

Why is there no magic number of sets, reps and duration for Achilles Tendinopathy Rehab?

The 40 year old CrossFit fanatic who’s transferred to minimalist shoes has a different perception of acceptable muscle pain to the 40 year old sedentary computer gamer who turned up to The Park Run almost by mistake, yet both of these people are common Achilles Tendon Presentations.

When the exercise is tailored to you, you are less likely fall at the first hurdle. If something hurts you are more likely to question is this good pain am I just working hard or is this a problem? Or, if there is a problem you’ll understand enough to find a work-around. Motivated people do exercises and perceiver when the going gets tough.

You need to buy into the exercises. This means you need understand exactly why the exercise is important and how much you need to do to have an effect. It should then feel important to you to do the exercise. This is an emotional belief.

In order to get this understanding, you need to be able to figure out yourself how much is right. This can be achieved by giving you principles to follow, ie the tools you need. Put another way you have to engage brain before muscle


But first here are the Achilles Tendon Rehab exercises:

Toe In Single Leg Calf Raise from Floor
Toe in Calf Raise. In this picture the model is facing straight ahead but the Great Toe is directed towards the mid-line.
Toe Out Single Leg Calf Raise from Floor
Toe Out Calf Raise. Again, the model is facing straight ahead but the Great Toe is directed away from the mid-line.

The Achilles tendon is part of the calf muscle complex so strengthening the tendon is synonymous with strengthening the calf.

The exercises are simple. You need to do a lot of them, but you should probably resist making them any more complicated than they need to be unless you have a very good reason. Remember we want to avoid compression from dorsiflexion which squashes the achilles tendon around the back of the calcaneus if you perform the exercises off a step.

Exercise 1: Two leg Calf raise from floor not step. (This exercise is often too easy and can be skipped. I tend to only use it for elderly clients)

Exercise 1a: Single Leg (SL) calf raise from floor.

Exercise 2: Toe in SL calf raise from floor

Exercise 3: Toe Out SL calf raise from floor

These simple calf raise exercises are often all that is required when pushed hard to the point of fatigue. The Toe in/out versions engage the stabilising muscles of the lower leg.

How much should you do? Engage brain before muscle.

Remember the right amount of exercise is a specific tailored amount for you. Use my 10 Principles of Rehabilitation Strengthening to figure out your prescription.

  • Start with a very easy fixed amount possibly 1-3 repetitions, probably just a static hold.
  • Work on increasing duration first until you reached a sensible limit (usually 45 seconds per repetition)
  • You might start with doing the exercises just twice per week.
  • Increase the exercises until you feel soreness.
  • Increase the amount of work done each time. You might get up to several times per day or you might keep it to just twice per week and really ramp up the duration and reps.
  • Soreness should be an indication of work done and not damage. This is the strengthning zone. If this doesn’t feel true speak to a professional
  • Keep a note of how much you do (Sets, reps, duration and frequency) and how sore you feel immediately after and the day after the exercise.
  • Increase the amount of work you do at every exercise session.
  • If you are not feeling some immediate soreness you are not working hard enough. Do more next time.
  • Your general symptoms should reduce over time. If your symptoms are getting worse speak to a professional.

Below is a sample progression chart which might give you some idea of how to progress the exercises over the first 8 days. The maximum dose I have ever seen is (5 x 45Secs) x5 – twice per week. This was for a very fit runner. And demonstrates that when you start getting up to very significant amounts of exercise daily might be too frequent.

Day 1Day 2Day 3Day 4Day 5Day 6Day 7Day 8
10 secs x210 secs x320 Secs x1 &

10 Secs x2

20 Secs x2 &

10 Secs x1

20 Secs x330 Secs x1 &

20 Secs x2

30 Secs x2 & 20 Sec x130 Secs x3

3 Most common mistake with treating Achilles tendinopathy.

The three most common mistakes usually happen when we treat it as a tendinitis.

  • Don’t apply ice. It’s not inflamed, why would you!
  • Don’t apply any compression. You want to go out of your way to avoid any compression Tendons hate compression.
  • Don’t rest it. Unless the tendon is very reactive you will get more relief from correct loading than resting. Tendons love load.