Achilles Tendinopathy

Pain and stiffness in the tendon, worst in the morning and at the start of activity, often warming up as you move and returning afterwards. A thickened, tender area either mid-tendon or at the heel bone insertion.

A sudden sharp pain with a sense of being struck or kicked in the back of the ankle, with difficulty pushing off, is an Achilles rupture. That needs same-day assessment, not a rehabilitation appointment.

Mid-portion tendinopathy, a few centimetres above the heel, responds well to the standard loading protocols including exercises through full dorsiflexion.

Insertional tendinopathy, at the attachment to the heel bone, is aggravated by that same full dorsiflexion. It needs loading within a reduced range and often a heel raise. Treating the two identically is a common reason a programme fails.

In the irritable phase, loading starts at a level the tendon tolerates; isometric holds are well tolerated, although a trial of 91 patients found they gave no immediate pain relief 2. Heavy slow resistance calf work follows — typically three sessions a week for at least twelve weeks 1. Load is progressed on a schedule; some pain during and shortly after exercise is acceptable.

Running or jumping volume is reduced rather than stopped where possible, because complete rest reduces tendon capacity and symptoms return on resumption.

Twelve weeks is the minimum for a fair trial and many people need longer 1. Shockwave therapy is a reasonable adjunct to loading in persistent mid-portion cases, where a systematic review found moderate-quality evidence for it; for insertional tendinopathy that evidence is lacking 3.

Corticosteroid injection into or around the Achilles is avoided — it is associated with tendon rupture. Fluoroquinolone antibiotics also raise rupture risk and are worth mentioning if you are taking one.

Mid-portion tendinopathy tolerates full range loading including heel drops below the step. Insertional tendinopathy, at the bone, is aggravated by that same movement because it compresses the tendon against the heel bone.

Loading for insertional problems is kept within a neutral range at first. Applying the mid-portion protocol unchanged to an insertional tendon is a common error: in an early series, twelve weeks of full-range eccentric training gave a satisfactory result in 89% of mid-portion tendons but only 32% of insertional ones 4.

Often yes, at a reduced and monitored load. In a randomised trial of 38 patients, those who kept running and jumping while following a pain-monitoring model did as well over 12 months as those who stopped these activities for the first six weeks 5. Both groups followed the same progressive calf-loading programme, so the running was an addition to the exercises rather than a replacement for them 5.

Returning to full sport is a separate step. Recovery can take up to a year and recurrence is common, especially during the return to sport, so the plan takes into account the severity of symptoms, the impairments that remain and the demands of the sport 6.