What it is

Achilles tendinopathy is a degeneration of the achilles tendon caused by “chronic overuse” and “wear-and-tear”, leading to pain, stiffness, and swelling in the back of the heel.

Achilles tendinopathy is usually associated with a problem of load and tolerance in the tendon that connects the calf muscles to the heel. It can occur at the insertion into the heel bone (insertional) or in the tendon body itself (non-insertional).

Pain is usually felt either 2 to 6 cm above the heel or right at the insertion. It often settles with a short rest, then returns when the tendon is asked to do more than it can currently handle. Stiffness on waking is common and eases as movement increases. Runners often notice pain during faster sessions, on hills, and after sudden increases in weekly distance. Walkers feel it on long days and with stairs. Ignoring it keeps the tendon irritable and limits training. The good news is that tendons adapt and respond well to a correct management plan that matches loading to capacity, allowing strength and tolerance to return.

What happens when it occurs

Repetitive loading causes microscopic changes in tendons, reducing their load tolerance. Pain is the signal that the tissue needs graded loading, not complete rest. It was previously known as Achilles tendinitis, but this term is now considered less accurate because it refers to degeneration rather than just acute inflammation.

Common causes and risk factors

  • Sudden increases in running or hiking volume, speed, or hills “too much, too soon”
  • Reduced calf strength or ankle dorsiflexion
  • Hard surfaces, stiff, worn or poorly supportive footwear
  • Lack of training variation
  • Higher body mass, metabolic factors, and previous tendon injury

Who is most affected

Runners, field and court athletes, and adults who increase activity after a period of inactivity. Adults who tend to lead an active lifestyle, yet spend excessive amounts of time stationary in prolonged postures such as sitting or standing when working.

Typical symptoms

  • Morning stiffness and tenderness, start-up pain, especially after rest or prolonged sitting
  • Localised tenderness mid-tendon or at the heel, worse with activity
  • Pain with hopping, sprinting, or uphill efforts
  • Cracking or creaking when moving the ankle

When to seek care

If pain persists beyond two weeks, limits training, or causes next-morning pain at levels above mild after activity.

How we diagnose

History and examination are usually sufficient.

Ultrasound or MRI is used when a partial tear or insertional calcific change is suspected.

Management

Conservative treatment

  • Relative load reduction rather than complete rest
  • Loading Progression: Tendon-specific strengthening, starting with isometrics, then heavy slow resistance
  • Footwear review and, for insertional pain, a temporary heel lift or rocker shoe
  • Calf mobility and hip strength work, then plyometrics when pain is controlled
  • NSAIDs and analgesics can help with pain
  • Low-impact activities
  • Orthoses and heel lifts
  • Shockwave therapy for persistent cases to reduce pain, improve blood circulation, and tendon gliding ability

Surgical treatment

  • Surgery is rarely required.
  • Typically reserved for severe cases where conservative treatment has failed after several months or in the case of a full rupture.

Rehabilitation milestones

Phase 1, weeks 0–2: pain control, isometrics, short, easy rides or pool sessions.

Phase 2, weeks 2–6: heavy slow calf raises three times per week, double to single-leg; seated raises for insertional pain.

Phase 3, weeks 6–10: plyometric drills, flat tempo running, hop progressions.

Phase 4, weeks 10–16: complete run programme, strides, and change-of-pace work.

Readiness to progress

  • Next-morning pain no higher than 2 out of 10
  • Single-leg calf raise strength and endurance within 90% of the other side
  • Pain-free hop tests and target session completed without flare

Prevention

  • Increase weekly load in small steps
  • Rotate shoes
  • Maintain calf strength year-round

Australia snapshot

  • Among runners, Achilles problems account for roughly 6 to 10% of injuries at any time.
  • Males present more often with Achilles tendon rupture, approximately four to five times more often, likely due to higher exposure to power sports.
  • Field codes, track, and recreational running are the common exposure groups.

Latest insights

Heavy, slow resistance is as effective as eccentric-only plans.

Preserve running exposure with modified volume rather than stopping altogether.

Plyometric preparation before speed work reduces the recurrence of injuries.

Frequently Asked Questions

Timeframes depend on the grade and your starting capacity. Mild injuries often settle within weeks when loading is matched to tolerance. Moderate injuries take longer to recover from, as strength and control are rebuilt. Severe injuries or those with instability need a longer block and closer supervision. Progress is criteria-based.

Yes, if pain during activity stays at or below 3 out of 10 and does not worsen the next morning. Reduce volume and intensity, maintain a tidy technique, and avoid movements that exacerbate symptoms.

Imaging helps when red flags are present, progress stalls after two weeks, or instability or a tear is suspected. Your clinician will advise on whether an X-ray, ultrasound, or MRI is most suitable for your condition.

Use a brace or tape during the early return or on uneven ground. Remove it for controlled strength and balance work so that muscles can relearn their job. We usually advise using a support for a period of at least 3 months after injury, in line with recent evidence.

Ice helps early when swelling and pain dominate. Heat helps later when stiffness is the main issue.

When next‑morning pain is 2 out of 10 or less, strength is within 90% of the other side, and you pass the functional test for this condition, such as single‑leg hops, figure‑of‑eight runs, or step‑downs.

Cut the next session’s volume by 20 to 30 per cent, keep strength work, and retest the following day. Progress again when baseline settles.

They can unload sensitive tissue early. Keep them while strength and control improve, then review fit and need.

Most people continue working on tasks and making standing adjustments. Drive when you can load and move the ankle safely and brake firmly without pain.