Achilles Tendinopathy

Back of two feet and ankles with a highlighted red area over the Achilles tendinopathy showing pain

What is Achilles tendinopathy?

Your achilles tendon is the largest tendon in the body, connecting the muscles in the back of your calf to your heel bone. This tendon allows you to stand on your toes when walking, running or jumping- so yeah, it's kind of important. 

Although people may use the terms interchangeably, Achilles tendinopathy and Achilles tendonitis are different conditions. Tendonitis occurs when the tendon becomes inflamed often due to sports or other activities, whereas tendinopathy is a degenerative condition thought to be caused by repeated tiny injuries to the tendon, and can affect anyone.

The different types

Achilles tendinopathy will be classified as either mid-portion or insertional depending on the location. Mid-portion usually presents with pain 2-6cm above the heel bone, compared to insertional, where the person will be experiencing pain at the point where the Achilles tendon inserts into the heel bone.

It's important to diagnose the correct type of tendinopathy as many of the exercises for mid-portion will aggravate an insertional condition if misdiagnosed. 

Back of two feet and ankles with a hand clutching one heel. Two shaded areas show the locations of two different Achilles tendinopathy conditions

Causes

Achilles tendinopathy generally occurs from gradual wear and tear of the tendon due to overuse or ageing. Although it may seem like a sudden injury, it is more likely that the tendon has weakened over time from completing the same actions over and over in your job, exercise routine or even regular daily activities.

The most common causes include: 

  • Overuse or over-training.
  • Wearing poorly supported footwear while exercising or training.
  • Sudden change in the intensity, duration and occurrence of your training routine.
  • Exercising on hard or uneven surfaces.
  • Poor exercise or training techniques.
  • Tight calf muscles from lack of stretching.

Who's at risk

Achilles tendinopathy is a fairly common condition that can affect both active and inactive people, however it is more often an issue for people who take part in running-based exercise and stop-start sports including tennis, netball, soccer, long-distance running etc.

It affects both men and women, however evidence shows it is more common among men over the age of 30.

Specifically, factors that can raise the risk of someone developing Achilles tendinopathy include:

  • Males
  • Over the age of 30
  • People with above-average body weight
  • Active runners, joggers and jumpers
  • People with chronic health issues eg. diabetes or rheumatoid arthritis
  • People with low muscle tone, especially in the calf muscles
  • People wearing poor footwear

Symptoms

Symptoms of Achilles tendinopathy can vary in people, but some of the more common symptoms associated with the condition include:

  • Morning stiffness: Many people often complain of stiffness around the back of the ankle area when they get up first thing in the morning. This stiffness would usually ease up after a few minutes of walking, but sometimes it may last longer.
  • Noticeable tenderness in the Achilles tendon: Most times the tendon would be very tender to touch or gently squeeze. If the injury occurs in the mid-part of the tendon (mid-portion Achilles tendinopathy), it would often result in an obvious, tender lump, usually 2-4cm above the heel. If it occurs at the attachment of the tendon onto the bone (Insertional Achilles tendinopathy), this may cause a painful spur on the back of your heel.
  • Achilles tendon pain: People can often push through the pain, but the degree of pain and the onset of pain usually varies from person to person. This means that people may not feel pain during their exercise, but then pain exacerbates after some rest. Other people may experience severe pain in their Achilles tendon which stops them from exercising.
  • Swelling/thickening may occur over the tendon
  • Inability to stand on tip-toe or plantar flex the foot against resistance: Plantar flexion is the movement where the top of your foot points away from your leg. Examples of when you use plantar flexion the most include standing on your tip-toes, pointing your foot downwards, or pressing down the accelerator in your car. The Achilles tendon facilitates these movements, so if it's not functioning correctly, these movements become very difficult. 
  • Inability to bear weight normally on the affected limb.

Self management

If you're experiencing pain in the back of your heel the morning after activity, there's a couple of things you can do yourself.

Follow advice from the POLICE!

P = Protection
The first thing you should do when you injure your Achilles tendon is to rest the injured tendon and reduce any weight and pressure to the area. During this time, you may use assistive devices, like crutches, to help you walk and NSAIDS for pain relief and anti-inflammatory properties.

OL = Optimal loading
With any muscular tendinous movements, if you don’t use it, you lose it! This rings true even in the case of an injury. While maintaining protection, you should be able to progress from a few days of rest, to gentle exercises. This progressive loading will help to promote healing and prevent muscle atrophy.

I = Ice
Ice the tendon with an ice pack wrapped in a towel for 15-20 minutes at the end of the day. This provides pain relief and reduces inflammation and swelling surrounding the tendon.

C = Compression
While icing the tendon, you can also add compression with bandages to assist in reducing the swelling surrounding the tendon — but be careful not to wrap it too tight.

E = Elevation
Raise your legs above the level of your chest. When the legs are higher than the heart, the blood will flow back to the heart faster, which will reduce swelling. It is easy to do by putting your legs over a pillow while you're lying down.

A man holding an ice pack against his painful ankle
The side of a bandaged foot held in the air
A girl with an injured foot has it elevated on a cushion to reduce swelling

Stretching

As briefly mentioned, tight calf muscles are one of the major contributors in developing Achilles tendon issues. When we start exercising with a tight calf, this usually means that the Achilles tendon is placed in greater stress. With more exercise, the tendon will be under stress that exceeds its normal threshold, which ultimately leads to tendon breakdown. 

When is a good time to start stretching?

The timing to start stretching is very important when dealing with Achilles tendon issues. It is important to start the stretching process as soon as we can to decrease the stress on the tendon, but too early may lead to further injury.

We generally recommend the following:

  • If you are experiencing pain greater than 3 out of 10, do not start stretching exercises.
  • If the pain is below 3, start gentle stretching exercises to the point of no pain. 

Some stretching exercises include:

A drawing of a man performing wall calf stretches including gastroc stretch and soleus stretch

Wall Calf Stretch
Gastroc stretch:
Position yourself facing the wall. Keep the leg to be stretched at the back and the forward leg bent. Lean forward until you can feel the calf stretch in the back leg. 

Soleus stretch: Same positioning as previous stretch. The only difference is bend both the back and front leg. You should feel the stretch in the lower part of the calf. 

Hold the position for 30s and repeat it 3 times for each leg.

Fit young woman stretching and rolling her calves with a foam roller


Calf foam rolling

Start off foam rolling gently in long strokes from the top of the calf to the bottom. Once the calf is warmed up, move to a spot of tenderness and hold the area for 20s. Once the area is finished you can then move on to the next. One technique you can use to increase the effectiveness is that while you are on the spot of tenderness, you can then move the ankle up and down.

Progressive Loading

Often when people experience pain in their feet or legs, their first response is to stay at home and avoid doing all forms of activities in an attempt to heal the area. Although resting is helpful, allow us to break your bubble and say that progressive loading is crucial for the healing of the tendon.

Similar to a rubber band,  if the load is stronger than the elasticity of the rubber band, the band will snap. With the Achilles tendon, if the load and forces acting on the tendon is greater than the elasticity/load capacity of the tendon, it will begin to tear. However, if a gradual load is being applied to the tendon without it reaching past breaking point, the tendon will adapt to the load applied and become stronger and more tolerable to stronger stimuli. 

The key word here is... progressive

To start things off, if you are experiencing high levels of pain, and unable to perform any dynamic loading of the tendon, you can start by doing some isometric exercises.

Two pairs of feet in green sneakers, one with feet flat on the floor, the other with the heels raised



Depending on the symptoms and tendon irritability, this exercise can be performed with either one or both legs.

  1. Hold for 45s and repeat 5 times.
  2. Have a 15-30s interval in between each rep.
  3. Repeat this 3-4 times a day.


If you are able to tolerate dynamic loading with minimal pain levels, you can start introducing some additional load into the tendon through:

Exercises
Protocol
1. Seated Calf Raises
3 sets of 10 reps
2. Double Leg Calf Raises
3 sets of 10 reps
3. Single Leg Calf Raises (with weights)
3 sets of 10 reps

Footwear

Do you feel your Achilles tendon is sometimes worse when you go for your usual stroll around the park in Dunlop volleys, or go to work in your ballet flats? Why is that?

Well, the most obvious answer is the support in the shoe- but it is also the pitch of the shoe.

The pitch of the shoe, or the heel drop, refers to the differences in height from the rearfoot to the forefoot. In the shoes mentioned above, the major similarity between them is the lack of heel pitch. This can increase the level of discomfort felt in the tendon, especially if your calves are tight.

One of the first things you can change is your shoes. Most traditional running shoes have a shoe pitch of 10-12mm. This tends to decrease the level of your discomfort as it reduces the stress on the Achilles tendon by elevating the heel towards the calf muscle. 

If you are already in good, supportive running shoes, your podiatrist may recommend using heel lifts, either prefabricated or custom made ones. You would place this in the heel region of your shoe, preferably under the innersole to assist in offsetting the negative effects of tight calf muscles and Achilles tendons.

Treatment

Hopefully by now, you are more confident in knowing what Achilles tendinopathy is and have learned a few tips to help you get back on your feet quicker. However, if you are still experiencing symptoms, don’t be afraid! There's definitely more we can do to help. 

1. Custom orthotic therapy

At The Feet People, we offer orthotic therapy to treat conditions such as Achilles tendinopathy. Custom foot orthosis are customised insoles, which we manufacture and fit into your shoes (may it be your running shoes or your day to day walking shoes). Their primary function is to distribute the pressure evenly across your foot, as well as correct biomechanical misalignment to improve function. 

2. Parotec in-shoe pressure analysis system

We also use the Parotec pressure analysis system, which accurately measures the pressures in the feet when performing dynamic movements. We use this to show the effectiveness of our interventions. 

A comparison image showing two scans of feet using the Parotec pressure analysis system, one shows pressure in the feet before treatment compared to good pressure levels in the feet after treatment


3. Dry needling and FMT

If the stretching exercises are not producing any short term benefits, we offer dry needling and foot mobilisation (FMT) to help you gain back your ankle's range of motion in a short period of time. 

4. Shockwave Therapy (ESWT)

For long standing Achilles tendinopathy issues, we can also treat using radial shockwave therapy. Shockwave therapy works by introducing radial shock waves into the body using a transmitter. When introduced into the tissue, these pressure waves will effectively increase local blood flow and the formation of new blood vessels to create an improved environment for tissue repair. 

We will often combine these treatment measures with a range of stretches, strengthening exercises and possibly a recommendation for a change in footwear to ensure we give you an accurate treatment plan. 

Prevention

It may not be possible to prevent Achilles tendinopathy, however there are a number of preventative measures you can take to reduce your risk. 

  1. Load management: gradually increase the distance, speed and intensity of your activities. 
  2. Strengthen: the progressive loading exercises mentioned above are also great for preventing an Achilles tendon injury by strengthening the muscles.
  3. Stretching: It is key to stretch daily, particularly before and after exercise, to ensure the calf muscles don't become too tight.
  4. Footwear: Wear supportive shoes when possible. 

FAQs

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