Achilles Tendinopathy: Causes, Symptoms & Evidence-Based Management
- Feb 27
- 3 min read
Expert Physiotherapy Guide to Reducing Pain, Restoring Function & Returning to Sport
Achilles tendinopathy is one of the most common overuse injuries affecting both athletes and active individuals, particularly runners, jumpers and those exposed to repetitive tendon loading.
It can significantly impair performance and daily function, but with the right evidence-based management, most people recover well.
What Is Achilles Tendinopathy?
Achilles tendinopathy is characterised by:
Localised pain
Swelling
Impaired function
of the Achilles tendon — the structure connecting the calf muscles to the heel bone.
It is usually caused by repeated mechanical overload over time, leading to structural and cellular changes in tendon tissue.
There are two main presentations:
Mid-portion Achilles Tendinopathy
Pain occurring 2–6 cm above the heel.
Insertional Achilles Tendinopathy
Pain at the tendon’s attachment at the heel.
Both share similarities but require slightly different management considerations.
Why Does It Happen? Key Risk Factors
Achilles tendinopathy is multifactorial.
The primary driver is relative overload — when tendon load exceeds its capacity.
Other contributing factors include:
Training errors or rapid increases in activity
Biomechanical changes during running or jumping
Muscle-tendon strength deficits
Age and systemic comorbidities (e.g. diabetes, obesity)
Research suggests altered foot and ankle biomechanics, such as changes in ankle inversion moments, may increase stress through the tendon during running.
Clinical Presentation & Diagnosis
People with Achilles tendinopathy typically report:
Pain during or after activity (especially running)
Morning stiffness
Tenderness to touch
Local swelling
Diagnosis is primarily clinical, based on:
Injury history
Physical examination
Imaging (ultrasound or MRI) may assist in complex cases but often does not change management.
If you are unsure whether your symptoms relate to Achilles tendinopathy, a structured assessment with a sports physiotherapist in Drummoyne can help clarify diagnosis and treatment direction.
Evidence-Based Management
1. Progressive Exercise & Load Management
Exercise-based rehabilitation remains the cornerstone of treatment.
Key components include:
Progressive loading exercises targeting the calf and Achilles tendon
Eccentric training
Heavy slow resistance exercises
Transitioning into functional and sport-specific exercises
While eccentric training was historically considered the gold standard, modern research supports comprehensive loading programs addressing kinetic chain deficits to improve tendon capacity and reduce recurrence.
Early introduction of isometric exercises can:
Reduce pain
Improve force tolerance
Allow loading without symptom aggravation
2. Activity Modification & Training Adjustment
Complete rest is generally not recommended.
Tendons require controlled loading to recover.
Temporary reduction in:
Running volume
Jump frequency
High-load activities
while maintaining strength training is often necessary.
3. Adjunct Interventions
In persistent cases, additional options may include:
Extracorporeal shockwave therapy
Platelet-rich plasma (PRP) injections
These may offer short-term benefits when combined with structured exercise, but they should not replace progressive loading programs.
What About Surgery?
Surgical intervention is rarely required.
It is reserved for cases failing structured conservative management for over 12 months, or in cases involving structural tendon tears.
Procedures may include:
Tendon debridement
Tendon augmentation
These are considered only when non-operative management has been exhausted.
Rehabilitation Stages: A Practical Framework
Acute Phase
Isometric holds
Gentle loading
Irritability management
Address contributing factors (e.g. foot intrinsic weakness)
Strength & Capacity Building
Eccentric exercises
Heavy slow resistance training
Gradual load progression
Early rate of force development training
Functional Performance
Sport-specific movements
Plyometrics and agility (as tolerated)
Return to Activity
Progression is based on:
Load tolerance
Pain response
Functional capacity
—not timelines alone.
Rehabilitation should be tailored based on:
Mid-portion vs insertional presentation
Individual goals
Sport demands
Summary: What Works Best
Achilles tendinopathy is a common overload condition often driven by poorly managed load.
✔ Progressive loading programmes incorporating strength and kinetic chain work are most effective.
✔ Eccentric training remains important but should sit within a broader program.
✔ Plyometric training should be graded and integrated carefully.
✔ Education and activity modification improve outcomes.
✔ Surgery is rarely required.
At Sports Performance Physiotherapy in Drummoyne, we combine evidence-based rehabilitation with personalised programming to restore tendon capacity and support safe return to sport.
If you are experiencing persistent Achilles pain in Drummoyne or the Inner West, book an assessment today.
References (APA 7)
Post, A. A., Rio, E. K., Sluka, K. A., Moseley, G. L., Bayman, E. O., Hall, M. M., … Danielson, J. S. (2020). Effect of pain education and exercise on pain and function in chronic Achilles tendinopathy: Protocol for a randomized trial.PMC7678911.
Ganderton, C., Cook, J., Docking, S., Rio, E., Van Ark, M., & Gaida, J. (n.d.). Achilles tendinopathy: Understanding the key concepts to improve clinical management.
MDPI. (2021). An overview of Achilles tendinopathy management.
PubMed. (2021). Achilles tendinopathy: Clinical overview.
Rowe, V., Hemmings, S., Barton, C., Malliaras, P., Maffulli, N., & Morrissey, D. (2012). Conservative management of midportion Achilles tendinopathy.
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