What is Achilles Tendinopathy?

Achilles tendinopathy is an overuse injury of the Achilles tendon; the band of tissue that connects the calf muscles at the back of the lower leg to your heel bone. It is a common condition that causes this tendon to become irritated, thickened and very tender to touch.

Achilles tendinopathy often occurs in runners and active individuals who have suddenly increased the intensity or duration of their runs and sport. It is common in people who play sports, such as tennis, netball, football and  basketball. It can affect people of all ages, however is much more prevalent in people over the age of 35.It can also occur in more sedentary individuals.

The term tendinopathy encompasses two slightly different tendon issues.

Tendonitis – implies the presence of inflammation within the tendon. This can often be related to the lining or sheath around the tendon, known as the paratenon. Inflammation of the paratenon is known as ‘paratendintis’.

Tendinosis – refers to a degeneration of the tendon’s collagen in response to overuse, without the presence of inflammation. It occurs when the tendon is not given adequate time to rest and repair after a single bout of overactivity or due to repetitive overuse. This can result in micro-tears within the tendon.


If left untreated, the trauma and tears in your tendon fibres can, in some cases, cause a complete or partial tear in your tendon. You might hear a “pop” and immediate pain in the back of your heel or calf. An achilles tendon rupture needs immediate medical attention.


A tendon is a tough band of fibrous connective tissue that connects a muscle to the bone and is capable of withstanding very high forces, however repeatedly overstressing it can injure it.

There are tendons all over your body; the Achilles tendon is the largest tendon, and connects the calf muscles to the heel bone, which plays a vital role when you walk, run, climb stairs, jump, and stand on your tiptoes.

Achilles tendon issues are often categorised into two zones, insertional and mid-portion problems.

Mid portion Achilles pain involves the middle part of the tendon only.

Insertional Achilles pain relates to the lower part of the tendon, where the tendon attaches onto the heel bone (Calcaneus).

The type and location of your Achilles problem will determine the appropriate treatment pathway for you.

What Causes Achilles Tendinopathy

Achilles tendinopathy is usually caused by overuse of the tendon. The tendon struggles to cope with the pressure put upon it, resulting in micro-tears and weakening of the structure; this causes swelling of the tendon and pain.

If it is managed timely and appropriately with rest or modification of activity then the tendon can recover and heal quite quickly, however repeated overstrain and ongoing trauma can exceed the rate of repair, resulting in an incomplete, suboptimal healing response.

At first, the damage may only be minor and not cause any problem, but damage will progressively become worse, causing the tendon to become more inflamed and thickened, which results in significant pain and dysfunction.

Any sports or activity that puts stress on your Achilles Tendon can lead to Achilles tendinopathy. This includes running and any sports that involve jumping.

Intrinsic Risk Factors of Developing Achilles Tendinopathy:

  • Age – As you get older your Achilles tendon becomes less flexible and less able to cope with stress
  • Sex – Achilles tendinitis occurs most commonly in men
  • Previous achilles injury
  • Foot posture – Having high arches or flat feet
  • Certain long-term health conditions such as rheumatoid arthritis, diabetes, high cholesterol or thyroid problems
  • Muscle weakness or tightness – especially in the calf muscles
  • Poor technique
  • Being very overweight or obese

Extrinsic Risk Factors of Developing Achilles Tendinopathy:

  • Type of activity/sport that you participate in
  • Playing/ running surface
  • Incorrect footwear or equipment
  • Sudden increase in the intensity or frequency of your exercise

What are the Symptoms of Achilles Tendinopathy?

Your pain and symptoms will likely start gradually, rather than a sudden onset. When you first feel pain, it will probably only come on after you have exercised. As time goes by you may feel pain during activity; starting as soon as you begin exercising, but then easing after you warm up. This may then develop into constant pain for the duration of the activity and may even affect your normal activities of daily life.

Common Symptoms of Achilles Tendinopathy:

  • Pain – This can be sharp or more of a dull ache.
  • Pain initially eases with activity, but then significantly increases again shortly after activity has stopped.
  • Stiffness in your tendon – often this is worse first thing in the morning or if you’ve been resting for a while.
  • Swelling and/ or redness around the tendon at the back of your ankle.
  • Tenderness when you touch your tendon.
  • Creaking noise (crepitus) when you move your ankle.
  • Thickening or palpable lump in the tendon.

If you have noticed any of these symptoms, and would like to book in to see one of our expert physiotherapists, then please call 0207 482 3875 or email info@complete-physio.co.uk.

How is Achilles Tendinopathy Diagnosed?

Achilles tendinopathy is one of a number causes of lower calf or heel pain. It is essential to get an accurate diagnosis of your problem to ensure that you are started on the best and most effective treatment plan. Achilles tendon pain can mimic; calcaneal stress fractures, posterior impingement of the ankle joint and a calf tear.

Our Physiotherapists at Complete are highly skilled at diagnosing Achilles Tendinopathy. At your initial appointment your Physiotherapist will carry out a comprehensive subjective and clinical assessment.

This will involve your Physio asking questions about your past health, your symptoms, aggravating and easing factors, and your exercise regime, and normal daily activities. This will help to build up a picture of what is the likely cause of the problem.

After this interview, the therapist will complete a series of clinical tests to confirm their diagnosis; this may include:

  • Assessing the range of movement of your ankle and foot.
  • Measuring the strength of your muscles around the calf and ankle.
  • Assessing muscle length and flexibility.
  • Looking at your posture and lower limb alignment.
  • Watching you move your ankle, and how you perform certain activities such as squatting, hopping, jumping, running.
  • Checking other regions of the body; such as knees, hips, feet and lower back, to determine if other areas are contributing to the problem.
  • Gently and skilfully, feeling around your achilles tendon, calf and heel, to find exactly where it is most painful.

The clinical assessment is normally sufficient to diagnose achilles tendinopathy, however in order to gain a more specific diagnosis, and better information about exactly which part of the tendon is affected, we can also carry out a diagnostic ultrasound scan.

Diagnostic Ultrasound Scan

Research suggests that Diagnostic ultrasound is the gold standard imaging tool for assessing tendon structure in the Achilles; it is superior to MRI for this condition and many other tendon complaints.

An ultrasound scan will be able to give you the following information:

  1. Which part of the tendon is injured.
  2. How severe the condition is and if there is inflammation present.
  3. If there are any tears in the tendon.
  4. If there are any other structures involved.

At Complete Physio we are able to offer a unique service that sets us apart from other Physiotherapy clinics. We have a team of qualified sonographers who can carry out an ultrasound scan as part of your clinical assessment. You are not required to have a GP referral, and we do not charge extra for this service.

You will need to be booked in with one of our dual trained  Clinical Specialists, so please ensure you inform our administration team at the time of booking.

How do we Treat Achilles Tendinopathy?

Achilles tendon issues can be very debilitating, and can be quite challenging to treat, due to the high level of recurrence and patient variables. Which is why it is essential to get a clear diagnosis and a focussed treatment programme as soon as possible. At complete Physio, we are experts in treating tendon problems.

Achilles tendinopathy treatment has progressed significantly in recent years due to the large amount of research that has been done in this area.  At complete Physio we ensure that our treatment approach is inline with the latest research. We see hundreds of patients with Achilles Tendinopathy each year, and our Physiotherapists are highly skilled in the management of this condition.

Your treatment is determined by a number of factors:

  • Age
  • Normal activity level
  • Severity of the problem
  • Pain levels
  • Whether the problem is an insertional or mid portion tendinopathy

Physiotherapy Treatment for Achilles Tendinopathy

Your physiotherapist at Complete will provide you with a tailored regime based on your assessment and personal profile.

Pain Relief and Swelling management

It is important to try and reduce your pain and any swelling as quickly as possible. Ice can be very helpful at this stage, to reduce swelling and inflammation, as well as providing some pain relief. You may also benefit from taking a short course of painkillers or non steroidal anti-inflammatory drugs (NSAIDs). You should discuss this with a Pharmacist or GP before taking any medication.

Exercise and Load Management

Exercise is an important part of your rehabilitation programme. This needs to be managed carefully by your therapist. Initially you will need to reduce the load/stress on your tendon to allow it to recover; this may mean total rest from your sport or modifying your training.

Exercise load monitoring is crucial to the success of your Achilles tendinopathy. Mild load increases will stimulate new tendon growth, however, overload can lead to further tendon deterioration.

Most patients should undertake a tendon loading programme, ideally following these general principles:

  1. Low repetition
  2. High weight/load
  3. Speed – exercises should be performed slowly
  4. Frequency – three times a week
  5. Duration – the loading program needs to last for around 12 weeks

Strengthening for Achilles Tendinopathy

Stregthening exercises have always played a key role in the treatment of tendinopathy rehabilitation; however, while they are important, premature or overloaded exercises can delay your recovery. The aim is to commence strengthening that does not significantly aggravate your Achilles tendinopathy. You may initially be started on isometrics (static strengthening exercises) to avoid tendon compression, and progress to a more advanced heavy eccentric and concentric exercise program over a couple of weeks/months.

Massage, Foam Rollers & Stretches

Soft tissue massage or foam roller work can release your calves, shins, quadriceps, ITB, and hamstrings, which can assist in your recovery from Achilles tendinopathy, however are unlikely to cause long term improvement.

Lower Limb Biomechanics

Researchers have identified a number of lower limb biomechanical issues that may predispose you to Achilles tendinopathy. These may include flat feet, poor gluteal (buttock) strength, poor running or jumping technique, altered knee and hip alignment.

Your physiotherapist will individually assess these and advise on appropriate treatment to address any deficiencies. We also offer a more specialised, in depth running assessment if this is required.

Functional and Sports Specific Training

Once your pain, strength, and range of movement improve, your therapist will work on functional and specific, sports related training, to help you safely resume more demanding activities and get you back to doing the sport or exercise that you enjoy.

Shockwave Therapy – also known as Extracorporeal Shockwave Therapy (ESWT) for Achilles Tendinopathy

Physiotherapy will always be the fundamental component of any Achilles Tendinopathy treatment pathway, but there are other options alongside physiotherapy that can be used to improve your pain and promote tendon healing. Shockwave therapy compliments your rehabilitation programme and can significantly speed up your recovery.

Shockwave therapy produces a series of powerful sound waves which causes a small amount of controlled microtrauma to the Achilles Tendon. Research has shown that these shockwaves stimulate the tendon’s natural healing process, initiating new healing. The shockwave pulses also help to desensitise the local nerve endings surrounding the tendon, resulting in reduced pain.

Recent evidence suggests positive outcomes following 3-5 shockwave treatment sessions running concurrently with a progressive loading exercise program for the treatment of all lower limb tendinopathies.

Complete Physio offers shockwave therapy at three of our clinics – Bury Street (next to Gherkin), Chelsea and Angel clinics.

Injection Therapy for Achilles Tendinopathy

If your pain has persisted for over 3 months and you have not improved with physiotherapy then you may be appropriate for injection therapy. Injection therapy is used within musculoskeletal medicine to reduce pain and inflammation, allowing you to effectively rehabilitate your condition.

There are a couple of  injection options for Achilles Tendinopathy.

1. Ultrasound-guided high-volume injection

An ultrasound-guided high-volume injection uses a combination of saline (sterile water) mixed with a local anaesthetic to reduce pain. This technique has been practised for over 10 years and current research shows that ultrasound guided high-volume injection for Achilles tendinopathy can significantly reduce pain and increase function when accompanied by a progressive exercise loading program.

2. Ultrasound-guided platelet-rich plasma (PRP) injection

PRP is a natural and safe treatment that has been clinically proven to enrich the healing process and speed up the recovery of tendons. There are very few side effects and the procedure is well tolerated.

A small amount of blood is taken from a vein and then spun, at high speeds, in a centrifuge machine to separate the PRP from other blood molecules. PRP is then injected, under ultrasound guidance, in and around the most affected regions of the Achilles Tendon. If a tear is identified on ultrasound, it can be directly injected to facilitate accelerated healing.

Research suggests that a series of three injections is required to successfully treat tendinopathic pain.

Surgery for Achilles Tendonitis

Surgery is very rarely required, however in a very small number of cases, if all other treatment has failed, then it may be an option. At Complete we work closely with some of the most senior and experienced foot and ankle consultants in the country, and so if a surgical opinion is required, then we will make sure that you are given the best possible care.

Throughout your treatment with us your Physiotherapist will ensure that you feel supported, and have an active involvement in your recovery process. We will regularly reassess your symptoms and objective markers to track your goals. We are dedicated to getting you back to full function and have an exceptional team of clinicians and specialists.

If you would like to speak to one of our expert physiotherapists or to book an appointment please call 020 7482 3875 or email info@complete-physio.co.uk

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