How to treat Achilles Tendinopathy: physio treatment for Achilles tendon pain

Lucas Anderson

May 13, 2024

Table Of Contents

What causes Achilles Tendinopathy?

People may experience Achilles pain for a variety of reasons, but in the case of a tendinopathy this often correlates with a recent increase in activity. For a long time, it was believed that inflammation was the main driver of these symptoms, but we now know this is not the case. Consequently, this has shaped the way we manage Achilles tendinopathy, with physiotherapy being one of the most effective treatments.

Click here to check out one of our previous blogs on all things Tendinopathy for more info.

Who is at highest risk?

Achilles tendinopathy has its highest incidence in 40-60-year-olds (equally in females and males) and is common in runners or running athletes (AFL, soccer, basketball). You may also get it from ramping up your walking or tennis game.

Achilles tendinopathy pain in men
Achilles injury on running outdoors. Man holding Achilles tendon by hands close-up and suffering with pain. Sprain ligament or Achilles tendonitis.

Clinical Presentation?

Achilles Tendinopathy is a condition where the tendon becomes aggravated with activities such as walking, running, or hopping. A common presentation of this condition includes the following:

–   Recent change in load (i.e. rapid increase in running mileage)

–   Pain with weight-bearing following prolonged rest or sleep (i.e. ‘morning stiffness’)

–   Activity-related pain & stiffness

–   Local tenderness

–   Visible thickening of tendon

–   May be associated with calf tightness

– May be associated with walking barefoot or wearing flat shoes

Diagnosis

Clinical diagnosis is determined through reproduction of pain at the Achilles region with loading tests (i.e. calf raise or hopping). Imaging is not commonly used as up to 45% of people without Achilles pain show changes consistent with tendinopathy (Docking et al. 2022). Your tendon physio will also assess for location. Pain at the insertion of the Achilles or an insertional Achilles tendinopathy is treated differently to a mid-portion Achilles tendinopathy.

How long will I be in pain?

Whilst every case is different, we know that with tendon healing timeframes it can take up to 12-weeks of exercise therapy to see significant improvements in pain and function (Murphy et al. 2018). However, mild symptoms may persist among 60% of cases for up to 5 years (Van der Plas 2012).

How can I manage it?

It is important to mention that appropriate management of Achilles tendinopathy requires accurate diagnosis to determine stage and severity of presentation. However, research states that graded rehabilitation is most effective, including exercise therapy, load management, education on avoiding provocative positions.

Rehab

Exercise rehabilitation can be divided into three phases, which are progressed through based on ability to perform:

1. Early stage: pain-free muscle activation, range-specific strength

a. During this phase we aim to activate the calf muscles without provoking symptoms. This is best achieved through heel raises holds or isometric contractions. These can be repeated and held for up to 45 seconds.

b. See Isometric calf raises options below:

Standing double leg holdBend knee holdsStanding single leg hold

2. Middle stage: Strength through range

a. The aim of this phase is to begin progressively loading the Achilles and calf muscle complex through range to build strength capacity. To begin this, your pain must be within a tolerable level (i.e. 3/10).  

b. Dosage for these exercises should be 3 sets of 6-8 reps, 3-4x per week.

c. See some heavy resisted calf raise variations:

Seated Smith Machine calf raiseStanding Smith Machine calf raiseStanding single leg calf raise with dumbbell

3. Late stage: Plyometric/Sports-specific training

a. In a recreational runner population, the research states that once able to complete a 6RM of 1.5x your body weight in a seated calf raise, you may commence running and plyometric drills (e.g. a 70kg individual must perform 6 reps of a 105kg seated calf raise to run) (Sancho et al. 2022).

b. The following can be performed: plyometrics (hops, skips, jumps) and return to running

Adjunct options

The gold standard treatment for Achilles tendinopathy is exercise, and we know there is no substitute for it (Rabusin et al. 2021). However, there is some evidence to suggest an additional benefit from heel wedges in footwear, or acupuncture, in reducing pain and disability. Manual therapy such as massage, joint mobilisation and dry needling, and treating up the chain can also be beneficial for reducing discomfort and increasing ability to perform exercises.  

Summary

Achilles tendinopathy is a very common condition that occurs in runners and running athletes from recreational to elite populations. Our tendon injury physios can guide you through an individualised program. The best management of this conditions is through activity/load modification, addressing biomechanical contributing factors, and following a specific, graded exercise program.

About the Author

Lucas Anderson graduated from the University of Melbourne with a Bachelor of Science and Doctor of Physiotherapy with Honours. Lucas is a passionate physiotherapist and health advocate who has a range of experience including sports injuries, orthopaedics, post-surgical rehabilitation, falls and balance training. Lucas has experience in local sports, working with Sandringham Zebras VFL in 2023, and is currently a physiotherapist with the Geelong Falcons Girls program. 

Lucas has previously represented Victoria in baseball and is also keen runner and completes triathlons, so also has a special interest in treating lower limb injuries such as Achilles Tendinopathy.

To book an appointment with Lucas in our Torquay clinic click here.

Lucas

References

·  Docking SI, Rio E, Cook J, Orchard JW, Fortington LV. The prevalence of Achilles and
patellar tendon injuries in Australian football players beyond a time-loss defini- 71.tion. Scand J Med Sci Sports. 2018;28:2016–2022.

·  Murphy M, Travers M, Gibson W, Chivers P, Debenham J, Docking S, et al. Rate of 62. improvement of pain and function in mid-portion Achilles tendinopathy with loading protocols: a systematic review and longitudinal meta-analysis. Sports Med. 2018;48:1875–1891.

·  Van der Plas A, de Jonge S, de Vos R-J, Van Der Heide HJ, Verhaar JA, Weir A, et al.
A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. Brit J Sports Med. 2012;46:214–218.

·  Sancho I, Morrissey D, Willy RW, Tayfur A, Lascurain-Aguirrebeña I, Barton C, et al. Recreational runners with Achilles tendinopathy have clinically detectable im- pairments: A case-control study. Phys Ther Sport. 2022;55:241–247.

·  Rabusin CL, Menz HB, McClelland JA, Evans AM, Malliaras P, Docking SI, et al. Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (HEALTHY): a randomised trial. Brit J Sports Med. 2021;55:486–492.