Achilles Tendinopathy: 4 Causes, Symptoms, and Treatment

Achilles tendinopathy can make staying active a real challenge. In my practice at Daniel da Cruz Physiotherapy, it’s a condition I see often, especially among those pushing their limits or adjusting to new routines.

This tendon, which links your calf to your heel, is the strongest in your body, handling up to 12 times your body weight with activities like running and jumping.¹ That’s why it’s prone to overuse injuries.

Unlike a simple injury, tendinopathy involves wear and tear that leads to stiffness, pain, and trouble moving.

But with the right care, including specific exercises, it’s possible to manage the pain, strengthen your tendon, and get back to what you enjoy.²

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What is Achilles Tendinopathy?

Achilles tendinopathy, also known as Achilles Tendinitis, is a condition involving pain, stiffness, and tenderness in the Achilles tendon due to gradual wear and tear.

It often affects people who engage in repetitive or high-impact activities, like running or jumping. Unlike an acute injury, tendinopathy develops over time as the tendon fibers start to weaken and degenerate from overuse or strain, rather than healing fully.³

Who is Most Affected?

Achilles tendinopathy is common, especially in athletes and active individuals. About 10% of all runners experience this condition at some point, making it one of the leading causes of tendon pain in sports.⁴

However, you don’t need to be an athlete to suffer from it—people who spend long hours on their feet or suddenly increase their activity levels are also at risk. Research shows it can impact people of all ages but is more common in those over 30, as tendons lose elasticity with age.¹

Why It’s Common in Active People

The Achilles tendon can handle a lot of force, but repetitive strain—like from running or jumping—can break down its fibers over time. People who increase their workout intensity too quickly or run on hard surfaces are especially prone to this condition.

Cold weather and improper footwear may also contribute to the strain on the tendon, making it harder for the body to repair small injuries before they turn into bigger problems.²

Common Signs and Symptoms of Achilles Tendinopathy

• Morning Stiffness in the Heel or Calf: The Achilles tendon often feels tight or stiff in the morning, especially with the first steps out of bed.
• Pain When Pressing on the Achilles Tendon: Pressing on the tendon just above the heel can cause a sharp or tender sensation.
• Swelling or Thickening of the Tendon: Many people notice that the Achilles tendon appears thicker or slightly swollen compared to the other side, especially after exercise.
• Pain During or After Activity: The pain might fade during exercise but usually returns afterward, often feeling worse after resting.
• Difficulty Standing on Tiptoes: Standing on tiptoes or pushing off with the foot may feel weak or painful, making it hard to perform movements that require balance or push-off strength.
• Achy Pain After Prolonged Sitting: Sitting for a long time may cause the tendon to feel achy or tight when you first start moving again, often requiring a few steps to “loosen up.”

Why Does Achilles Tendinopathy Happen?

Achilles tendinopathy happens when the Achilles tendon slowly breaks down over time. This isn’t like a sudden injury, but more of a gradual weakening that makes the tendon less able to handle normal movements or exercise. Here’s what’s happening inside your tendon and why it feels the way it does.

What’s Going Wrong Inside the Tendon?

In a healthy Achilles tendon, the fibers are organized in a smooth, strong structure that lets you move powerfully. But with Achilles Tendinopathy, these fibers start to get jumbled and frayed, kind of like a rope that’s starting to unravel.

The body tries to repair the damage, but with constant use and little time for rest, it just can’t keep up, so the tendon gets weaker and more painful.³

Why Isn’t the Tendon Healing?

Normally, your body repairs small injuries quickly. But in Achilles Tendinopathy, the constant use—like from running, jumping, or even lots of walking—creates more damage than the body can keep up with.

Without enough time to recover, the tendon falls into a cycle where it’s always trying to heal but never quite getting there.²

Blood Flow Issues

The Achilles tendon doesn’t have a strong blood supply, especially in the part just above the heel. Blood carries the nutrients and oxygen needed to heal, so without enough of it, the tendon can’t easily repair itself.

This limited blood flow makes it tough for your body to fix the damage and leaves the tendon vulnerable to ongoing problems.⁵

Repeated Stress on the Tendon

Achilles tendinopathy often shows up in people who do a lot of repetitive movements, like running, jumping, or even standing for long hours. All this pressure on the tendon can cause tiny tears in the fibers.

When these tears happen again and again without enough rest, they eventually add up to a bigger problem. People who suddenly increase their activity levels or change their exercise routine are especially at risk.¹

What Other Conditions Could It Be?

Achilles Tendon Rupture

An Achilles tendon rupture happens suddenly, often with a sharp pain and a “pop” feeling. Unlike tendinopathy, which worsens gradually, a rupture makes it difficult to walk immediately.³

Retrocalcaneal Bursitis

Retrocalcaneal bursitis is inflammation of the bursa near the heel. This causes pain on the sides of the heel, especially with side pressure, unlike tendinopathy, where the pain is along the tendon itself.³

Posterior Ankle Impingement

Posterior ankle impingement, common in ballet dancers, causes pain when the foot is pointed downward. This pain is felt deeper in the ankle, unlike the surface-level tendon pain in tendinopathy.⁶

Haglund’s Deformity

Haglund’s deformity is a bony bump on the heel that can irritate the tendon, especially with tight shoes. This pain is usually felt around the heel bone, while tendinopathy pain is directly in the tendon.⁷

Plantaris Tendon Pain

The plantaris tendon, which is located near the Achilles, can cause localized pain along the inner ankle without the thickening seen in tendinopathy.⁵

Common Problems of Ignoring Achilles Tendinopathy

Ignoring Pain

Pushing through the pain, hoping it will disappear, is a common mistake. Pain is your body’s way of saying, “Take it easy.”

Ignoring it can lead to worse damage, making even simple activities like walking painful and turning a short-term problem into something long-lasting.⁸

Getting Back to Activity Too Soon

When the pain starts to ease, it’s tempting to jump back into regular activities. But if the tendon isn’t fully healed, this can make the problem worse.

It’s crucial to ease back slowly; otherwise, you risk undoing your progress and extending your recovery.³

Wearing the Wrong Shoes

Wearing shoes with poor support, or using worn-out footwear, can put extra pressure on the Achilles tendon.

Proper, supportive footwear (or using inserts) can really help the tendon recover. Ignoring this step might make recovery longer or cause recurring pain.²

Consequences of Neglect

If left untreated, Achilles tendinopathy can lead to chronic pain and lasting damage to the tendon, making it weaker and less flexible.

In severe cases, untreated tendinopathy can result in a tendon tear, which often requires surgery and a lengthy recovery.⁴

Types of Scans for Diagnosing Achilles Tendinopathy

Ultrasound

An ultrasound is often the first choice. It’s quick, painless, and allows us to see the tendon in real-time, looking for swelling, thickening, or frayed fibers. This scan also shows blood flow, which can indicate irritation or damage.²

MRI (Magnetic Resonance Imaging)

MRI provides a detailed picture of the tendon and surrounding area. With MRI, we look for signs of tendon damage, thickening, or tiny tears, along with any fluid buildup that might indicate inflammation.³

X-Ray

While X-rays don’t show the tendon itself, they help us check for bone spurs or calcium deposits near the tendon, which can irritate it and cause pain. This scan is useful for spotting structural issues in the bone that may be contributing to tendon pain.⁶

Surgical Treatment for Achilles Tendinopathy

Surgery is usually the last option for Achilles tendinopathy and is considered only after trying several months of non-surgical treatments like exercises and rest.

Surgery may be recommended if the pain is severe, limiting daily activities, and does not improve despite all efforts. The purpose of surgery is to remove damaged parts of the tendon and repair any areas that aren’t likely to heal on their own.⁹

When Surgery Might Be Needed

Surgery might be recommended if:

• Non-surgical treatments haven’t worked after several months.
• Scans show severe tendon damage that likely won’t heal without surgery.⁷

The Role of Physiotherapy After Surgery

Physiotherapy is essential after surgery to help you regain strength. At first, we’ll focus on gentle movements to reduce swelling and get you moving comfortably.

Over time, we’ll add exercises to build strength and flexibility in your tendon and surrounding muscles. This process helps restore normal movement and reduce the chances of re-injury.¹⁰

Treatment Options for Achilles Tendinopathy

Exercise Therapy

Exercises, especially eccentric exercises (lowering the heel slowly), are proven to help strengthen the tendon and reduce pain over time. Regular exercise therapy helps the tendon become more resilient.⁴

Myofascial Release

Myofascial release applies gentle pressure to muscles and tissues around the tendon, reducing tension, improving blood flow, and easing pain. Releasing tight calf muscles can reduce strain on the tendon.⁸

Orthopedic Manual Therapy

This hands-on technique helps improve joint mobility and reduce stiffness in the ankle and foot, which can relieve pressure on the Achilles tendon and improve overall movement.³

Laser Therapy

Low-level lasers target areas of pain and inflammation, promoting healing by improving blood flow. Studies suggest that combining laser therapy with exercise may speed up recovery.⁸

Dry Needling

This involves placing thin needles into tight spots in the calf muscles to relieve tension and reduce pain around the Achilles tendon. Improved blood flow and less tightness help ease strain on the tendon.⁹

Strapping and Taping

Taping or strapping supports the Achilles tendon, reducing strain and making movement more comfortable. This technique is helpful for staying active while managing symptoms.⁴

Conclusion

Achilles tendinopathy doesn’t have to limit your life. With the right exercises, treatments, and a bit of patience, you can reduce the pain, rebuild strength, and get back to what you enjoy.

Recovery takes consistent effort, but every step—whether it’s sticking to exercises, resting as needed, or wearing supportive shoes—counts toward your healing.

I’m here to support you, answer questions, and adjust your plan as needed. Together, we’ll work toward a full recovery and get you back to moving freely and pain-free.

About the Author

Daniel da Cruz is an HPCSA-registered physiotherapist based in Sandton, South Africa, with extensive experience treating Achilles tendinopathy and other lower-limb injuries in runners, athletes, and active professionals.

At Daniel da Cruz Physiotherapy, his approach combines the latest evidence-based rehabilitation strategies with practical education to help patients understand their condition, restore tendon strength, and return to pain-free movement.

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References

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