Achilles Tendinopathy

This condition commonly presents with pain in the Achilles and/or heel region. For a long time, we referred to tendinopathies as ‘tendinitis’. This was because we believed it was a condition that mainly involved inflammation, leading to treatments such as steroid injections and strong anti-inflammatory medication. However, our understanding of tendon-related pain has improved and we now know that tendons are less likely to inflame in response to overload ⁽⁶⁾.

Our understanding of the best way to manage tendon problems is continually developing and we work hard to try and provide the most up to date evidence based information on this page.

The Achilles tendon is very strong and withstands up to twice our body weight when walking, which increases up to six times when running ⁽⁶⁾. It is essentially a spring-like mechanism and thus stores and releases energy very quickly as we walk or run. Repetition of this spring-like activity over a single exercise session, or with insufficient rest to enable repair and remodelling between sessions, can induce pathology and a change in the tendon’s mechanical properties, which is a risk factor for developing symptoms ⁽⁹⁾. Despite this, it is rare that damage is caused and the tendon is very good at healing itself.

• Achilles tendinopathy is a moderately common condition, particularly in the sporting population.
• In the general population, it is less common, with less than 0.5% getting the condition. It is estimated to affect more than 150,000 people in the UK every year ⁽¹⁾.
• Achilles tendinopathy is one of the most frequently observed ankle and foot overuse injuries.
• It may affect 9% of recreational runners and cause up to 5% of professional athletes to end their careers.

A musculoskeletal physiotherapist can provide you with an accurate and timely diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.

Your physiotherapist will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like magnetic resonance imaging (MRI) or ultrasound scans are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.

As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your Achilles tendinopathy. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference. 

If walking or running is your main activity that brings on symptoms, try to modify rather than stop completely. See some of the guidelines below.

For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to the sport, a rehabilitation programme should incorporate plyometric based exercises; this might include things like bounding, cutting and sprinting exercises ⁽¹¹⁾.

As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and establish appropriate progression of treatment.  Ongoing support and advice will allow you to self-manage and prevent future re-occurrence.

• Podiatry referral to address gross biomechanical alignment issues may be helpful in the short term.
• Heel inserts for your footwear may help relieve symptoms if occurring nearer the heel ⁽¹²⁾. Your therapist will guide you on this.
• Steroid injections are not a recommended treatment for the Achilles tendon as it can affect the integrity of the tissue and has been shown to lead to long-term problems ⁽¹³⁾.
• Surgery –this should be the last option if all other treatment attempts have been exhausted ⁽²⁾.