The Achilles tendon connects and anchors your calf muscles to your heel bone. When your calf muscles contract (shortens), they pull on the Achilles tendon. Your Achilles tendon then pulls on your heel bone (calcaneus) to make your toes point – like a ballet dancer. This muscle-tendon-heel-bone-pulling happens when you raise your heels off the ground when you stand on your toes. The opposite action, for example pulling your toes towards your shin, will stretch (lengthen) your calf muscles because the heel bone (calcaneus) is pulling on the Achilles tendon in the opposite direction.

Your Achilles tendon is essential for all ankle movements. It is specifically active in pushing off movements or controlling your landing onto surfaces. Examples of pushing off movements include the push off phase when you are walking or running, pushing your heel off the ground when you’re standing on your toes or jumping, and pushing your foot off of a surface like the start before a sprint. Opposite examples include your Achilles tendon absorbing the force of landing from a jump or exercising control when walking down an incline.

Without your Achilles tendon, you won’t be able to do some of the most basic ankle movements, never mind walk or run. Your foot will feel like it is flopping about when you try to walk.

Healthy tendons are brilliant white in color and have a fibro-elastic structure that consists mostly out of collagen fibers. However, the blood supply and oxygen consumption of tendons and ligaments is 7.5 times lower than that of muscles. The fact that tendons have poor blood supply, means that tendons heal a lot slower after an injury.

The structure of a tendon will change if repetitive strain is put on it. Either through compression or tension. The network of collagen fibers in a tendon gets disrupted by micro-trauma caused by too much strain. It leads to hypercellular activity in the tendon, which is an excess production of collagen cells. So, in an attempt to heal, your body produces more new collagen cells. However, this leads to the tendon thickening and becoming less flexible and ultimately the collagen structure weakening.

Your Achilles tendon must be able to withstand the tension of your calf muscles pulling on it, while also withstanding the compression force of pushing off with your heel. The tendon is elastic, meaning it can stretch and recoil. However, straining the Achilles tendon during physical exercise and overburdening the tendon above it’s physiological limit can cause micro-trauma. Continuous micro-trauma and thickening of the tendon causes increased friction between the fibers. Changes in the tendon changes the ability and strength of the tendon to handle the load put on it. Ultimately it could lead to degeneration of the tendon.

To illustrate using an example: Imagine a bungee cord with no elasticity. When the person at the end of the rope falls, the lack of elasticity means the rope won’t recoil. This means that the cord might snap, because of the sudden jerk (force) without the ability to absorb the shock. The same principle applies with your Achilles tendon. If a sudden force is placed on the tendon, when it is unable to absorb shock or recoil, it gets injured, “frizzles out” or worst case scenario it snaps (Achilles tendon tear/rupture).

Note: Achilles tendon tears are explained in a different article.

The root of the problem

Achilles Tendonitis describes the injuring and subsequent overburdening and wearing out of your Achilles tendon. Wearing out this tendon involves repetitive pulling on the tendon (referred to as ‘overuse’ e.g. jumping into the air) or putting the tendon under excessive force (referred to as ‘overload’ e.g. landing on hard surface from a jump). Other factors like your body weight, biomechanics and metabolic health might make you more prone to get an injury like this.

The term tendonitis, tendinitis and tendinopathy all mean basically the same. The meaning of these terms all boil down to pain, inflammation and pathology of a tendon. Thus, Achilles tendonitis can be described as a generic term used to describe pain and pathology associated with overuse in and around your Achilles tendon. The pain is typically worse with or after movement.

There are different stages of Achilles tendonitis. The condition of the tendon is especially susceptible to change in the early stages of tendonitis. Later on degeneration sets in, and it comes to a point where the tendon cannot change back to a healthy tendon. In the early phase of Achilles tendonitis there might be some inflammation present, but it is mostly the sheath around the tendon that becomes swollen and inflamed. In later stages of tendonitis or chronic tendonitis, very little inflammation will be present in the tendon, if any. The main problem can be traced back to the weak or disrupted tendon fibers.

Interestingly enough it has been shown that not using a tendon enough is just as bad as overburdening it. The same kind of changes happens in an ‘unburdened’ tendon that changes the mechanical integrity of the tendon.

There are two distinct and different areas where Achilles tendinopathy can develop:

Insertional Achilles tendinopathy:

Pain located at the base of your heel, where the Achilles tendon anchors its fibers directly onto the calcaneus.

Mid-portion Achilles tendinopathy:

Anywhere along the Achilles tendon, but more than 4 centimeters above the heel and before the tendon and calf muscles connect. Pain in this area can be experienced on any side of the tendon e.g. inside border, outside border or middle/belly.

• A sudden increase in force – pushing yourself off the ground during high jump
• Running further and faster – sprinting the last 100 m of a 10 km race
• A change in your activity – starting to train for a marathon when you haven’t really jogged in a while
• Changes to the surface on which you exercise – jumping and landing on hardwood floors vs. concrete floors
• The shoes you wear when walking or running – Shoes that are worn out or not giving enough support vs new shoes that you aren’t used to
• Pushing through your pain continuously – Continuing to train even though you’ve injured yourself

• Alignment of the foot and ankle – Increased pronation of the foot can be associated with Achilles tendinopathy
• Calf muscle strength – Calf muscles of one leg stronger than the other
• Flexibility – Lack of flexibility of your calf muscles puts more strain on the Achilles tendon
• Body weight and biomechanics – This influences how much of the load your Achilles tendon takes
• Age and gender – Flexibility tends to decrease with old age
• Hormones – Certain levels of hormones can influence the flexibility of ligaments and tendons
• Diabetes – Diabetes can lead to circulation problems and slow healing of tissues
• Poor circulation – Certain health conditions cause poor blood circulation in your body and can slow down healing of tissues
• Use of certain medications – It has been shown that certain medications (like certain antibiotics) can weaken the structure of tendons

Tendonitis can be classified into three different stages. It starts with acute Achilles tendon pain and if the right steps are not taken to get the tendon back to a healthy state, it progresses. The structure of the tendon weakens over time and can start degenerating and disintegrating. Ultimately leading to an Achilles tendon rupture.

1. Reactive tendonitis (First stage)

The acute phase of Achilles tendonitis (reactive tendonitis) is caused by a change in the amount of work that your Achilles tendon needs to do. Straining, overload and overburdening the Achilles tendon is the biggest deciding factor. Usually, in this phase there will be some inflammation and possibly swelling around the tendon or tendon sheath (synovium).

Let’s say you felt your Achilles ‘pulling’ during a run uphill, but it seems to go away after a while. Now you continue running every day for the rest of the week. At the start of each run you feel pain in your heel, but it improves when you run. It can’t be that bad then, can it? When you push through this pain every time, you are repeatedly causing micro-trauma to your Achilles tendon. If you do not get the right treatment during this phase, the structure of your Achilles tendon starts to change and it gets weaker. At this stage the tendon has the potential to recover and revert back to its normal structure. 

2. Tendon dysrepair (Second stage)

Reactive tendonitis (first stage) can progress to tendon dysrepair (second stage) if the tendon is not allowed to recover. During this phase there is continuous breakdown and disorganisation of the collagen network as your body continues to try and heal the tendon. This means that the collagen fibers are not neatly arranged in bundles, but they tear away from each other, like a cable or rope where the individual strands break and seperate. Applying more force will cause more damage.

In this phase, you will feel a dull pain in your heel at the start of your run, but it will linger a little bit longer, and bother you more and more. Now you start to feel the pain not just during your run, but also throughout the day with simple activities like walking or climbing stairs. As the tendon structure changes, it is not capable of doing the work it should and this causes you more pain. If you do not decrease the burden on your Achilles tendon and allow it to rest, further damage will occur and it can now lead to problems elsewhere, like the knee, hip and lower back.

3. Degenerative tendonitis (Final Stage)

Degenerative tendonitis is the final stage and at this stage there is a poor prognosis for the tendon. The degeneration of the tendon are now irreversible. The structure of the Achilles tendon weakens further. Adhesions form between the tendon and the sheath around it. These adhesions are patches of wound tissue that attempts to heal the torn fibers. The adhesions, together with the fact that the tendon thickens, makes the tendon less flexible. The normal gliding movement of the tendon inside the sheath becomes impossible.

Now, the tendon is able to carry even less load. Leaving you in pain with simple daily activities. This phase of tendonitis usually bothers older people who has had underlying and ongoing Achilles tendon problems, or younger people who has continued to overload the tendon.

Our physiotherapists are able to accurately diagnose your Achilles tendonitis without expensive scans. We know and understand the anatomy of the lower leg, foot and ankle and we know which other soft tissue structures could be involved with Achilles tendonitis. We consider the the intricacy of the biomechanics of walking, running and jumping.

Different factors will contribute to each patient’s Achilles tendon pain. Therefore we look at the bigger picture. We look at what is important to you and what you would like to achieve with your training. During your physiotherapy evaluation, we will be able to determine how bad your Achilles tendonitis is by stretching and stressing the tendon as well as different joints and muscles in the area. We also test muscle strength and length, range of movement and can measure swelling in the area. This is why our physiotherapists are the best at diagnosing this type of problem.

Treatment for Achilles tendonitis is something that can take a very long time. It will feel like your pain takes a long time to improve. Tendons heal a lot slower than other structures and Achilles tendonitis is a type of injury where you will need to change your routine. Tendons don’t like sudden changes to the amount of load they have to carry.

By increasing the distance that you are walking or running, you are increasing the amount of work that your Achilles tendon must do. Increasing your speed, changing your shoes or even changing your route to run uphill more often, are all things that increase the load on your Achilles tendon. Pushing through the pain that has developed in your heel is not the way to go. It will feel like your pain is improving when you move. Only to come back after training or the next morning.

The only way to address this issue is a change in the load that your Achilles tendon must carry. That means that you must decrease your distance or speed or that you might have to do another form of exercise to let your Achilles tendon rest.

You can create a cycle of damage if you constantly overload or overuse the tendon before it heals. An overused or overloaded Achilles tendon causes pain, inflammation or disintegration of the tendon. It takes a long time to recover from this type of injury, which means early diagnosis is very important. Don’t wait too long before you see a physiotherapist and don’t push through pain each time you move!

A common problem we see is that patients wait too long before they seek help for their Achilles tendon pain. By the time patients come to see us, they have had Achilles tendon pain for 6 months to a year and they continued training. Now, the tendon structure has already started to change and weaken, leading to recovery taking so much longer.

Often, patients try to take anti-inflammatory medication in the hopes of decreasing their pain. This, however, only slows the process of healing. And tendons already heal a lot slower than other structures. The only long-term solution for your pain is to change the load that you put on your Achilles tendon. Taking medication will not fix your problem.

The use of an ankle brace or special insoles is another problem we see. An ankle brace will support your ankle and foot, which might help you to feel better when you walk or exercise. However, long-term use of a brace like this will only lead to you getting used to and dependent on the brace. It will lead to the joints and muscles in and around your foot and ankle to become very stiff and weak. This in turn will lead to a few other problems and only increase your recovery time. The same can be said about insoles. Be careful to change your shoes and get insoles too quickly. It will change the biomechanical way that your foot and ankle moves when you walk or exercise. This can put strain on other structures and lead to more pain.

We have seen many patients with Achilles tendonitis, and we can provide the best possible treatment for Achilles tendon pain, that leads to faster recovery. Physios understand that patients are often anxious to get back to their normal activities, so that is why we are here to provide guidance and answers. We can implement a very effective and structured plan of action that treats all the aspects of the problem and get you back on to where you want to be living your best life. However, it’s important that you commit to the treatment plan for your Achilles tendonitis, as this improves your chances of successful long-term recovery.

The basic structure of our treatments:

1. Determine what is injured
2. How bad is it injured?
3. Protect it from further injury
4. Give it time to heal
5. Strengthen surrounding muscles
6. Re-evaluate to monitor progress

We will be looking at different aspects like testing and measuring the ability of the Achilles tendon to take load. However, we will also look at other aspects like muscle strength, range of motion, flexibility and stability. Treatment techniques will include: soft tissue massage, joint mobilisations, dry needling, strapping, laser therapy, nerve mobilisations and guiding you through a rehabilitation program of gradual strengthening, lengthening and conditioning of the tendon.

Your best bet would be to come and see us for comprehensive rehabilitation. We work on all the phases of healing until we can get you back to where you were before your injury.

If you keep in mind the slow healing rate of tendons, then you can plan on physiotherapy treatment for Achilles tendonitis taking anything between 6 weeks to 3 months. Every patient is different and will have different goals. You could experience flare ups in between, but if the full rehabilitation program is followed, we aim to get you back as soon as possible.

The first few weeks, while dealing with the acute phase, we will focus on pain management and healing and then we will progress to gradual tendon loading, and finally rehabilitation. For the first week or two you will need two physiotherapy treatments per week. Thereafter, your treatments will be spread out to once a week. You will have time in between to continue with your rehabilitation program.

• Medication can be used for treatment of your Achilles tendonitis, but long term use of anti-inflammatory medication is not advised as it slows down healing.
• Cortisone injections will not be the solution to your problem. Initially, you might be given a cortisone injection by a doctor for treatment of your Achilles tendonitis. This could help with pain and inflammation and give you some relief. However, cortisone is not good for joint and tendon integrity in the long run.
• Getting an alignment done to improve the way you run or walk will not be the solution or the right form of treatment for your Achilles tendonitis. A sudden pulling movement like this could damage your already weakened Achilles tendon.
• Seeing a biokineticist is not a bad idea. However, in the initial stages of treatment for your Achilles tendonitis, you will need to be seen by a physiotherapist first. Your physiotherapist will then refer you to an appropriate biokineticist when you are ready to progress to the final stages of your rehabilitation program.

If your pain continues without reason and your physiotherapist is worried that something else is wrong, you will be referred to the appropriate specialist. Generally, surgery is not really something to consider with Achilles tendonitis. There is a minimally invasive technique called ‘Tendon stripping’ that could be done by an orthopaedic surgeon. Adhesions formed between the tendon and the surrounding sheath are ‘stripped’ or scraped away. This could improve Achilles tendon pain, because the tendon can now move more freely.

Weighing up surgery and conservative treatment of your Achilles tendonitis is something to think about. A surgical technique could relieve pain in your Achilles tendon, but with physiotherapy and the right rehab, you will improve not only your pain, but any contributing factors to your pain will also be addressed. Surgery will address the symptoms that you feel now. Whereas, your physiotherapist will help you to take a step back and look at the bigger picture. Addressing all the problems and weaknesses that cause your Achilles tendonitis to come back time after time is the best long-term solution.

Plantar fasciitis – Pain at the bottom of your heel or pain stretching over the arch of your foot. It is especially painful when taking the first few steps in the morning.

Haglund deformity – A prominent bony point at the back of your heel bone (calcaneus) that feels especially painful and irritated when you wear tight shoes that rub against the back of your heel.

Sever’s disease – A common cause of heel pain in growing children and adolescents. It is inflammation of the growth plate at the back of the heel bone due to repeated stress and tension of the achilles tendon on the heel bone.

Calcaneal fracture or stress fracture – It is a hairline crack or fracture of the heel bone (calcaneus). It usually happens due to overuse (like marching) or a hard fall directly onto the heel. Walking, marching or running will be painful.

Heel fat pad syndrome  – Deep, bruise-like pain in the center of the heel. Usually due to changes to the fat pad in the heel. The fat pad can become worn and thin or painful and inflamed. It is especially painful when you put pressure on the heel, walking or stepping on your heel specifically.

DVT (deep vein thrombosis) – Pain, redness, throbbing and swelling in your calf due to a blood clot in the area. Especially worse when you try to flex your foot (trying to pull up your toes toward you) or when you try to step on your leg.

Joint Causes

Posterior ankle impingement – Pain at the back of your ankle or heel due to compression of the bones, joints and soft tissue structures. Compression like this happens during repeated and forceful plantarflexion (pointing your toes). It often affects ballet dancers.

Ankle arthritis – Pain and stiffness of your ankle and foot. Your pain feels especially worse in cold weather, after resting and after walking far. Arthritis can affect any of the many joints around your foot and ankle.

Nerve causes

Tarsal tunnel syndrome (posterior tibial nerve impingement) – Ankle and heel pain due to a compressed nerve. It usually happens due to an injury or previous injury that causes irritation or compression to the nerve. You will feel burning pain around your foot that worsens when you are standing or moving your ankle and foot.

Referred pain from your lower back – Pain in your leg, heel and foot that seems to spread from your lower back. Usually you will feel symptoms like pain or stiffness in your back as well. The spreading pain usually worsens when you sit or bend forward. It can also include symptoms like burning, numbness or pins and needles.

Partial or complete achilles tendon tear – A sudden, sharp pain or even snapping sound that you feel at the back of your heel. The achiles tendon can tear (or even tear only partially) during sports, sprinting or even walking. You won’t be able to lift your foot up when you walk or point your toes.

• Achilles tendinitis
• Pulled Calf muscle
• Stiff Achilles
• Achilles tendinopathy