Achilles tendinopathy
A common painful condition of the Achilles tendon, the strong band of tissue connecting the calf muscles to the heel bone. It develops gradually due to overuse and degenerative changes in the tendon.
📊 Achilles tendinopathy affects approximately 6% of the general population at some point in their life, and is particularly common in runners, where lifetime incidence is around 50%.
What is Achilles tendinopathy?
The Achilles tendon is the largest and strongest tendon in the body, formed by the joining of the gastrocnemius and soleus muscles in the calf, and inserting onto the back of the heel bone (calcaneus). Every time you walk, run, or push off, this tendon transmits considerable load. Over time, repetitive loading - particularly when it exceeds the tendon's capacity to recover - leads to microscopic damage and degeneration within the tendon, a process called tendinopathy.
The condition is divided into two types based on location. Mid-portion tendinopathy affects the tendon 2-6cm above its insertion and is the most common form. Insertional tendinopathy affects the point where the tendon attaches to the heel bone and is often associated with a bony prominence (Haglund deformity) or calcification within the tendon. The two types respond differently to treatment, so accurate diagnosis is important.
Despite its name (ending in "-itis"), Achilles tendinopathy is not primarily an inflammatory condition. Microscopic studies show disorganised collagen fibres, increased water content, and abnormal blood vessel growth, but minimal inflammatory cells. This understanding has shifted treatment away from anti-inflammatories and rest, towards progressive loading exercises that stimulate the tendon to remodel and strengthen.
Common causes
- Sudden increase in running distance, frequency, or intensity
- Inadequate warm-up or stretching
- Tight calf muscles
- Change to harder running surfaces or hills
- Unsupportive or worn-out footwear
- Quinolone antibiotics (rare but recognised cause)
- Inflammatory arthritis or diabetes
Who is at risk? Risk factors include age 30-50, male sex, obesity, diabetes, inflammatory arthritis, fluoroquinolone antibiotic use, and high-impact activities such as distance running, basketball, and tennis. A previous Achilles tendon problem is one of the strongest predictors.
Symptoms
Symptoms vary depending on the severity and duration of the condition. Common symptoms include:
- Gradual onset of pain and stiffness in the back of the heel or just above it
- Morning stiffness that improves with movement but returns after rest
- Pain that worsens with activity, particularly running, jumping, or hill walking
- Localised swelling or thickening of the tendon
- Tenderness on squeezing the tendon
- A creaking sensation when moving the ankle (crepitus) in some cases
When to seek help: See a specialist if pain has persisted for more than 6 weeks despite rest and activity modification, if pain is limiting daily activities, or if there is any sudden severe pain or inability to push off the foot (which may indicate a tendon rupture - a medical emergency).
How is it diagnosed?
Your foot and ankle specialist will take a detailed history and examine the foot. The following investigations may be arranged to confirm the diagnosis:
- Clinical examination - localised tenderness 2-6cm above the heel (mid-portion) or at the insertion
- Single-leg heel raise test - reproduces pain on the affected side
- Royal London Hospital Test - pain reduces when ankle is dorsiflexed in mid-portion tendinopathy
- Ultrasound - shows tendon thickening, hypoechoic areas, and abnormal vessels (neovascularisation)
- MRI - reserved for diagnostic uncertainty, surgical planning, or to exclude partial rupture
It is important to distinguish tendinopathy from a partial or complete tendon rupture. The Simmonds-Thompson calf squeeze test (lack of plantarflexion when squeezing the calf) is highly sensitive for complete rupture. Suspected rupture warrants urgent same-day assessment.
Treatment pathway
Treatment is tailored to the severity of the condition, your age, activity level, and overall health. Most conditions are treated in a stepwise fashion, starting with the least invasive options.
Eccentric loading exercises (Alfredson protocol)
A specific exercise programme involving slow, controlled heel drops off a step, performed daily over 12 weeks. This is the most evidence-based treatment for mid-portion Achilles tendinopathy, with around 75-80% of patients seeing significant improvement.
Activity modification and footwear
Reducing aggravating activities, gradual return to running, and ensuring supportive footwear. Heel raises in shoes (10-15mm) can reduce strain on the tendon, particularly in insertional disease.
Extracorporeal shockwave therapy (ESWT)
For patients who do not respond to exercise alone after 3 months, ESWT has good evidence of benefit, particularly when combined with continued loading exercises.
High-volume injection or platelet-rich plasma
Image-guided injections may be considered in chronic cases. Evidence is mixed, and corticosteroid injections directly into the tendon are generally avoided due to risk of tendon rupture.
Surgical debridement or tendon reconstruction
Reserved for severe cases that fail at least 6-12 months of conservative treatment. Surgery involves removing degenerate tendon tissue and stimulating healing. Insertional disease may also require removal of a Haglund deformity. Recovery takes 6-12 months.
Recovery
Recovery from Achilles tendinopathy requires patience and consistency. The eccentric loading programme works by stimulating the tendon to remodel, but this is a gradual process. Pain may initially worsen during the first few weeks of loading - this is expected and not a sign of harm, as long as the pain settles within 24 hours and is not severe. A graduated return to running is usually possible from around 3-4 months.
- Initial eccentric loading: 12 weeks
- Significant improvement expected: 3-6 months
- Return to full running: 6-9 months
- Recovery from surgery (if needed): 6-12 months
What results can I expect?
Around 75-80% of patients improve significantly with eccentric loading and conservative measures within 6 months. Insertional tendinopathy tends to be more resistant to treatment than mid-portion disease. Up to 25-30% of patients have persistent symptoms despite treatment.
In numbers
When can I…?
Typical activity timelines for this condition. These are approximate and vary considerably between patients. Always follow the specific guidance given by your surgeon and physiotherapist.
| Activity | Typical timeline | Notes |
|---|---|---|
| Walk | Most days | Walking is encouraged. Avoid the temptation of complete rest.[1] |
| Drive | No restriction | Achilles tendinopathy does not affect fitness to drive. |
| Start loading exercises | Day 1 | A structured calf-loading programme (such as the Alfredson protocol) is first-line treatment.[1] |
| Reduce running | Initially | Cut running volume by around half for the first few weeks. Cycling and swimming are useful alternatives.[1] |
| Return to running | 8-12 weeks | Gradual return guided by symptoms during and after running. A small amount of tendon discomfort is acceptable; sharp pain is not.[1] |
| Expect benefit | 3-6 months | Symptoms improve gradually with consistent loading. Most patients see substantial change by 3-6 months.[1] |
Is this normal?
Common concerns from patients with this condition or recovering from treatment, and whether they are expected or worth mentioning to your team.
Preparing for surgery?
Read our step-by-step guide: what to expect before, during, and after your procedure.
Related conditions
Your questions, answered
Plain-English answers to the things people most often ask, grounded in published guidance. Tap a question to open it.
About thisIs this the same as a ruptured Achilles?
No. Tendinopathy is pain and gradual wear in the tendon from overuse, not a tear. It causes pain and stiffness at the back of the heel or a few centimetres above it, often worst at the start of activity.
A rupture is a sudden complete tear with a very different story, usually a sharp snapping sensation and weakness pushing off.
Your choiceWhat is the main treatment?
Progressive loading exercises for the calf and tendon, building strength gradually, are the cornerstone and the most effective treatment. A physiotherapist can guide the programme.
It works but it is slow, typically taking three to six months of consistent effort. Insertional tendinopathy at the very back of the heel can be slower again.
InjectionsShould I have a steroid injection into the tendon?
Steroid injected into or around the Achilles is generally avoided because it can weaken the tendon and raise the risk of rupture.
Other measures such as a structured loading programme and, in selected cases, shockwave therapy are preferred.
Pain & sleepShould I rest it completely?
Complete rest tends to make tendon problems worse over time. The aim is to modify load rather than stop, keeping activity within a tolerable level of discomfort while you build strength.
Some ache during and after exercise is acceptable as long as it settles and is not getting steadily worse.
Getting backHow long until I am back to sport?
Most people need several months of regular rehabilitation before returning to running or jumping sport, building back gradually.
Returning to full load too quickly is the commonest reason symptoms flare again.
Your choiceWhen is surgery considered?
Surgery is only considered when at least six months of a good non-surgical loading programme has not helped. It may involve clearing diseased tissue or a calf-lengthening (gastrocnemius recession).
Most people never need an operation.
UrgentWhat should make me seek help quickly?
Sudden severe pain with a snap or a feeling of being kicked in the calf, and difficulty pushing off or standing on tiptoe, can mean the tendon has ruptured.
Get this assessed promptly, as early treatment matters.
References & further reading
- 1.British Orthopaedic Foot & Ankle Society: Achilles tendinopathy patient information
- 2.NICE CKS: Achilles tendinopathy (clinical knowledge summary)
- 3.British Orthopaedic Foot & Ankle Society: Achilles tendon rupture patient information
- 4.NHS: Achilles tendinopathy
References are to UK clinical guidance and patient information from recognised organisations. This page is for general information and does not replace personalised advice from your own clinical team.