Achilles Tendonitis: Symptoms, Treatment and Exercises

01What

What is Achilles tendonitis?

The Achilles tendon joins the calf muscles to the heel bone and carries forces several times body weight in running and jumping. Repetitive overload leads to tendon changes (tendinopathy) that cause pain, stiffness and thickening. Pure inflammation is uncommon in long-standing cases. Midportion and insertional tendinopathy are the two main types, and they differ in treatment details.

02Types

Midportion versus insertional

• Midportion: pain and swelling 2–6 cm above the heel; more common in runners and younger active people; responds well to eccentric or heavy slow loading through full range.
• Insertional: pain at the back of the heel where the tendon attaches, often with a bony bump (Haglund’s deformity) and sometimes bursitis; more common in older and less active people; avoid stretching the heel below the step and avoid tight heel counters.
• Both can coexist, and a clinician can distinguish them by examination and, if needed, ultrasound.

03Symptoms

Symptoms

• Pain and stiffness at the back of the ankle or heel, worst on first steps in the morning.
• Pain at the start of exercise that eases as you warm up and returns later.
• Tenderness and thickening of the tendon.
• Pain on tiptoe, climbing stairs or hills.
• Swelling, sometimes a nodule on the tendon.
• Crepitus (creaking) in some cases.

04Causes

Causes and risk factors

• Sudden increases in running volume, speed or hill work.
• Returning to sport after a break.
• Tight or weak calf muscles; limited ankle movement.
• Poor footwear, worn shoes or abrupt change of shoes or surfaces.
• Overpronation, high-arched feet and biomechanical factors.
• Obesity, diabetes, high cholesterol, inflammatory conditions and age.
• Fluoroquinolone antibiotics, corticosteroids and statins.

05Self-care

Self-care

• Reduce running and jumping to a level that keeps pain low; replace some runs with cycling or swimming.
• Use paracetamol or topical anti-inflammatories; ice or heat for comfort.
• Wear supportive shoes with a modest heel; a small heel lift (about 10–12 mm) may reduce load on the tendon.
• Avoid walking barefoot and wearing flat shoes on hard surfaces if painful.
• Do not stretch aggressively, particularly in insertional tendinopathy.
• Avoid steroid injections into the tendon.

06Exercise

Exercise programme

• Phase 1 – isometrics: double-leg or single-leg heel raise held in the mid-position for 30–45 seconds, 4–5 times, once or twice daily to ease pain.
• Phase 2 – calf raises: double-leg raises, progressing to single-leg raises on the floor, slow tempo (3 seconds up, 3 seconds down), 3 × 10–15, once or twice daily.
• Phase 3 – eccentric or heavy slow resistance: Alfredson protocol (3 × 15 straight-knee and 3 × 15 bent-knee eccentric heel drops, twice a day for 12 weeks) for midportion; add weight with a backpack as tolerated. For insertional, keep the heel at or above the step level.
• Phase 4 – tendon energy storage: skipping, hopping and jogging progressions.
• Phase 5 – return to sport: gradual increase of running volume and speed.
• A pain level of up to 3–5/10 during exercise is acceptable if it settles within 24 hours.

07Other

Other treatments

Extracorporeal shockwave therapy can help chronic Achilles tendinopathy, particularly insertional, as an adjunct to exercise. Platelet-rich plasma, high-volume injections and sclerosing injections have limited or mixed evidence. Corticosteroid injections are not recommended because of the risk of rupture. Surgery is considered after at least 6 months of well-conducted rehabilitation, with options including debridement, release or removal of bony prominences.

08Time

Recovery time

Many people notice improvement within 6–12 weeks, but full recovery often takes 3–6 months and chronic cases longer. Return to sport should be gradual. Maintain calf strengthening once or twice a week after recovery to reduce recurrence.

09Prevention

Prevention

• Build up running and jumping gradually.
• Strengthen calves regularly, with straight-knee and bent-knee raises.
• Replace worn shoes and avoid sudden changes in footwear and surfaces.
• Warm up before exercise.
• Address foot mechanics if relevant.
• Do not ignore early heel pain.
• Discuss tendon risks with your doctor before using fluoroquinolone antibiotics or steroids if you have had tendon problems.

11Cases

Three common situations

A runner with morning heel stiffness and pain at the start of runs: midportion tendinopathy; reduce volume and begin calf raises.

A middle-aged person with pain at the back of the heel and a bump: insertional tendinopathy; avoid heel drops below a step and ask a physical therapist about a tailored programme.

A new pop and inability to push off: urgent assessment for rupture. See Achilles tendon rupture.

12Summary

Key points to remember

Achilles tendonitis improves with progressive calf loading, load management and supportive footwear, usually over 3–6 months. Avoid tendon steroid injections and aggressive stretching, and see a doctor urgently for a suspected rupture. Our physical therapy team can design an exercise programme for you.

This guide is for general information and does not replace an assessment by your own doctor or physical therapist.