What is the Achilles tendon?

The Achilles tendon is the large tendon at the back of the ankle. It connects the calf muscles to the heel bone and plays an important role in:

• Foot posture
• Arch behaviour when standing
• Joint movement
• Flexibility
• Muscle strength
• Tendon function
• Ankle range of motion
• Heel alignment
• Walking pattern
• Footwear
• Activity level
• Pain location
• Relevant medical history

This helps determine whether the foot shape is flexible, rigid, symptomatic or potentially
progressive.

What causes Achilles tendon pain?

One of the most common causes is Achilles tendinopathy.

This refers to a painful change within the tendon that is commonly associated with repeated loading, altered tendon structure and reduced load tolerance.

However, not all pain at the back of the heel is caused by Achilles tendinopathy.

Other possibilities can include:

• Partial tendon injury
• Retrocalcaneal bursitis
• Insertional tendon pathology
• Haglund-type prominence
• Calcaneal bone changes
• Referred pain
• Less commonly, acute tendon rupture

Assessment helps determine which condition is most likely.

Is it Achilles tendonitis or Achilles tendinopathy?

The word tendonitis implies that inflammation is the main problem.

Although inflammation may be involved in some stages of tendon pain, persistent Achilles problems are more commonly described as Achilles tendinopathy.

Tendinopathy reflects changes in tendon structure, function and load tolerance rather than simply ongoing inflammation.

This distinction matters because treatment usually involves progressively rebuilding tendon capacity rather than relying only on anti-inflammatory treatment or rest.

What is mid-portion Achilles tendinopathy?

Mid-portion Achilles tendinopathy affects the tendon a short distance above the heel bone.

Symptoms commonly include:

• Localised tenderness
• Tendon thickening
• Morning stiffness
• Pain when beginning activity
• Pain after running or jumping
• Stiffness after sitting

Some patients find the tendon feels better after warming up, only to become sore again later.

What is insertional Achilles tendinopathy?

Insertional Achilles tendinopathy affects the area where the tendon attaches to the heel bone.

Pain is usually felt directly at the back of the heel.

It may be aggravated by:

• Uphill walking
• Running
• Deep ankle movement
• Shoes pressing on the heel
• Repeated calf loading

Insertional tendon problems can behave differently from mid-portion tendon problems and may require a different rehabilitation approach.

What are the symptoms of Achilles tendinopathy?

Common symptoms include:

• Pain behind the ankle or heel
• Morning stiffness
• Pain when first beginning to walk
• Pain during or after exercise
• Tenderness when touching the tendon
• Thickening of the tendon
• Reduced tolerance for running or jumping
• Discomfort when climbing stairs
• Pain after prolonged sitting followed by walking

Symptoms vary depending on the stage and location of the tendon problem.

Why does Achilles tendon pain develop?

Achilles pain often develops when the load placed on the tendon exceeds what it is currently able to tolerate.

Common contributing factors include:

• Sudden increase in running
• Increase in walking volume
• Hill training
• Speed work
• Jumping activity
• Returning to sport too quickly
• Changes in footwear
• Reduced calf strength
• Reduced ankle mobility
• Changes in training surface
• Previous Achilles injury
• Age-related tendon change

There may be several contributing factors rather than one single cause.

Can Achilles pain happen without exercise?

Yes.

Although Achilles tendinopathy is common in runners and athletes, it also occurs in people who do not participate in regular sport.

Walking, occupational activity, changes in body weight, ageing, medical factors and everyday loading can also contribute.

How our podiatrists assess Achilles tendon pain

Assessment may include:

• Exact location of pain
• Duration of symptoms
• Recent change in activity
• Running or training history
• Morning stiffness
• Tendon swelling or thickening
• Calf strength
• Ankle mobility
• Foot mechanics
• Walking or running pattern
• Footwear
• Previous treatment
• Relevant medical history

The aim is to determine the likely diagnosis and what is limiting tendon recovery.

Do I need an ultrasound or MRI?

Not always.

Many Achilles tendon problems can initially be assessed clinically.

Imaging may be considered when:

• The diagnosis is uncertain
• Symptoms are persistent
• There is concern about a partial tear
• There is significant swelling
• Progress has been unexpectedly poor
• Surgery is being considered
• Another condition needs to be excluded

Ultrasound can assess tendon thickness, structure and surrounding tissue.

MRI can provide a more detailed assessment of the tendon and surrounding structures in selected cases.

Imaging findings should always be interpreted alongside the patient’s symptoms and examination.

How is Achilles tendon pain treated?

Treatment should be individualised.

For many patients, the most important components are:

• Managing aggravating load
• Progressive tendon rehabilitation
• Improving calf strength
• Appropriate footwear
• Gradual return to activity

Other treatments may be added depending on the clinical findings.

Should I completely rest my Achilles tendon?

Usually not.

Complete rest may reduce pain temporarily, but prolonged unloading can also reduce the tendon’s capacity to tolerate activity.

The objective is usually to reduce excessive loading while maintaining an appropriate level of activity.

Our podiatrists can help determine what should be temporarily reduced and what can safely continue.

Load management

Load management means adjusting activity so that the tendon is challenged enough to maintain and improve capacity without repeatedly aggravating symptoms.

This might include temporary changes to:

• Running distance
• Running speed
• Hills
• Jumping
• Sport
• Long walks
• Frequency of training

The aim is usually modification rather than complete cessation.

Strength and rehabilitation

Progressive strengthening is a central part of Achilles tendinopathy treatment.

Depending on the stage of rehabilitation, exercises may include:

• Isometric calf loading
• Heel raises
• Seated calf raises
• Standing calf strengthening
• Single-leg heel raises
• Progressive resistance
• Functional loading
• Gradual return to jumping or running

The exercise program should be progressed according to symptoms and function.

Do eccentric exercises help Achilles tendinopathy?

Eccentric calf exercises have been widely used for Achilles tendinopathy and can be effective for some patients.

However, they are not the only effective strengthening method.

Modern rehabilitation often uses a broader progressive loading program that may include both concentric and eccentric muscle work.

Insertional Achilles pain may also require modification of exercises to avoid excessive compression at the heel attachment.

Footwear and Achilles tendon pain

Footwear can influence symptoms.

Our podiatrists may assess:

• Heel height
• Shoe stiffness
• Heel counter
• Cushioning
• Fit
• Sporting requirements
• Whether footwear presses on the painful area

Sometimes a temporary footwear modification can reduce irritation while rehabilitation progresses.

Do heel lifts help Achilles tendon pain?

A heel lift can reduce the amount of ankle movement and tendon stretch in some patients.

This may be useful temporarily, particularly during an irritable stage.

Heel lifts are not necessarily a permanent treatment.

They should be used as part of a broader rehabilitation strategy where appropriate.

Can orthotics help Achilles pain?

Orthotics may help selected patients when foot mechanics appear to contribute to tendon loading or when an orthotic improves comfort and function.

However, not every patient with Achilles pain needs orthotics.

Our podiatrists can determine whether a biomechanical assessment is relevant.

Returning to running and sport

Returning too quickly to previous training levels can lead to repeated flare-ups.

A graded return may involve:

• Increasing walking tolerance
• Building calf strength
• Introducing light running
• Gradually increasing distance
• Reintroducing speed
• Reintroducing hills
• Returning to sport-specific activity

The exact sequence depends on the activity and the patient’s progress.

How long does Achilles tendinopathy take to improve?

Recovery varies.

Some patients improve within weeks, while persistent tendinopathy can require several months of progressive rehabilitation.

Factors that influence recovery include:

• Duration of symptoms
• Tendon severity
• Activity demands
• Strength
• Adherence to rehabilitation
• Medical factors
• Previous injury

A gradual recovery should not automatically be interpreted as treatment failure.

What if my Achilles pain does not improve?

Persistent symptoms should prompt reassessment.

Our podiatrists may review:

• The diagnosis
• Exercise progression
• Training load
• Footwear
• Biomechanics
• Strength deficits
• Imaging
• Other medical factors

For some patients, additional treatment options may be considered.

What advanced treatment options may be considered?

When symptoms remain significant despite an appropriate rehabilitation program, further options may be discussed based on the diagnosis.

These may include:

• Further imaging
• Specialist musculoskeletal assessment
• Shockwave therapy in selected cases
• Other evidence-informed adjunctive treatments
• Referral for medical or surgical opinion when appropriate

These treatments should not replace a well-structured rehabilitation program.

HealthiClinic should not position Achilles tendon care as primarily injection-based.

Are injections used for Achilles tendon pain?

Injection treatment around the Achilles tendon requires careful consideration because the tendon is a load-bearing structure and different injection types have different evidence and risks.

Any injection-based treatment should only be considered after:

• A clear diagnosis
• Appropriate discussion of evidence
• Consideration of alternatives
• Assessment of potential risks
• Clinical justification

It should not be presented as routine first-line treatment for Achilles tendinopathy.

When may surgery be considered?

Most Achilles tendinopathy does not require surgery.

Surgical assessment may be considered in selected patients with:

• Significant persistent symptoms
• Structural tendon pathology
• Insertional disease with associated bony pathology
• Functional limitation despite prolonged appropriate conservative care
• Selected partial tears
• Other structural problems that warrant surgical opinion

Surgery is generally considered only after appropriate conservative treatment has been attempted.

What about an Achilles tendon rupture?

A sudden rupture is different from chronic Achilles tendinopathy.

Possible signs include:

• Sudden sharp pain
• Feeling as though someone kicked the back of the leg
• A popping sensation
• Difficulty pushing off
• Difficulty walking normally
• Sudden loss of strength

An acute Achilles rupture requires prompt medical assessment.

It should not be managed as routine tendinopathy.

When should I see a podiatrist?

Consider podiatry assessment if:

• Achilles pain has lasted more than a few weeks
• Symptoms repeatedly return
• Morning stiffness is increasing
• Running or walking is becoming limited
• The tendon appears thickened
• Pain occurs at the back of the heel
• You are unsure how much activity is safe
• You have tried rest without lasting improvement
• You want guidance on rehabilitation
• You are considering orthotics or footwear changes
• Previous treatment has not helped

Seek urgent medical assessment if there is sudden pain with major weakness or suspected Achilles rupture.