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Achilles Tendonopathy: Our overview and recommendations for treatment and recovery

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Here, we take a look at the Achilles tendon and issues that come up with it, and answer some of the most common questions we get about it, from symptoms and causes to prevention and treatment. We’ll go over topics and questions including:

– What is the Achilles tendon? 

– What’s the difference between Achilles tendonitis, tendinosis and tendinopathy?

– What are the symptoms of Achilles problems?

– What causes Achilles tendonitis?

– How is Achilles tendonitis diagnosed?

– How can physical therapy help? 

– Exercises and stretches for your Achilles tendon

– How long does it take to recover from Achilles issues?

– Tips on preventing Achilles problems



What is the Achilles tendon?

Before we can talk about anything Achilles tendon related, it’s key to define exactly what this tendon is! Your Achilles tendon is the connective tissue attachment that connects your calf to your heel. It’s a really important structure because it handles the forces of anything weight-bearing you do with your feet, like running and walking. It handles a huge amount of stress, and is also a really strong structure, being a combined tendon of several different calf muscles. When your Achilles tendon is completely healthy, it has the ability to handle a lot of force.


It’s also important to understand the different movements your body does and how they relate to your Achilles tendon, especially when looking at problems that can arise. For example, when you point your toes straight out, your calf muscle pulls on your Achilles. As well, when you land from movements like running or jumping, there’s an absorption of forces that can be greater than what you’re actually using to jump off or push off, which is another key dynamic to keep in mind. 



What’s the difference between Achilles tendonitis, tendonosis and tendinopathy?

You may have heard of Achilles tendonitis, Achilles tendonosis, or Achilles tendonopathy. While these names sound similar, there are differences between them.


Achilles tendonitis: Here, the “itis” part of the word means that there’s some degree of inflammatory process going on as it relates to the tendon. You may have pain in your Achilles without having tendonitis, and you might also have tendonitis without pain. However, generally when there is inflammation we usually see swelling and achiness in the tendon area, and the symptoms tend to be more acute and uncomfortable.


Achilles tendinosis: This is something that can happen in the absence of inflammation and is a type of degradation or a wear and tear on your tendon. It usually happens over time, and can happen at a very small, microstructure level, or can be more obvious in more severe cases. We also sometimes see something called calcific tendinosis, where there are calcium formations building up in the tendon as the body tries to reinforce the area because it’s been overloaded so much.


Tendonopathy: This is a broader term referring to the pathology of the tendon, and it might be the term you see most often. Below, we’ll discuss tendon issues more generally, because for us the most important thing is looking into the many factors going into the issues you might be having, and how we can help fix or prevent it at Endeavour. 



What are the symptoms of Achilles problems?

Like many other issues, the symptoms of Achilles problems can vary widely, from ankle pain when running, to tendon pain after sleeping. Typically we see issues in two groups of people: those who are quite active, and those who are very inactive. We also see pain in a couple different areas along the tendon. Where there is pain that’s located right where the bone and the Achilles tendon meet, this is called insertional tendinopathy or insertional Achilles tendonitis. We also see pain between the middle of the tendon and the bone, which we call a mid-tendon Achilles problem. We also see pain in the musculotendinous junction, which is essentially the attachment between the muscle and the tendon. While this is more rare as it relates to the Achilles tendon, it’s still possible. 


Achilles tendon pain can be really sharp and stabbing, or it might be more of a dull achiness—a lot depends on the person, their activity level, and the location of symptoms. Many people experience tendon pain when waking up in the morning or after a period of inactivity. Getting up and moving around can reduce the pain, which is a great way to address the pain, though it doesn’t solve the root problem. Pain might also flare up in the period of inactive time following an activity like a sport or a long walk. It may also only occur after certain activities, like running or going up stairs. 


Finally, when talking about symptoms another consideration is peroneal tendonitis or peroneal tendinopathy in relation to the Achilles tendon. The peroneal muscles, or the evertor muscles/fibularis muscles, run along the outside of the calf and wrap around the outside of the ankle, which means that in these cases, symptoms will be more on the outside of the ankle, but not along the prominent Achilles tendon. 



What causes Achilles tendonitis or Achilles tendonosis?

Causes of Achilles problems ultimately boil down to a combination of two things: overload and insufficiency. 

Overload: This is challenging your Achilles more than it’s able to withstand. This might be a sudden change in activity where you’re suddenly walking or running a lot more, or maybe you’ve had a change in footwear relating to the seasons or playing different sports, such as going from a running shoe to a soccer cleat, or a basketball shoe to flip flops. We often get asked “Can shoes cause Achilles issues?” and while shoes aren’t necessarily the cause in themselves, a change in footwear can definitely contribute to overload happening over time. 


Insufficiency: This is your body’s inability to handle those extra forces. The entire posterior chain of your body, including the calf in the Achilles region, hamstrings, the gluteal muscles and the lower back all work together. If the calf in the Achilles region is working harder relative to those other regions, we often see a higher degree of wear and tear on these tissues, and slowly there’s an insufficiency that develops.


There can also be other factors at play such as a lack of blood flow, other metabolic issues, and sub-optimal nutrition, that can influence your body’s ability to heal and regenerate the Achilles tendon. 


As well, it’s important to consider local causes: things like old ankle injuries, old foot related injuries to the toes, the arch of the foot or the ankle, or a history of calf strains and pulls. These can all change the dynamics of the forces that go through the Achilles in the ankle region. 


Root causes of the issue are things that are more distant from the calf, some of which we’ve touched on above, such as issues throughout your calf, hamstrings and glute muscles. We see many people with tight calves, and while people with tight calves don’t always experience Achilles pain, this doesn’t mean it can’t affect things higher up the chain. 


If all of that is functioning well, the cause may be related to biomechanics or training errors—moving in ways that put extra stress on your ankle joint. For example, poor control of the foot and ankle can mean you have a tendency to overload your ankle while doing things like running, walking or climbing stairs. Or there could be an alignment issue that causes increased stress on one side. With training errors, this is typically a big increase or spike in activity, such as training for a marathon after taking several months off, or going for a long hike after a longer period of inactivity. 



Finally, a question we get asked frequently is “Does running cause Achilles problems?” While running can definitely be a factor in you experiencing Achilles problems or in aggravating them, running in itself doesn’t mean that you’ll necessarily have an Achilles problem or pain. 



How is Achilles tendonitis diagnosed?

Often, diagnosing Achilles problems is very straightforward, because people will quickly identify that they have pain in their Achilles region. We’ll listen closely to each individual patient to understand where their symptoms have been and the ways in which the symptoms present themselves, as well as asking about potential old injuries. We’ll do an Achilles tendon pinch test and assess whether or not there is tenderness around the Achilles, and see where the pain is and if there’s any swelling. In rare cases, we’ll do imaging on the Achilles, but this would only typically be in cases unresponsive to high-quality treatment. 



How can physical therapy help? 

When it comes to our treatment approach in our physiotherapy clinic at Endeavour, there’s a lot of things that physiotherapy can do to have a positive impact on people suffering from Achilles pain and having Achilles problems.


The first phase: identifying and addressing contributing factors

Are there old injuries? Ankle issues? Foot biomechanics and control issues? Do you have good function of that posterior chain? Is there good core strength? Are there any blood floor or biomechanics issues, or perhaps training errors? These are all key areas for our physiotherapists at Endeavour to understand and that will inform our treatment approach. 


Acute management

In the acute phase, treatment could include things like ice in very small doses and for a limited scope of time, or insoles or heel lifts on a temporary basis. In some cases, these approaches in the acute phase can help calm inflammation and manage acute symptoms.

We may need to give you advice on reducing activity, whether that’s walking, running or sports, or changing your activity level to ensure we’re not perpetuating problems while trying to address them. After this, we’ll guide you in re-integrating activities and getting back to doing the things you love. 


Maintenance and prevention

Once we’ve gotten you out of pain, we’ll build toward the maintenance and prevention stages of the rehab program. In this phase, electroacupuncture is a great tool for addressing the different factors that may go into you having Achilles problems. We’ll use it to focus not only locally on the Achilles but also the entire kinetic chain, including your hamstrings, glute and back. Acupuncture can also be used in the acute phase to calm down some of the inflammation and irritation. Manual therapy and soft tissue work can also be really helpful, whether you have swelling around your Achilles or some restrictions from old injuries in areas like your ankle or calf. 

Your physical therapy treatment for Achilles tendonosis or Achilles tendonitis will involve us prescribing some exercises personalized to you—more on that below! Finally, we always have long-term goals in mind with each patient, which for many is a return to sport. We’ll guide you through a graded exposure program with tips and structure around how to return safely to your activities without re-aggravating symptoms.



What are some exercises for Achilles tendonitis/ Achilles tendonosis?

Everyone’s recovery is going to look different when it comes to Achilles problems, so the best exercise program is one that is personalized to you and your specific needs. The overall goal with exercises is to work on the mobility of the entire chain while addressing any weaknesses you have, working on both Achilles tendon stretches as well as exercises to strengthen your Achilles tendon.


Calf stretches: For some people, calf tightness can be a contributing factor. Here, we often recommend exercises such as leaning up against the wall, keeping your back legs straight with your foot flat. 


Foot exercises: We often recommend rolling a ball under your foot (check out this video on our Instagram for more info!), as well as stretching your toes backwards toward the top of your foot, or leaning your foot against the wall with your toes arching backwards and extending upward towards your shin.


Hamstring and hip stretches: There are a variety of stretches for your hamstrings and hips—look for one that feels most comfortable to you. For a more in-depth overview of hip exercises, check out our hip impingement blog.


Ankle strengthening: Single-leg balance exercises, working on bringing your foot inward or outward, and balancing on an unstable surface like a bosu ball can all be really helpful in working on strengthening your ankles.


Calf strengthening: Calf-raises—going up onto your toes and back down slowly—can be very helpful. If you’re comfortable with it, we often recommend doing calf raises on the edge of a stair or a ledge, then on the way down, dropping your heel below the level of your foot.


Glute exercises: This can range from squats, to deadlift movements, to lunges.


Core strengthening: Since the core and back can play a big role in Achilles problems, we will often incorporate core strengthening into your exercise program, such as squats and deadlifts. 


Rotational stability exercises: The Paloff press is an exercise with a resistance band that you’ll hold out in front of you and press it out and back down. 


With any exercise program, our team at Endeavour will work with you to take into consideration whether you’re experiencing symptoms with certain movements, and finding suitable alternatives where needed.



How long does it take to recover from Achilles issues?

Recovery from Achilles issues can range widely depending on your specific situation and how long you’ve been experiencing symptoms before coming into the clinic. In average cases, we typically see notable changes within four to six weeks. For someone who needs to continue participating in a sport, or someone who has been experiencing more aggressive symptoms, this timeline may be longer.



What are some ways to prevent Achilles tendonitis/ Achilles tendonosis?

Our biggest prevention recommendation is to have a consistent routine of lower body strength and mobility exercises. Some of the exercises mentioned above can be great here.


When you’re transitioning between activities, sports or even footwear, it’s important to not jump in too quickly to something new and to give yourself transition time, which will help avoid causing overload and Achilles problems. Booking a proactive physiotherapy appointment can help identify any risk factors with exercises and movements you’re doing. 


We often see old injuries building up and creating new problems that are worse than the original ones, so a physiotherapist can help address these issues and help reduce the risk of you experiencing an Achilles related problem. 


Looking for a physiotherapy clinic in Toronto or have more questions? Contact us at Endeavour to learn more and book your treatment.




The medical information on this blog is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. This information does not create any patient-therapist relationship and should not be used as a substitute for professional diagnosis and treatment.

Please consult your health care provider before making any health care decisions or for guidance about a specific medical condition. Endeavour Sports Performance and Rehabilitation and its practitioners expressly disclaim responsibility, and shall have no liability, for any damages, loss, injury, or liability whatsoever suffered as a result of your reliance on the information contained in this article.

Category : Understanding Physiotherapy