Achilles Tendinopathy.
What is Achilles tendinopathy?
Achilles tendinopathy is a painful condition of the Achilles tendon — the largest and strongest tendon in the body, connecting the gastrocnemius and soleus muscles of the calf to the heel bone (calcaneus). It is characterised by activity-related tendon pain, focal tendon tenderness and often visible or palpable tendon thickening.
The older terms "Achilles tendinitis" and "Achilles tendinosis" have largely been replaced by the umbrella term "tendinopathy," which reflects the current understanding that the pathology involves a failed healing response rather than simple inflammation. Histological studies consistently show tendon degeneration — disorganised collagen fibres, increased ground substance, neovascularisation — rather than the inflammatory cell infiltrate that "tendinitis" implies. This distinction matters because purely anti-inflammatory treatments (rest, ice, NSAIDs) target the wrong mechanism, while progressive tendon loading — which initially seems counterintuitive — is the most evidence-based treatment.
Mid-portion versus insertional Achilles tendinopathy
This distinction is clinically important because the management differs between the two.
Accurately identifying which type is present — through clinical palpation and assessment of which positions provoke symptoms — is an essential first step in management.
What causes Achilles tendinopathy?
Achilles tendinopathy is usually caused by overuse and repetitive strain on the tendon. Activities that require sudden changes in direction, jumping or running, as well as those that involve sudden acceleration or deceleration, put stress on the Achilles tendon. The condition typically develops when the cumulative load exceeds the tendon's capacity to adapt and recover — most commonly from a sudden increase in training volume or intensity, inadequate recovery time, or a transition in training surface or footwear.
Other contributing factors include poor ankle and foot biomechanics such as flat feet or overpronation, wearing inappropriate footwear, and age-related changes that reduce tendon flexibility and blood supply. Fluoroquinolone antibiotics, metabolic conditions including diabetes and obesity, and the perimenopause transition in women are also associated with increased Achilles tendinopathy risk.
What are the symptoms?
Pain and stiffness along the Achilles tendon — typically localised to the mid-portion or insertion — that is characteristically worse with the first steps in the morning and with the initiation of activity, improving after a brief warm-up period and then potentially worsening again with prolonged or high-intensity loading. A visible or palpable tendon thickening at the mid-portion is common. Tenderness to pinch palpation at the affected zone is the most reliable clinical finding.
How is it diagnosed?
Clinical assessment involving palpation, the arc sign (thickening that moves with ankle movement rather than remaining fixed to the tendon sheath), the Royal London Hospital test, and assessment of calf strength and flexibility is the primary diagnostic tool. Ultrasound confirms the diagnosis by visualising tendon degeneration, thickening, neovascularisation and the integrity of the tendon fibres. MRI provides more comprehensive information for complex presentations or where partial tearing is suspected.
How can physiotherapy help?
Physiotherapy is a highly effective treatment for Achilles tendinopathy and can help to alleviate pain, improve function, and prevent recurrence.
Progressive tendon loading is the cornerstone of management, with the strongest evidence base of any single intervention. The principle is simple but requires careful application: the tendon needs to be progressively loaded to stimulate collagen remodelling and rebuild load capacity, but the loading must be carefully dosed to stay within the tendon's current tolerance. Too much load produces a reactive flare; too little produces no adaptation.
The progression typically follows this sequence: isometric exercises first (sustained contractions without movement, which have the additional benefit of immediate pain reduction), then isotonic exercises through progressive range, then heavy slow resistance loading, and finally sport-specific loading including plyometrics and running. Each stage is entered when the previous stage is tolerated without a significant pain flare — specifically, pain should return to baseline within 24 hours of exercise.
Load management — reducing the aggravating activities while the loading program builds tendon capacity — is the essential parallel intervention. This does not mean complete rest, which leads to tendon deconditioning and is counterproductive. It means temporarily reducing the provocative loads (typically running volume and intensity) while maintaining loading through the physiotherapy program.
Calf flexibility work and stretching addresses the tightness that increases Achilles tendon load during the propulsive phase of gait. Hip and gluteal strengthening improves the proximal control of lower limb mechanics that contributes to Achilles overloading patterns in runners.
Dry needling of the gastrocnemius and soleus assists with pain management and muscle relaxation. Real time ultrasound monitors tendon structural changes over the course of rehabilitation and guides loading progression decisions.
Clinical Pilates provides a controlled environment for calf and lower limb loading through precisely managed ranges and loads during the rehabilitation period when full running training is not yet appropriate. For runners, a structured return-to-running program with progressive increases in volume before intensity is introduced is central to preventing recurrence.
For patients managing Achilles tendon rupture repair rehabilitation after surgical intervention, see our dedicated post-surgical page.
Our physiotherapists Eliane Machado and Bethany Kippen both have experience in tendinopathy management and are members of the Australian Physiotherapy Association. Eliane's doctoral research in running biomechanics and lower limb loading is directly relevant to the load management and return-to-running programs central to Achilles tendinopathy rehabilitation.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Book your initial physiotherapy appointment
Achilles tendinopathy is a painful condition of the Achilles tendon — the largest and strongest tendon in the body, connecting the gastrocnemius and soleus muscles of the calf to the heel bone (calcaneus). It is characterised by activity-related tendon pain, focal tendon tenderness and often visible or palpable tendon thickening.
The older terms "Achilles tendinitis" and "Achilles tendinosis" have largely been replaced by the umbrella term "tendinopathy," which reflects the current understanding that the pathology involves a failed healing response rather than simple inflammation. Histological studies consistently show tendon degeneration — disorganised collagen fibres, increased ground substance, neovascularisation — rather than the inflammatory cell infiltrate that "tendinitis" implies. This distinction matters because purely anti-inflammatory treatments (rest, ice, NSAIDs) target the wrong mechanism, while progressive tendon loading — which initially seems counterintuitive — is the most evidence-based treatment.
Mid-portion versus insertional Achilles tendinopathy
This distinction is clinically important because the management differs between the two.
- Mid-portion tendinopathy — affecting the zone two to seven centimetres above the heel bone — is the most common presentation and responds well to progressive loading including eccentric calf exercises. The affected zone corresponds to the area of relative avascularity in the Achilles tendon, which heals poorly and is most vulnerable to cumulative loading stress.
- Insertional tendinopathy — affecting the tendon at its attachment to the calcaneus — requires a modified approach. Pure eccentric exercises that bring the heel below the step — the classic Alfredson protocol for mid-portion tendinopathy — are contraindicated for insertional tendinopathy, as they compress the tendon against the calcaneal bone and worsen symptoms. Heavy slow resistance (HSR) exercises that avoid deep calf lowering are the preferred loading approach for insertional presentations.
Accurately identifying which type is present — through clinical palpation and assessment of which positions provoke symptoms — is an essential first step in management.
What causes Achilles tendinopathy?
Achilles tendinopathy is usually caused by overuse and repetitive strain on the tendon. Activities that require sudden changes in direction, jumping or running, as well as those that involve sudden acceleration or deceleration, put stress on the Achilles tendon. The condition typically develops when the cumulative load exceeds the tendon's capacity to adapt and recover — most commonly from a sudden increase in training volume or intensity, inadequate recovery time, or a transition in training surface or footwear.
Other contributing factors include poor ankle and foot biomechanics such as flat feet or overpronation, wearing inappropriate footwear, and age-related changes that reduce tendon flexibility and blood supply. Fluoroquinolone antibiotics, metabolic conditions including diabetes and obesity, and the perimenopause transition in women are also associated with increased Achilles tendinopathy risk.
What are the symptoms?
Pain and stiffness along the Achilles tendon — typically localised to the mid-portion or insertion — that is characteristically worse with the first steps in the morning and with the initiation of activity, improving after a brief warm-up period and then potentially worsening again with prolonged or high-intensity loading. A visible or palpable tendon thickening at the mid-portion is common. Tenderness to pinch palpation at the affected zone is the most reliable clinical finding.
How is it diagnosed?
Clinical assessment involving palpation, the arc sign (thickening that moves with ankle movement rather than remaining fixed to the tendon sheath), the Royal London Hospital test, and assessment of calf strength and flexibility is the primary diagnostic tool. Ultrasound confirms the diagnosis by visualising tendon degeneration, thickening, neovascularisation and the integrity of the tendon fibres. MRI provides more comprehensive information for complex presentations or where partial tearing is suspected.
How can physiotherapy help?
Physiotherapy is a highly effective treatment for Achilles tendinopathy and can help to alleviate pain, improve function, and prevent recurrence.
Progressive tendon loading is the cornerstone of management, with the strongest evidence base of any single intervention. The principle is simple but requires careful application: the tendon needs to be progressively loaded to stimulate collagen remodelling and rebuild load capacity, but the loading must be carefully dosed to stay within the tendon's current tolerance. Too much load produces a reactive flare; too little produces no adaptation.
The progression typically follows this sequence: isometric exercises first (sustained contractions without movement, which have the additional benefit of immediate pain reduction), then isotonic exercises through progressive range, then heavy slow resistance loading, and finally sport-specific loading including plyometrics and running. Each stage is entered when the previous stage is tolerated without a significant pain flare — specifically, pain should return to baseline within 24 hours of exercise.
Load management — reducing the aggravating activities while the loading program builds tendon capacity — is the essential parallel intervention. This does not mean complete rest, which leads to tendon deconditioning and is counterproductive. It means temporarily reducing the provocative loads (typically running volume and intensity) while maintaining loading through the physiotherapy program.
Calf flexibility work and stretching addresses the tightness that increases Achilles tendon load during the propulsive phase of gait. Hip and gluteal strengthening improves the proximal control of lower limb mechanics that contributes to Achilles overloading patterns in runners.
Dry needling of the gastrocnemius and soleus assists with pain management and muscle relaxation. Real time ultrasound monitors tendon structural changes over the course of rehabilitation and guides loading progression decisions.
Clinical Pilates provides a controlled environment for calf and lower limb loading through precisely managed ranges and loads during the rehabilitation period when full running training is not yet appropriate. For runners, a structured return-to-running program with progressive increases in volume before intensity is introduced is central to preventing recurrence.
For patients managing Achilles tendon rupture repair rehabilitation after surgical intervention, see our dedicated post-surgical page.
Our physiotherapists Eliane Machado and Bethany Kippen both have experience in tendinopathy management and are members of the Australian Physiotherapy Association. Eliane's doctoral research in running biomechanics and lower limb loading is directly relevant to the load management and return-to-running programs central to Achilles tendinopathy rehabilitation.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Book your initial physiotherapy appointment
If you are unsure about which appointment type is right for you, please don't hesitate to get in touch with our friendly reception staff by calling 07 3706 3407 or emailing [email protected].
