You get out of bed and the first few steps are stiff and sore at the back of the heel. It loosens up as you move, and by the time you are running it feels almost fine, until the next morning. Then it gradually starts to hurt during the run as well, and you begin to wonder whether it is going to snap.

That is the classic story of Achilles tendinopathy, one of the most common injuries in runners, field sport athletes and active adults. This article covers what it is, why it happens, why the usual instinct to rest and stretch does not work, and what the evidence says fixes it.

What is the Achilles?

The Achilles is the largest and strongest tendon in the body. It connects the calf muscles to the heel bone and transmits the force that pushes you off the ground with every step, stride and jump. During running it handles loads of several times body weight.

What does tendinopathy mean?

Tendinopathy is the term for a tendon that has become painful and lost some of its ability to tolerate load. The older term “tendinitis” implied inflammation, and for a long time it was treated with anti-inflammatories and rest. We now know that the main process is not inflammation. It is a failed adaptation to load: the tendon has been asked to do more than it could recover from, its structure has become disorganised and thickened in response, and it has become sensitive. There is no tear and, in most cases, no risk of rupture.

Two types of Achilles Tendinopathy: mid-portion and insertional

Where the pain sits matters, because the two types are managed differently.

Mid-portion Achilles tendinopathy is pain and thickening in the tendon itself, typically two to six centimetres above the heel bone. This is the more common type, particularly in runners, and it responds well to loading programs.

Insertional Achilles tendinopathy is pain where the tendon attaches to the heel bone. It is often associated with a bony bump on the back of the heel and irritation of the bursa nearby. Because the tendon is compressed against the bone whenever the foot is pulled up towards the shin, this type is aggravated by stretching, by walking uphill and by exercises done with the heel dropped below the level of the toes. That changes the exercise prescription, as we will come to.

Why do you get Achilles Tendinopathy?

Achilles tendinopathy is most common in people between 30 and 60 who run, play field or court sports, or have recently become more active. It affects around one in twenty recreational runners each year.

The underlying driver is almost always a change in load that outpaced the tendon’s ability to adapt. Common triggers:

• A sudden increase in running distance, speed or hill work.
• A return to sport after a break, when the tendon has deconditioned.
• Pre-season training, holiday camps or a run of games on hard or artificial surfaces.
• A change in footwear, particularly to a lower heel or a minimalist shoe.
• A big increase in walking, stairs or standing at work.
• New plyometric or jumping training.

Other factors raise the risk: weak or fatigued calf muscles, reduced ankle movement, a higher body weight, diabetes, high cholesterol, and certain medications, particularly fluoroquinolone antibiotics and long courses of corticosteroids. The risk rises with age.

What does Achilles Tendinopathy feel like?

• Pain and stiffness at the back of the heel or in the tendon on the first steps in the morning, or after sitting for a while.
• A warm up phenomenon: pain eases with activity early on, then returns afterwards and the next day.
• Tenderness when you squeeze the tendon between finger and thumb.
• A thickened or lumpy area in the tendon that you can feel.
• Pain with running, jumping, hill walking and stairs, progressing over weeks.
• In insertional cases, pain and sometimes a bump at the heel bone, aggravated by the back of the shoe.

Sudden, severe pain at the back of the calf with a sensation of being kicked or struck, followed by weakness pushing off, is not tendinopathy. That is a rupture and needs an emergency department the same day.

Why rest and stretching don’t fix it

The instinctive response to a sore tendon is to rest it, stretch it and take anti-inflammatories. All three are less helpful than they seem.

Rest reduces pain in the short term, but tendons adapt to load in both directions. A rested tendon loses capacity, so when you return to activity it is even less able to cope than before, and the cycle repeats. This is why so many people with Achilles pain describe a pattern of six months of on and off rest with no real change.

Stretching the calf feels productive but does not improve tendon capacity, and in insertional tendinopathy it compresses the sore part of the tendon against the heel bone and often makes things worse.

Anti-inflammatories can take the edge off, and are fine to use for a few days on advice from your pharmacist, but they are treating a process that is not primarily inflammatory and they do nothing to restore the tendon.

What actually helps Achilles Tendinopathy?

Progressive loading

The treatment with the best evidence, by a wide margin, is a progressive strengthening program for the calf and Achilles. Tendons respond to load. Given the right amount, they remodel, become stronger and, over time, less painful. Given too little, they weaken. Given too much, they flare. The art is in finding the right dose and progressing it.

A typical program moves through stages:

• Isometrics. Holding a calf raise at mid-range for 30 to 45 seconds, several times, can reduce pain in the short term and is a good starting point when the tendon is very irritable.
• Heavy slow resistance. Calf raises done slowly, both with the knee straight and with the knee bent to target both calf muscles, with weight added progressively. This is the core of the program. Three sessions a week, with load that feels genuinely hard by the final repetitions.
• Energy storage. Once strength has built and pain is under control, the tendon is reintroduced to faster, spring-like loading through skipping, hopping and bounding, which prepares it for running and sport.
• Return to running and sport in a graded way, using pain and morning stiffness as the guide.

For mid-portion tendinopathy, calf raises are typically done through full range over the edge of a step. For insertional tendinopathy, they are done from the floor so the heel does not drop below the toes and compress the tendon, at least until symptoms settle.

Expect this to take time. Noticeable improvement often comes within six to eight weeks, but most people need 12 weeks to see substantial change and longer to fully rebuild. The program continues, in a maintenance form, after the pain has gone.

Managing load, not removing it

In the short term, activity is adjusted to a level the tendon tolerates rather than stopped. For runners that usually means cutting volume and intensity, removing hills and speed work, and keeping to flat, softer surfaces, then rebuilding by around 10 per cent a week.

Pain during activity of up to about 3 or 4 out of 10 is acceptable, provided it settles within 24 hours and morning stiffness is not worse the next day. Rising morning stiffness is the most reliable sign the load was too high.

Heel lifts and footwear

A heel lift of a centimetre or so, or shoes with a slightly raised heel, reduce load on the tendon and can make a real difference in the early weeks, especially for insertional tendinopathy. Shoes with a firm, rigid heel counter that rub the back of the heel should be avoided in insertional cases. Low drop and minimalist shoes are best left until the tendon has recovered.

Other treatments

Shockwave therapy has reasonable evidence, particularly for insertional and long standing cases, and can be a useful addition when a loading program alone has stalled. Hands-on treatment of the calf muscles can ease tightness and pain in the short term. Corticosteroid injections into or around the Achilles are generally avoided because of the risk of tendon rupture. Platelet rich plasma injections have not shown benefit over placebo in good quality trials. Surgery is reserved for a small number of people who have not improved after at least six months of appropriate, well delivered conservative treatment.

What doesn’t help Achilles Tendinopathy?

• Complete rest.
• Calf stretching, especially in insertional tendinopathy.
• Anti-inflammatories as the main treatment.
• Steroid injections.
• Ice and ultrasound as anything more than short term comfort.
• Repeatedly pushing through rising pain and morning stiffness.

Will my Achilles rupture?

This is the fear behind most Achilles pain, and it deserves a straight answer. Tendinopathy does not usually lead to rupture. Most people who rupture an Achilles had no pain beforehand. The changes in a painful tendon make it thicker, not thinner. Continuing a sensible loading program does not raise your risk. The main exceptions are people who have had steroid injections into the tendon or who are taking fluoroquinolone antibiotics, who should be cautious.

How long does Achilles Tendinopathy take to heal?

A rough guide, assuming a consistent program:

• Morning stiffness and pain on the first steps usually improve within two to four weeks.
• Running and sport related pain improves over 8 to 12 weeks.
• Full return to unrestricted sport is commonly between three and six months.

Insertional tendinopathy, symptoms that have been present for more than a year, and tendinopathy in people with diabetes or higher body weight tend to sit at the longer end.

When to get it checked

See us if Achilles pain has lasted more than two to three weeks, is changing how you walk or is stopping you running. Go to an emergency department if you had a sudden snap or a sensation of being kicked in the calf, cannot push off through the foot or have marked weakness pointing the toes. See a GP if you have heel pain with redness, swelling, fever, or a history of inflammatory arthritis or psoriasis, as the Achilles insertion can be involved in inflammatory conditions.

What treatment at VIBE looks like

Your first appointment includes a detailed history of your training, footwear, work and the events leading up to the pain. We examine the tendon to confirm the diagnosis and identify whether it is mid-portion or insertional, test calf strength and endurance, look at ankle range and assess how you walk, hop and run. Imaging is not usually needed, but if the diagnosis is unclear we will refer for an ultrasound.

You will leave with a clear plan: how to adjust your running or training in the short term, a heel lift or footwear advice if appropriate, and a starting loading program. Over the following weeks we progress the loading in stages, measure calf strength so you can see the tendon recovering, and manage the return to running and sport. Where needed, we add shockwave or hands-on treatment. The goal is a tendon that is stronger than it was before the injury and a plan that stops it coming back.

Wrap-up

Achilles tendinopathy is a tendon that has been loaded faster than it can adapt. Rest, stretching and anti-inflammatories give short term relief but do not fix it, and the pattern of on and off rest can drag on for months. What works is a progressive strengthening program over about 12 weeks, with training adjusted rather than stopped, sensible footwear choices and a graded return to running and sport. The tendon is not about to rupture, and the outlook with the right program is good.

If your Achilles is stiff every morning and sore after every run, book an assessment at VIBE Health & Performance in Homebush or Seven Hills. The earlier the loading is started, the shorter the road back.