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Where is the problem?
The Achilles tendon transfers force from the calf muscles to the heel bone. It contributes to pushing off, running and jumping. Tendinopathy generally means load-related pain and reduced ability to tolerate certain activities.
Midportion tendinopathy affects the tendon above the heel. Insertional tendinopathy affects its attachment to bone. This matters because bringing the foot far upwards can compress a sensitive attachment. Pain behind the heel may also have another cause, so assessment remains important.
Understand the picture
Distinguishing two locations
Calf muscles
They transfer force to the tendon.
Middle of the tendon
Progressive strengthening is a foundation for midportion care.
Heel attachment
Insertional symptoms may need a more limited initial range.
How can symptoms feel?
First steps after sleep or sitting may be stiff and sore. Symptoms may ease after a few minutes, then return after activity or the next day. Stairs, acceleration and carrying a load can be harder than gentle walking.
The tendon may be tender or thickened, but appearance alone does not predict pain or outcome. Feeling better during a warm-up is not an automatic signal to continue longer. The response afterwards and next morning helps guide the programme.
Why can pain develop?
A rapid increase in running, hills, jumping or standing may exceed current tendon capacity. Different activities or footwear can contribute. Several factors often interact, including previous problems, age, general health and muscle capacity.
There may be no single responsible movement. Mention illnesses and medicines, particularly recent fluoroquinolone antibiotics or corticosteroids. Your clinician considers their relevance; do not stop prescribed treatment on your own.
Which signs need more than strengthening?
A sudden blow-like feeling behind the leg, a snap and a clear loss of push-off may suggest rupture. Stop activity and seek prompt assessment even if you can still walk. Do not stretch the tendon to check whether it is intact.
Marked redness, fever, unusual calf swelling or a change from the usual activity-related pattern needs medical advice. With sudden breathlessness or chest pain, call 112. These situations take priority over exercise.
Do you need ultrasound or MRI?
Diagnosis often uses history, location and response to loading. The clinician also checks strength and other possible causes. Imaging may help with an unusual presentation, suspected additional injury or a specific decision.
A thick or altered tendon on a scan does not directly measure disability. Repeating ultrasound until the tendon looks perfect is not necessary in every case. Function and progress remain important guides to returning to activity.
Chapter sources [1]
What does adapting load mean?
Temporarily reduce what exceeds tolerance while keeping suitable activities. You might shorten a run, remove hills or choose another activity that does not provoke symptoms. Replacing running with an equally aggravating activity does not reduce the relevant load.
Observe next-morning steps, walking and exercise responses. Repeatedly increasing stiffness or limping suggests that the dose needs review. No single pain score makes every exercise safe for everyone.
How does strengthening help?
Progressive calf exercises are a foundation of care. Position, resistance, range and frequency are selected for your abilities. Starting seated or on two legs may be appropriate before greater loads and task-specific demands.
Midportion guidance supports regular work at least three times weekly, with suitably challenging, tolerated loading. This does not mean starting heavy without assessment. For either form, at least twelve weeks of active care may be needed before judging results. That is not a promise of recovery by that date.
In everyday life
More stiffness the morning after a run
Observe
Compare first steps and walking after each session.
Adjust
Reduce one factor, such as duration or hills.
Rebuild
Progress strength before faster movements.
What changes at the heel attachment?
Initially, floor-level exercises may suit the tendon better than lowering below a step. A large stretch is not a goal in itself. The physiotherapist adjusts range to attachment pain and walking needs.
Do not copy a heel-drop programme without understanding your situation. A heel lift or temporary footwear change may sometimes be discussed for comfort and reviewed. Aids do not automatically replace gradual loading or symptom monitoring.
Chapter sources [1]
Organising work, shoes and sport
A shoe pressing on the back of the heel may irritate it locally. Find a comfortable option for your activity without an abrupt change to very different footwear. Alternating tasks or splitting standing periods may reduce total work demands.
Fast running and jumping are reintroduced after sufficient strength and control work. Start with a limited stage and observe recovery. A comfortable sleeping position is usually enough; no night-time device is essential for every tendinopathy.
When should treatment be reviewed?
Progress is assessed over weeks through walking, strength, load tolerance and recovery. A programme that is impractical, too painful or ineffective needs adjustment and a check of the diagnosis. Continuing unchanged for months is not automatically useful.
Additional treatments may be discussed after appropriate active care. Benefits, risks and uncertainties differ. Injections or surgery are neither automatic steps nor guarantees. Shared decisions should reflect your circumstances and goals.
Your questions
Are tendinitis and tendinopathy the same?
Tendinitis is often used in everyday language. Tendinopathy more broadly describes tendon pain and reduced load tolerance without assuming inflammation explains everything.
Chapter sources [1]
Must I stop all activity?
Not routinely. Tolerated activity can remain or be adapted. Suspected rupture or a medical restriction changes the advice.
Can I lower my heel over a step?
Not automatically. A deep lowering movement can irritate an insertional problem. Begin according to assessment, often on level ground, with an appropriate range.
Chapter sources [1]
Why is the tendon still thick despite improvement?
Appearance and symptoms do not always change together. Walking, strength and activity tolerance help judge progress more than thickness alone.
Chapter sources [1]
Sources and references
- [1] Dutch multidisciplinary guideline on Achilles tendinopathy
- [2] AOPT/JOSPT — Midportion Achilles Tendinopathy: Revision 2024
- [3] Guy’s and St Thomas’ — Achilles tendinopathy
- [4] Achilles Tendon Rupture (Tear) - OrthoInfo - AAOS
- [5] Recommendations | Diabetic foot problems: prevention and management | Guidance | NICE
- [6] DVT (deep vein thrombosis) - NHS
Text updated on
Medical review: awaiting Hasib Selimovic.