Last updated: April 2020
Next review: April 2022
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What is Achilles Tendinopathy?  (Commonly known as Achilles Tendonitis)

A tendon is a thick fibrous band of connective tissue that connects muscle to bone. The Achilles tendon is located at the rear of the leg and connects the calf muscles to the foot (see figure 1). This tendon will allow for stretch and recoil of the calf muscles and will also transmit force between the muscles and foot.

Achilles tendinopathy often presents with pain in either the mid-portion, or insertion of the tendon at the heel and it is painful to touch. There may also be thickening in the tendon.

Evidence suggests there are two main stages of the disease; a reactive stage and a degenerative stage, all with varying symptoms.

What are the causes?

The most common cause of an Achilles Tendinopathy is compression or overloading the tendon, which can occur in people of all ages.  Other causes can include:

A sudden change in activity (i.e. increasing running distances to quickly or faster speed) or load (uphill running/stairs).

• Obesity
• Side effects of certain medications
• Systemic disease such as Rheumatoid Arthritis or Diabetes.
• Hormonal changes i.e. Post menopause

What are the symptoms?

Symptoms will vary dependent of the stage of the disease:

Reactive—an acute stage, where the Achilles can be constantly painful and wake you at night. There can also be swelling around the tendon. This needs to be managed by avoiding too much that aggravates the pain and ice or NSAID’s (ask your GP before taking).

Degenerative— this is the chronic stage where the tendon is no longer acutely painful but the tendon healing has plateaued. This stage will require physiotherapy input and a strengthening exercise regime which can be seen on the opposite page.

Phase 1: Weeks 1-2

Patient status: Pain and difficulty with all activities, difficulty performing 10 1-legged toe raises

Goal: Start to exercise, gain understanding of their injury and of pain-monitoring model

Treatment program: Perform exercises every day

• Pain-monitoring model information and advice on exercise activity
• Circulation exercises (moving foot up/down)
• 2-legged toe raises standing on the floor (3 sets × 10-15 repetitions/set)
• 1-legged toe raises standing on the floor (3 × 10)
• Sitting toe raises (3 × 10) – while sitting lift your heels off the ground
• Eccentric toe raises standing on the floor (3 × 10) – Up on both legs transfer weight to your bad leg and come down

Phase 2: Weeks 2-5

Patient status: Pain with exercise, morning stiffness, pain when performing toe raises

Goal: Start strengthening

Treatment program: Perform exercises every day

• 2-legged toe raises standing on edge of stair (3 × 15)
• 1-legged toe raises standing on edge of stair (3 × 15)
• Sitting toe raises (3 × 15)
• Eccentric toe raises standing on edge of stair (3 × 15) – Up on both legs transfer weight to your bad leg and come down
• Quick-rebounding toe raises (3 × 20) – Stand on the ground, go up on both legs and when you come back down return to tiptoe quickly

Phase 3: Weeks 3-12 (longer if required)

Patient status: Handled the phase 2 exercise program, no pain distally in tendon insertion, possibly decreased or increased morning stiffness

Goal: Heavier strength training, increase or start running and/or jumping activity

Treatment program: Perform exercises every day and with heavier load 2-3 times/week

• 1-legged toe raises standing on edge of stair with added weight (3 × 15)
• Sitting toe raises (3 × 15)
• Eccentric toe raises standing on edge of stair with added weight (3 × 15) – Up on both legs transfer weight to your bad leg and come down
• Quick-rebounding toe raises (3 × 20) – Stand on the ground, go up on both legs and when you come back down return to tiptoe quickly
• Plyometric training (explosive exercise) – Jumping, skipping, hopping etc

Phase 4: Week 12- 6 months (longer if required)

Patient status: Minimal symptoms, morning stiffness not every day, can participate in sports without difficulty

Goal: Maintenance exercise, no symptoms

Treatment program: Perform exercises 2-3 times/week

• 1-legged toe raises standing on edge of stair with added weight (3 × 15)
• Eccentric toe raises standing on edge of stair with added weight (3 × 15)
• Quick-rebounding toe raises (3 × 20)

Warning

Never do any activity that hurts your Achilles. It is normal to feel some discomfort, but do not push yourself to the point where you’re in pain. Be very careful with any activity you do. Pain is the warning sign; don’t ignore it. If you have any concerns contact your health professional that issued this leaflet

You should:

• Expect mild – moderate pain that stops with rest. Do not continue if pain persists all day.
• Add weight in a rucksack and increase resistance as tolerable (use pain as your guide).