Achilles Tendinopathy: Causes, Symptoms, and How We Can Help
- staystrongtherapy
- Jun 30
- 6 min read
All information in this blog is supported by a major 2024 clinical practice guideline and peer-reviewed research. There is currently no dedicated NICE guideline for this condition, so current evidence is used throughout. Reference numbers appear throughout, with the full list at the bottom of the page.
What Is Achilles Tendinopathy?
Achilles tendinopathy causes pain, stiffness, and muscle power deficits affecting the Achilles tendon, most commonly at the midportion of the tendon, the segment running between the calf muscle and the heel bone. ¹ It's a genuinely well-researched condition, with the most current, evidence-based guidance coming from a major clinical practice guideline published in late 2024, the third such revision from the American Physical Therapy Association on this specific topic. ²
Common Signs and Symptoms
Pain localised to the midportion of the Achilles tendon, typically a few centimetres above the heel
Stiffness, particularly first thing in the morning or after periods of rest
Pain that often eases somewhat with activity, only to return afterward
Reduced calf and ankle power, sometimes described as the calf feeling weaker or less responsive than usual
Thickening or tenderness of the tendon on palpation
Risk Factors
The risk of developing midportion Achilles tendinopathy is genuinely multifactorial, related to an interaction between intrinsic and extrinsic factors that lead to tendon overloading. ³
Lower limb biomechanical impairments, any abnormal movement pattern that specifically produces an eccentric overload of the Achilles tendon during weight-bearing activity may increase risk ³
Health conditions, medications, and genetic factors, the body's response to tendon loading is genuinely influenced by these factors, meaning some individuals may be more susceptible to tendon overload than others ³
Presumed tissue frailty, certain underlying conditions are believed to increase risk during loading activity, though the research notes that the precise relationship between physical load and tendon symptoms in these cases remains poorly understood ³
Limited ankle dorsiflexion range of motion, a recognised contributing biomechanical factor ⁴
Repetitive loading activities, particularly relevant to runners and athletes involved in repeated jumping or sprinting
What to Look Out For
Please seek prompt medical assessment if you experience:
A sudden, sharp pain at the back of the heel with an audible pop, alongside difficulty pushing off when walking (possible Achilles rupture)
Significant swelling or visible deformity following injury
Inability to rise onto your toes on the affected side
Fever or warmth around the tendon
Myths vs Facts
"Rest is the best treatment." Genuinely not supported by current evidence. The 2024 clinical practice guideline confirms tendon loading exercise is the first-line treatment for midportion Achilles tendinopathy, found to be effective for reducing pain and improving function in the majority of people, and research has shown exercise to be better than a simple wait-and-see approach. ¹ ⁵
"Manual therapy alone will fix this." The evidence specifically doesn't support this. There is a low level of evidence supporting the use of passive interventions alone, such as manual therapy, taping, and dry needling, for Achilles tendinopathy. ¹ This is genuinely important to know, these treatments have a role, but as a support to active exercise, not a replacement for it.
"I need a very specific type of eccentric exercise programme, or it won't work." Current evidence doesn't support this either. Tendon loading exercise is effective despite variations in the type of loading used, whether eccentric, heavy-load and slow-speed, or progressive concentric and eccentric programmes. ¹ Recent research has confirmed that multiple types of exercise are effective, not eccentric loading exclusively, and that exercise frequency, total number of sessions, and overall duration of care do not appear to meaningfully influence outcomes. ⁶ What matters is consistent, appropriate tendon loading, not a single "correct" protocol.
How We Can Help
Given the strong evidence supporting active tendon loading as the primary treatment, our approach genuinely centres on building and supporting a structured exercise programme, with manual therapy used to complement this, not replace it.
Osteopathic manual techniques and manual therapy: used to address restriction and compensatory tension in the ankle, calf, and surrounding lower limb structures, supporting your exercise programme rather than acting as a standalone treatment, in line with current evidence. ¹
Deep tissue and sports massage: targeted soft tissue work for the calf and surrounding muscles, supporting overall function alongside your loading programme.
Medical acupuncture and cupping: used as part of a broader treatment plan to support pain management, recognising that, as with manual therapy, these work best as a complement to active exercise rather than in isolation.
Stretching guidance: clinicians may use stretching of the calf muscles, with the knee both flexed and extended, to reduce pain and improve outcomes specifically in people who have limited ankle dorsiflexion range of motion. ⁷
Heel lifts: a temporary option to reduce ankle range of motion demand during aggravating activities, which some people find genuinely helpful as part of their overall management. ⁸
Exercise: The Cornerstone of Recovery
This is, without question, the most important and well-evidenced part of treatment for Achilles tendinopathy.
Tendon loading exercise (eccentric, heavy-load slow-speed, or progressive): clinicians should use mechanical loading, in whichever appropriate form, to decrease pain and improve function, with patients generally exercising at least twice weekly within their pain tolerance. ⁷
Calf stretching: where limited ankle dorsiflexion is present, stretching with the knee flexed and extended can genuinely help reduce pain and improve satisfaction with outcomes. ⁷
Neuromuscular and biomechanical correction: addressing lower limb impairments contributing to abnormal movement patterns that place eccentric overload on the tendon during weight-bearing activity. ⁷
Recent research on loading parameters: a 2025 study found that the speed and intensity of eccentric calf training meaningfully affects acute changes in Achilles tendon thickness and stiffness, reflecting how loading variables continue to be refined to optimise outcomes. ⁹
Mild, temporary symptom aggravation is a recognised and acceptable response to tendon loading exercise, and is the most commonly reported, minor harm associated with this approach. ⁶ Your practitioner will guide a structured, progressive loading programme tailored to your specific presentation.
What to Expect at Your First Appointment
We will take a thorough history and carry out a hands-on assessment of your Achilles tendon, calf, and ankle, including your range of motion and any contributing biomechanical factors. We will explain clearly what we find and build an evidence-based treatment plan centred on tendon loading exercise, with manual therapy and other treatments used genuinely as a support to this, in line with current best-practice guidance.
Frequently Asked Questions
Do I need a scan? Not always for initial diagnosis and treatment, which is usually based on history and clinical examination. Imaging may be considered in certain cases as part of a thorough assessment.
Will exercise make it worse? Some temporary discomfort during exercise is normal and expected, and is the most commonly reported response to tendon loading. Working within an appropriate level of pain tolerance, as your practitioner guides, is part of effective treatment rather than something to avoid entirely.
How long will it take to improve? This varies, but research has found that the duration of care, the total number of sessions, and how often you exercise within a reasonable range don't appear to significantly affect your final outcome, consistency over time matters more than rushing the process.
Is there one "correct" exercise programme I need to follow exactly? No, genuinely not. Multiple types of tendon loading exercise have been shown to be effective, what matters most is consistent, appropriately progressed loading, not strict adherence to one specific protocol.
Recognise these symptoms? Get in touch using the contact form and we will assess and build the right treatment plan for you.
References
Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision, 2024. Journal of Orthopaedic & Sports Physical Therapy. 2025;55(1):68-69. Available at: https://www.jospt.org/doi/10.2519/jospt.2025.0501
Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, Martin RL. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision, 2024. Journal of Orthopaedic & Sports Physical Therapy. 2024;54(12):CPG1-CPG32. Available at: https://pubmed.ncbi.nlm.nih.gov/39611662/
Midportion Achilles Tendinopathy: Clinical Practice Guidelines Revision 2018. Journal of Orthopaedic & Sports Physical Therapy. 2018;48(5). Available at: https://www.jospt.org/doi/full/10.2519/jospt.2018.0302
Exercise parameters to consider for Achilles tendinopathy: a modified Delphi study with international experts. PMC. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC12573378/
Achilles Pain (third revision) CPG 2024. APTA Orthopedics. Available at: https://www.orthopt.org/uploads/content_files/files/Achilles_Pain_Third_Revision_DRAFT_September_2024.pdf
Achilles Pain (third revision) CPG 2024. APTA Orthopedics. Available at: https://www.orthopt.org/uploads/content_files/files/Achilles_Pain_Third_Revision_DRAFT_September_2024.pdf
Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. Journal of Orthopaedic & Sports Physical Therapy. 2018;48(5). Available at: https://www.jospt.org/doi/10.2519/jospt.2018.0302
Midportion Achilles Tendinopathy Revision, 2024. JOSPT Perspectives for Practice. Journal of Orthopaedic & Sports Physical Therapy. 2025;55(1):68-69. Available at: https://www.jospt.org/doi/pdfplus/10.2519/jospt.2025.0501
Pringels L, Pieters D, Van Den Berghe S, et al. Loading Speed and Intensity in Eccentric Calf Training Impact Acute Changes in Achilles Tendon Thickness and Stiffness: A Randomized Crossover Trial. Medicine & Science in Sports & Exercise. 2025;57:895-903.
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