At RD Physiotherapy, we’ve recently observed a notable increase in presentations of Achilles tendon pain, particularly as patients return to outdoor physical activity with the onset of warmer weather. This seasonal surge aligns with a well-established correlation between increased load and the onset of Achilles tendinopathy a common overuse injury that can significantly impact function and quality of life.
Understanding Achilles Tendinopathy
The Achilles tendon is a dense, fibrous structure that connects the gastrocnemius and soleus muscles to the calcaneus. While the tendon is biomechanically robust, it is vulnerable to repetitive tensile loading—especially following periods of reduced activity or sudden increases in training volume, intensity, or frequency.
Achilles tendinopathy is typically a degenerative condition rather than an inflammatory one (hence the preferred term “tendinopathy” over “tendonitis”). It is characterised by:
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Collagen disorganisation
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Neovascularisation
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Increased ground substance
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Tendon thickening and reduced tensile strength
This pathology most commonly presents in either the mid-portion of the tendon (2–6 cm proximal to the calcaneal insertion) or at the insertional region.
Clinical Presentation
Patients with Achilles tendinopathy often report:
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Localised pain and stiffness, especially during the first few steps in the morning or after periods of inactivity
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Pain that initially improves with activity but worsens afterward
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Tenderness to palpation along the tendon, often accompanied by thickening or nodularity
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Reduced plantarflexion strength or endurance in more advanced cases
Risk Factors
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Sudden increase in load (running, walking, sports)
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Biomechanical deficits (e.g. overpronation, calf tightness)
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Poor footwear or training on hard/uneven surfaces
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Reduced tendon capacity from previous inactivity (e.g., post-winter deconditioning)
Pathophysiology of Injury
Tendinopathy develops when cumulative mechanical overload exceeds the tendon’s ability to remodel and adapt. This can lead to:
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Microtrauma accumulation
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Failed healing response
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A shift from reactive tendinopathy to degenerative tendinopathy, which is more difficult to reverse
In clinical practice, it is essential to identify where the patient lies on the tendinopathy continuum (Cook & Purdam model) to determine appropriate intervention.
Management Principles
Load Management
The cornerstone of treatment is optimal loading. This does not mean complete rest, but rather a graded exposure to mechanical load to facilitate collagen remodelling and improve tendon capacity.
Rehabilitation Strategies
Isometric Exercises
Used in the early reactive phase to reduce pain via cortical inhibition:
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Hold a mid-range heel raise (e.g., 70% effort) for 30–45 seconds
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Perform 4–5 reps, multiple times daily
Eccentric Loading (Alfredson Protocol)
Primarily beneficial in the degenerative stage, particularly for mid-portion tendinopathy:
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Eccentric heel drops off a step
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3 sets of 15 reps, twice daily, progressing to weighted eccentric exercises
Heavy Slow Resistance (HSR)
HSR training has shown outcomes comparable or superior to eccentric-only protocols:
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Slow, controlled concentric and eccentric calf raises using external load
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3–4 sets of 6–8 reps, 2–3 times per week
Adjunct Therapies
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Manual therapy for associated calf tightness
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Biomechanical assessment and gait retraining if relevant
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Shockwave therapy (in chronic cases with poor response to exercise)
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Orthotics or heel lifts for offloading (especially in insertional tendinopathy)
Note: Passive modalities (e.g., ultrasound, massage) offer minimal long-term benefit if not combined with an active rehabilitation program.
Referral Guidelines
Refer a patient to physiotherapy if:
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Symptoms persist beyond 2 weeks despite load reduction
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There is notable loss of function or activity modification
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The patient has a history of recurrent tendon issues or multiple lower limb pathologies
Prognosis and Return to Activity
With early and appropriate intervention, most patients with mid-portion Achilles tendinopathy respond well to conservative management. Full resolution of symptoms may take 8–12 weeks or longer depending on severity and chronicity.
A return-to-activity plan should be gradual, guided by symptom response and progressive load tolerance.
Need a Clinical Review or Targeted Rehab Plan?
At RD Physiotherapy, our clinicians specialise in the assessment and treatment of lower limb tendinopathies. We use evidence-based protocols to reduce pain, restore function, and improve tendon resilience.
Let’s work together to keep you moving with strength and confidence.
