Achilles Tendinopathy - Diagnosis, Causes and Management

Updated: Apr 22, 2020

The achilles tendon is a very common injury site for a lot of active people and especially our running community. In this article we look at the diagnosis process, the causes and the recommended treatment methods, as guided by the current research.

The achilles tendon is the largest and arguably on of the most important tendons in the human body. It connects the calf muscles (soleus and gastrocnemius) to the foot (heel bone) and plays the crucial roles of enabling us to propel our body forwards when walking or running. The tendon itself is thick and made up of strong connective tissue.

How do you know if you have injured your Achilles Tendon:

Common signs and symptoms:

  • Achilles pain in runners usually comes on gradually (instant pain = probably tearing

  • When squeezing the tendon 3 - 6cm above the heel bone will generate some pain

  • Physical activities which load the tendon are likely to make the pain worse, especially things like hill walking, stairs, standing for long periods and running.

  • You may have just returned to running after a break? Or increased your speed or distance?

  • To look at, the achilles tendon on the affected side is likely to be thicker and may even have a small nodule (lump) at the most painful site.

  • The stiffness is likely to be more noticeable in the morning when you get out of bed or during the day when you get up after a period of sitting but improves with 5-10mins of being mobile.

Other possible diagnosis for this pain you are having:

Achilles insertional tendinopathy - This is still associated with the achilles tendon but the site of injury is at the very bottom of the tendon where it attaches to the calcaneus (heel bone). Insertional tendinopathy requires very different management and you should make sure you get a correct diagnosis for this as early as possible. If you follow rehab for mid portion achilles tendinopathy you are likely to make it a lot worse due to the compressive forces you will put on the injury site. Refer to (this) article to read more about this.

Retrocalcaneal Bursitis - Similar location of the insertional achilles tendinopathy but a different structure. The bursa is a sack of fluid that plays a role in allowing the tendon to move freely. More detail on this in the insertional achilles tendinopathy article.

Posterior tibial tendon dysfunction - similar presentation but your achilles wont be sore to pinch as other tendons are causing the pain. However, similar management is used so misdiagnosis here is slightly less risky.

Calf muscle injury - A calf injury, such as a tear or a strain, is likely to present high up the leg compared to an achilles injury and will generally require a lot different management. Check in on this article for plenty of gems on managing calf injuries!

Peritendon - This is another whole separate diagnosis in itself. Not a tendinopathy as it can happen in a completely normal tendon. Peritendon or paratenon pain is an inflammation caused by friction load to the membranes/structures in front or behind the actual tendon itself. A key symptom to help identify this condition is the intense 'follow up pain' after exercise, which signifies the inflammatory response of friction load to the structures that felt seemingly fine during the exercise. Differentiating this yourself is difficult so again, consult your physio to identify this as you will require a different treatment plan to a tendinopathy.

To help identify the correct diagnosis and management plan required we strongly recommend talking to us directly or your own physio. Mis-diagnosis leads to longer term injuries and being unable to reach your fitness goals - nobody wants this!

Some of this sounding familiar? Here are the most likely causes for Achilles tendinopathy:

How it can effect you as a Runner:

  • Reduced ability to participate in normal activity - especially running

  • Pain may be enough to stop you from running completely or it may just be enough to slow you down causing endless frustration and lost progress.

  • Patient has fear of further damage -> reduced compliance to rehab -> drawn out injury

  • This can significantly effect improvement as we know how important the loading program can be!

Treatment for Achilles Tendinopathy:

Treating an achilles tendinopathy is a fine art and needs to be completely individualised. Tendon injuries continue to be a tricky area for all researchers and therapists worldwide but there are a few people who have a fairly good idea on what tendons respond well to and what they don't like. Let's start with this diagram from one of Tom Goom's posts.

Image credit - Tom Goom's tendinopathy blogpost

Training errors - A MASSIVE category that i'll try to fit into a few paragraphs.

Your tendons can only handle so much load. If you exceed the amount of load your achilles can handle, like trying to run 10km at PB pace after not running for 6 months, there is a high chance of injury because your tendon doesn't have time to adapt to the new load.

Another common example of this is running too much too soon. Training for a marathon can lead to people thinking they need to run everyday with high intensity to continually progress. You may as well kick a brick wall 10 times as hard as you can. This is not optimal for your end goal and WILL almost certainly lead to injury.

The best way to manage your training load, if you are getting injuries or don't know how, is consult someone that does know. Get a plan or even just an understanding of what a training plan looks like. Even more importantly, learn what your body can handle and progress your training slowly whilst listening to how your body is reacting. The 10% rule is a nice one. Progress milage by 10% each week and if you feel like your 28km long run on Sunday isn't a good idea with a stiff and sore achilles, you are probably right and substituting it for a different session may be the perfect option.

In my marathon training I have come to realise one key thing. Train the session you planned, don't get carried away and change the plan during. A long run is training my endurance, to teach my body to run for a longer period of time. If I try and add speed to this I am shooting myself in the foot. Leave the speed for the speed sessions... Sounds simple but you know exactly what I'm talking about. Even if you feel like Mo Farah on one of your long runs, increasing your pace will lead to your body reacting poorly. If you are lucky, this will just mean an increased recovery time.

Tendons adapt to load. This load must be introduced gradually or the tendon will get grumpy. See the seesaw diagram - find the balance and your tendons progress at the same rate of your training resulting in both you and the tendons being happy chappies!

Biomechanics/Movement control:

There are a number of possible aspects to address in regards to a runners biomechanics and they include leg length difference, over pronation, high foot arch and poor mobility in the foot and ankle. A number of research articles have looked at changing these aspects and how that affects a runners achilles pain but again, the treatment needs to be specific to the patient. The best evidence in my experience here is to get a progressional who specialises in runners to look at you running with video assistance and pick the specific biomechanical aspects that need to be addressed.

Things such as the heel drop in your shoe, a heel raise insert, hip/knee/ankle control and ankle mobility are things which a good physio will look at and generally some form of strength program will be beneficial as 95% of injured runners ive seen have benefited from some specific exercise rehabilitation to work on strengthening specific areas.

Specific strength/endurance exercises:

The main muscles requiring strength in regards to achilles tendinopathy are the soleus and the gastroc (calf muscles). Prescribing strength exercises for runners recovering from an achilles injury is all about timing. Symptoms need to have improved and the tendon must be able to handle the exercise without flaring it up. When ready, endurance can be improved using calf raises of various forms to 15-20 reps (or to fatigue) and doing 3 sets per day. Again, this needs to be prescribed by a professional or you risk irritating a sensitive achilles.

See our post on tendinopathy to find out more about how we need to apply some specific load progressive exercises to tendons to help them improve. These will generally come under the progression of isometic hold, isotonic exercises followed by plyometric and functional strength work. All this is patient specific and when and how much the exercises are progressed depends on how that particular tendon reacts to load.


Having tight structures, in particular calf muscle and ankle joint, are likely to increase the tension through the achilles tendon when you are loading it. Therefore, the solution is... Loosen these structures off so they move more silky smooth. When your achilles is ready, calf stretches with a straight and bent knee for 20 seconds 3-5x per day will help take some of the added tension away from the muscle and the achilles. These stretches can also help with the ankle range of motion but for more ankle mobility tricks, send us a message and we can help.


As a runner or a physically active person getting an achilles tendinopathy injury can really effect your ability to train and therefore can change your life. The underlying takeaway from this article is to introduce load progressively to your body to avoid the injury in the first place. If you feel the achilles is unhappy, ADAPT your training and address the aspect we discussed above to ensure you have a quick resolution of the injury.

The help of a physio who knows how to help runners and has experience with running injuries can be a huge benefit so send us a message at Runfit Physio, we would love to help get you back out on the trails/roads asap.


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