Management of Your Achilles Tendinopathy

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Original Editor - Katherine Mcbeth Top Contributors - Katherine McBeth, Rucha Gadgil, Kim Jackson and Dione Crasta

Read Me First[edit | edit source]

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Overview[edit | edit source]

Achilles tendinopathy is an over-use condition, which is caused by repeated energy storage and release with excessive compression. Over time, if untreated, a tendinopathy can lead to sudden injury and rupture of the tendon. Reduction in the tendon’s flexibility or an increase in the tendons stiffness can increase the risk of injury.
The Tendon Continuum (Cook and Purdum) outlines the stages of a tendinopathy. These stages can be imagined on a line similar to that of a timeline; however, your injury can move either way on the scale from one stage to another, depending on how much load (use) or unload (non-use) on the tendon, particularly in the initial stages.

Causes[edit | edit source]

Risk factors include:
• Obesity
• High blood pressure
• Rapid change to load
• Type II Diabetes
• Prolonged steroid use
• Family history of tendinopathy
• Other factors including inappropriate footwear and an increase in age

Symptoms[edit | edit source]

• Pain in the morning
• Sensitivity and pain on the tendon
• Increased pain when loading
• Swelling (less common)
• The tendon can become thicker in parts

Diagnosis[edit | edit source]

Observation – Looking for loss of muscle (atrophy), swelling, asymmetry and redness of the skin also known as erythema.

Palpitation – Felling the tendon will allow your healthcare professional to see if there is any localised tenderness on the tendon, as well as feel for nodules and thinking of the tendon.

Your health care professional may also want to test you range of motion, strength, and flexibility where there is suspected tendinopathy as there is often reduced on the on the side of the tendinopathy . Some movements you may be asked to do include ankle dorsiflexion and heel raises

• Arc sign


• Royal London Hospital test


Positive tests would suggest tendinopathy

Exercises[edit | edit source]

Reducing the intensity of daily activities is recommended to reduce the amount of work required by the tendon; however, you should not stop all activity as it can result in reduced muscle mass.

The key goal of tendinopathy treatment is to improve the energy storage capacity of the tendon. It is the ability of the tendon and associated muscle to work and manage load, essentially acting as a ‘spring’ in storing and then releasing energy. Three key exercises for Achilles tendinopathy are:

  1. Isometric Loading - Allows the tendon to be put under tension without changing the length of the tendon.
  2. Isotonic Loading - The muscle shortens against a load.
  3. Energy Storage Loading. [3] - Movements that make the tendon act like a spring.

Phase 1: Isometric Loading- Achilles tendon holds

Isometric tendon loading can help to reduce pain in tendons, whilst preserving some strength. Depending on your symptoms and tendon irritability these can be performed with either double legs or a single leg. For highly irritable (reactive) Achilles tendons double leg holds, of often shorter duration, and fewer repetitions may be performed. The position of the isometric hold can either be mid- or end-range (i.e. right up on the toes, or halfway up).


Phase 2: Isotonic Loading- Calf raises

Once your pain level and the tendon’s irritability reduce you can start these exercises. There are no ‘hard and fast’ rules for when to start on isotonic loading for the rehabilitation of Achilles tendinopathy. Graduated isotonic loading is initiated once you have less than 5/10 pain or tolerable and acceptable pain on repeated single leg calf raises, and your morning tendon stiffness has reduced significantly.

The ultimate goal of the isotonic exercise is to develop strength in the tendon and the surrounding muscles. In the case of the Achilles tendon, the strength of soleus and gastrocnemius muscles plays a major role. Recurring loading, such as when walking or running does not induce enough adaptation of the tendon matrix, nor the work capacity of the muscle-tendon unit. Hence heavier loads are required with the isotonic loaded exercises.

  • Isotonic seated calf raises can be performed with a gradual increase in loading. Perform each repetition of 3-6 seconds in length to develop tension in the tendon.

  • Isotonic standing calf raises should be performed at the mid-range of the muscle’s movement. The benefit of performing Heavy slow resistance (HSR) exercise in the mid-range is that it will avoid the compression of the tendon at end of the range that can occur with exercising with heavier loads. For example, at the very end range of ankle plantarflexion (toes pointed), or dorsiflexion (think letting the heel drop off the edge of a step) the Achilles tendon is subject to compressive loads against the heel bone (calcaneum) which can be potentially irritating and pain-producing.

Phase 3: Energy Storage Loading- Plyometric Exercises

The crucial last stage of rehabilitation is the initiation and execution of ‘energy storage’ tendon exercises. These exercises include deformation of the tendon with jumping and hopping based exercises. These exercises help the tendon to regain its capacity to absorb and then release energy via the stretch-shortening cycle, that happens when you land and then pushes off at toe-off.

These exercises can be initiated when you have minimal or markable reduction in morning stiffness in the Achilles tendon on waking. In addition, you will need to have been progressing well with isotonic calf raise exercises, have very mild tenderness on palpation of the Achilles tendon, and be able to tolerate light running without a flare-up in tendon irritability and aggravation of symptoms.

For example, increasing duration under tension during heavy slow-resistance training may increase a strain on the tendon and result in greater adaptation, however increasing speed is going to be more likely to improve power and prepare for sporting activities involving the Stretch Shortening Cycle.

Exercises outlined is as follows:

  • Double-leg hop
  • Single leg hop
  • Single leg step hops
  • Hopscotch with activation band


Management[edit | edit source]

Activity modification is key to helping improve symptoms and achieving recovery.

Nonacute Achilles tendinopathy, complete rest is not suggested, continue with recreational activity within your pain tolerance while participating in rehabilitation.

Reducing body mass index can help reduce the load on the tendon.

Getting footwear that fits well and is suitable for the activity you are completing can also help reduce the load or the impact of load and may help reduce symptoms and prevent reoccurrence. If needed shoe can be made for the perfect fit.

Prevention[edit | edit source]

Try to eliminate any risk factors, additionally to this when increasing activity levels do this over a period of time rather than all in one go.

Resources[edit | edit source]

The following links will lead you to information on specialist services, charities, or organisations that may offer additional help and support.

Achilles Tendinopathy

References[edit | edit source]

  1. CRTechnologies.Arc SIgn Achilles (CR). Available form
  2. Royal London Hospital Test (CR)CRTechnologies. Available form
  3. Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. British journal of sports medicine. 2014 Apr 1;48(7):506-9.
  4. Single leg heel raise isometric hold available from
  5. Single leg heel raise isometric hold available from
  7. Achilles Tendonitis Rehab Phase 3 available from