Achilles tendonitis or tendinopathy

What are the symptoms of Achilles tendinopathy?

Morning pain during your first steps is the most typical and telling symptom. This stiffness usually lessens after a few minutes of movement, a phenomenon known as "warming up." However, the pain may then return during or after physical activity.

Typical Symptom Progression:

In the early stage, pain only appears after exercise. At an intermediate stage, it occurs at the beginning of activity, lessens with warming up, then reappears. In the advanced stage, pain persists during activity and limits performance. At the severe stage, constant pain affects daily activities.

Clinical Signs to Watch For:

• Noticeable pain and stiffness in the morning during the first few minutes
  
• Tenderness when touching the tendon, often in a specific spot
  
• Visible or palpable thickening of the tendon (a nodule)
  
• Crepitation (a cracking sensation) during movement
  
• Pain that increases when putting weight on the balls of your feet
  
• Weakness when pushing off or jumping
  
• Discomfort when climbing stairs, hills, or walking on uneven ground

Warning sign requiring immediate consultation: Sudden and intense pain accompanied by an audible popping sound, a palpable gap in the tendon, or a complete inability to push off on your toes suggests a partial or complete rupture. This situation is a medical emergency requiring rapid evaluation to determine if conservative or surgical treatment is indicated.

How is Achilles tendinopathy diagnosed?

Diagnosis primarily relies on a clinical examination and a detailed history of your symptoms. When performed by an experienced physiotherapist, this clinical assessment is over 90% reliable in identifying Achilles tendinopathy.

Components of Clinical Assessment:

The detailed history explores when your symptoms started, identifiable triggers, how they've progressed over time, and their impact on your daily activities. The clinician will ask about any recent changes in your training, footwear, or activities.

Systematic palpation precisely locates the painful area. The physiotherapist will feel along the entire length of the tendon to identify any thickening, nodules, or areas of increased tenderness.

The painful arc test confirms that the pain originates from the tendon. By moving the foot into plantarflexion and dorsiflexion, the sensitive area moves with the tendon, confirming its tendinous origin rather than involvement of surrounding tissues.

Functional Tests Assessing Capacity:

• Single-leg heel raise (unilateral strength test)
  
• Repeated single-leg hops
  
• Stair descent test
  
• Ankle dorsiflexion assessment
  
• Calf isometric strength measurement

When is Imaging Necessary?

Musculoskeletal ultrasound allows for direct visualization of the tendon's internal structure, identifying areas of degeneration, measuring thickening, and detecting partial tears. This imaging method is accessible, radiation-free, and allows for a dynamic examination.

MRI offers superior resolution and visualizes surrounding structures. It is indicated in complex cases, when an associated condition is suspected, or before surgery.

Standard X-rays do not show the tendon itself (soft tissues are invisible to X-rays), but they can be useful for identifying calcifications within the tendon, bone problems in the heel, or structural abnormalities contributing to the injury.

Imaging is primarily used to confirm atypical cases, assess severity in resistant chronic cases, or plan interventional treatment. In most cases, a clinical examination is sufficient to establish the diagnosis and begin treatment.

What are the physiotherapy treatments for Achilles tendinopathy?

Eccentric exercises are the gold standard treatment, with a success rate of 70 to 90%. This approach is based on strong scientific evidence.

The physiotherapist supervises your progression and combines different therapeutic approaches. Treatment is personalized according to the stage of the injury and your activity level.

Supervised Eccentric Exercise Program:

The classic protocol spans 12 weeks with two daily exercises: straight-knee exercises to target the gastrocnemius, and bent-knee exercises to engage the soleus. Each exercise includes 3 sets of 15 repetitions, performed slowly (3 seconds for the lowering phase).

Progressive loading starts with body weight, then gradually adds a weighted backpack or dumbbells as tolerated. Mild pain during the exercise (up to 5/10) is acceptable and even desirable, but it should not persist the next day or progressively increase.

Education on Load Management:

The concept of load management is a fundamental pillar of modern treatment. The physiotherapist helps identify irritating activities and modify them temporarily, without imposing complete rest, which would be counterproductive.

Gradual progression towards a full return to activities follows a continuum: modifying activities, adapting load, progressing volume, increasing intensity, and finally returning to sport-specific activities.

Complementary Manual Therapy:

Soft tissue mobilization targets restrictions in the sural-Achilles complex. The physiotherapist works on myofascial release of the triceps surae, improves ankle mobility, and treats trigger points in the calf.

Working on the entire posterior muscle chain optimizes biomechanics. Restrictions in the knee, hip, or back can alter ankle mechanics and overload the Achilles tendon.

Complementary Therapeutic Modalities:

Extracorporeal shockwave therapy is used in resistant cases after 3 to 6 months of conservative treatment. This modality stimulates healing processes.

Dry needling can stimulate healing in refractory chronic tendinopathies.

Neuromuscular taping can offer temporary relief by partially offloading the tendon, although evidence for its long-term effectiveness remains limited.

Why Complete Rest is Not Recommended:

Tendons need mechanical load to heal and strengthen. Complete rest leads to deconditioning, loss of strength, and muscle atrophy, which makes returning to activity more difficult. Maintaining modified physical activity (cycling, swimming, elliptical) stimulates healing while preserving cardiovascular fitness and overall muscle strength.

Our physiotherapists at Physioactif use an evidence-based approach. Physiotherapy for sports injuries integrates these principles into all our rehabilitation protocols.

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What specific exercises help heal Achilles tendinopathy?

Heel drop exercises, also known as eccentric exercises, form the foundation of rehabilitation. This eccentric movement, where the muscle lengthens under tension, stimulates the reorganization of tendon fibers and gradually strengthens the tendon's ability to bear load.

Detailed technique for classic eccentric exercise:

Stand on a stair step or a step platform with the balls of your feet on the surface and your heels hanging off. Rise up onto the balls of both feet by contracting your calves. Then, shift all your weight onto the affected foot (lift the other foot). Slowly lower your heel below the level of the step, counting to 3 seconds, while controlling the movement. Use both feet to push back up to the starting position.

Perform two variations: with knees straight (targets the gastrocnemius) and with knees bent at approximately 30 degrees (targets the soleus). Complete 3 sets of 15 repetitions for each variation, twice a day, 7 days a week for 12 weeks.

Load progression:

Weeks 1-2: Body weight only, establish technique
Weeks 3-4: Add 2-5 kg in a backpack if the exercise becomes easy
Weeks 5-8: Gradually increase the load by 2-5 kg each week
Weeks 9-12: Maintain a load that allows you to complete repetitions with moderate effort

Complementary strengthening exercises:

Standing bilateral calf raises strengthen concentric force. Perform 3 sets of 15-20 repetitions with a 2-second pause at the top of the movement.

Isometric exercises in a raised calf position provide short-term pain relief. Hold the elevated position for 30-45 seconds, repeating 4-5 times.

Progressive functional training incorporates squats, lunges, and single-leg exercises to prepare for a return to specific activities.

Mobility and flexibility exercises:

The straight-knee calf stretch targets the gastrocnemius. Face a wall, place your back foot flat on the floor with your knee straight, and lean forward until you feel the stretch. Hold for 30 seconds, repeat 3 times.

The bent-knee stretch targets the soleus and Achilles tendon. Use the same position but with the back knee slightly bent, focusing on lowering your heel towards the floor. Hold for 30 seconds, repeat 3 times.

Dorsiflexion mobilization with an elastic band improves ankle range of motion. Attach an elastic band around your ankle, pull your shin forward while keeping your heel on the ground. Perform 20 slow repetitions.

Interpreting pain during exercises:

Mild to moderate pain (2-5 out of 10) during exercise is normal and even desirable. It indicates that the tendon is being challenged without being overloaded. Stop if the pain exceeds 5 out of 10 during exercise, or if it persists for more than 24 hours after the session. A gradual increase in pain over several days indicates that the load should be reduced.

When to progress to more advanced exercises?

Progression towards running, jumping, and specific sports activities follows precise criteria. You should be able to perform 25 single-leg calf raises without pain, jump in place 10 times on one foot without pain, and walk for 30 minutes without symptoms before considering a gradual return to running.

Rehabilitation exercises are customized according to your condition and goals. Our physiotherapists specializing in sports injuries supervise this progression to ensure a safe return to sport.

Can You Treat Achilles Tendinitis Yourself?

Self-treatment can relieve mild Achilles tendinitis (ice, rest, gentle stretches). However, without specific eccentric exercises, healing is much slower. Without an accurate diagnosis, you risk maintaining compensations or doing counterproductive exercises that delay healing.

The physiotherapist prescribes eccentric exercises with optimal progression for tendon healing. An evaluation helps identify the exact cause, rule out red flags, and create a progressive treatment plan. Exercises are tailored to your specific condition, not generic.

Our approach: professional assessment + supervised home exercise program = better long-term results.

Are you hesitating between self-treatment and a consultation? Free 15-min consultation to discuss your situation.

How Long Does Healing Take and How Can Relapses Be Prevented?

Recovery time:

Complete healing for Achilles tendinopathy typically takes 3 to 6 months. This duration may seem long, but it reflects the time needed for structural changes to occur within the tendon. The first symptomatic improvements usually appear after 4 to 6 weeks of appropriate treatment.

Factors influencing healing time:

The duration of symptoms before treatment affects the prognosis. Tendinopathy treated promptly responds better than a chronic condition. Adherence to the exercise program is the most important factor. Daily consistency over 12 weeks is more effective than a sporadic program. Continuing irritating activities slows down healing.

Typical recovery timeline:

Weeks 1-3: Adapting to exercises, learning load management.

Weeks 4-6: First improvements, decreased morning stiffness, better daily tolerance.

Weeks 7-12: Continuous improvement, increased functional capacity, gradual reintroduction of activities.

Months 4-6: Consolidating gains, gradual return to full activities, maintaining a preventive program.

Objective criteria for returning to sport:

The absence of pain in all daily activities is a prerequisite. Climbing stairs, walking on uneven terrain, and standing on your tiptoes should not cause any discomfort.

Calf strength reaching at least 90% of the healthy side is measured by standardized tests. The number of single-leg calf raises and isometric strength measured with a dynamometer provide objective measurements.

The ability to perform single-leg jumps without pain demonstrates that the tendon can tolerate high dynamic loads. Test progressively: jumping in place, forward jumps, lateral jumps, then jumps with changes of direction.

The eccentric control stair descent test evaluates functional capacity. Descend one step by controlling the movement with one leg, repeat 10 times without pain or excessive fatigue.

Signs that progression should be slowed down:

An increase in morning pain or worsening stiffness indicates overload. Pain that lasts more than 24 hours after an activity or requires regular painkillers suggests that you need to reduce the intensity or volume of your activity.

The appearance of swelling, redness, or increased tenderness to the touch signals excessive irritation. Your tendon communicates its limits: learn to recognize and respect them.

Rehabilitation after a sports injury requires patience and consistency. Our physiotherapists support you at every stage, adjusting the rehabilitation program according to your progress.

How to prevent recurrence:

Gradual progression of training is the best prevention. The 10% rule recommends not increasing your total weekly volume by more than 10%. This conservative approach protects the tendon by giving it time to adapt to increasing loads.

Effective training strategies:

Training periodization alternates between high-load weeks and recovery weeks. A typical cycle might include three weeks of progression followed by one week with a 40-50% reduction in volume.

Diversifying training surfaces reduces repetitive stress. Alternate between asphalt, synthetic tracks, dirt trails, and grass. Each surface engages the tendon differently and distributes mechanical stress.

Gradually incorporating high-intensity activities prevents overload. Interval, hill, or speed sessions should be introduced gradually, never all at once. Start with moderate intensities for short durations before increasing.

Preventive strengthening program:

Maintain calf strength with eccentric exercises 2-3 times a week, even after full recovery. This maintenance program takes 10-15 minutes and significantly reduces the risk of recurrence.

Proprioception and balance exercises improve ankle motor control. Stand on one foot for 30 seconds, progress to unstable surfaces, add perturbations, or close your eyes.

Overall strengthening of the posterior chain (glutes, hamstrings, lower back) optimizes running biomechanics and reduces the load on the Achilles tendon.

Footwear selection and management:

Excessive shoe wear (more than 600-800 km for running shoes) reduces cushioning and alters biomechanics. Track your mileage and replace shoes before the sole is completely worn out.

Transitions to different shoes require very gradual progression. Switching to minimalist shoes or those with a reduced drop significantly increases the load on the Achilles tendon. This transition should span 6-12 months with very gradual increases in the volume covered with the new shoes.

Rotating between several pairs of shoes that vary slightly in characteristics (drop, cushioning, support) distributes mechanical stress differently with each outing.

Respecting pain signals:

Pain is a warning signal that should never be ignored. A slight discomfort at the start of a run that disappears with a warm-up may be acceptable, but pain that increases during effort or persists after activity requires immediate load modification.

The principle of "not exceeding 3 out of 10" during activity is a practical guide. If pain reaches or exceeds this level, the activity is likely too intense or prolonged for the tendon's current capacity.

Lifestyle factors:

Adequate hydration influences tendon health. Tendons are composed of 65-70% water, and chronic dehydration can affect their mechanical properties.

Sufficient sleep (7-9 hours) is essential for tissue repair processes. Chronic sleep deprivation compromises healing and increases the risk of injury.

Stress management and overall recovery impact training load tolerance. High psychological stress combined with a high training load creates an environment conducive to injuries.

Recurrence statistics and implications:

The recurrence rate reaches 27% within 5 years following an initial episode of Achilles tendinopathy. This figure significantly decreases in individuals who maintain a regular strengthening program and adhere to gradual progression principles.

Recurrences most often occur when activities are resumed too quickly after healing, when progression principles are not followed during training, or when strengthening exercises are prematurely abandoned.

Sports injury prevention integrates these principles into a holistic approach to maintaining musculoskeletal health. Our physiotherapists offer preventive assessments and personalized programs for athletes of all levels.

When should you consult a physiotherapist for Achilles tendinopathy?

Consult if Achilles tendon pain persists for more than two weeks despite reducing your activities. Early intervention significantly shortens healing time and prevents the condition from becoming chronic.

Reasons to consult promptly:

Pain that does not decrease with relative rest or progressively worsens requires a professional evaluation. Prolonged waiting allows tendon degeneration to advance and complicates treatment.

Symptoms present for more than 2-3 weeks without significant improvement indicate that self-treatment is not sufficient. The tendon does not heal spontaneously at this stage and requires active intervention.

Pain that affects your daily activities like walking, climbing stairs, or simply getting up in the morning already has a significant impact on your quality of life. Do not let the condition deteriorate further.

Sudden, intense pain accompanied by a snapping sensation is an emergency. This presentation suggests a partial or complete rupture that requires immediate evaluation to determine the appropriate treatment.

Significant difficulty or inability to stand on your tiptoes indicates significant functional impairment. This shows that the tendon can no longer support normal loads.

What a physiotherapy assessment includes:

A thorough history explores the onset of symptoms, triggering factors, how symptoms have changed over time, treatments already tried, and their effectiveness. This information guides the diagnosis and treatment plan.

A systematic physical examination includes tendon palpation, strength tests, range of motion assessment, gait observation, and biomechanical analysis. These elements help establish an accurate diagnosis.

Identifying contributing factors involves examining your equipment (shoes), training habits, biomechanics, and individual risk factors. Correcting these elements is an integral part of the treatment.

Establishing a personalized treatment plan considers your goals, activity level, the severity of your condition, and your ability to follow the program. The plan evolves based on your response to interventions.

Benefits of early consultation:

Tendinopathies treated within the first 3 months generally respond better and faster than chronic conditions. The tendon structure is less degenerated, and the necessary changes are less significant.

Prompt identification and correction of causal factors prevent worsening and reduce the risk of the condition becoming chronic. The longer you wait, the more biomechanical compensations develop and complicate the clinical picture.

Early learning about load management and appropriate exercises gives you the tools to actively take charge of your recovery. This empowerment improves treatment adherence and long-term results.

Our services at Physioactif:

At Physioactif, our physiotherapists specializing in musculoskeletal disorders use protocols based on the best available evidence. You do not need a medical referral to consult for physiotherapy in Quebec, as we are first-line healthcare professionals.

Our approach integrates comprehensive biomechanical assessment, supervised exercise programs, manual therapy techniques, and regular follow-ups. Book an appointment today to start your rehabilitation.

For other causes of calf and ankle pain, consult our complete guide to calf pain. If you are a runner concerned about injury prevention, our guide to common running injuries offers comprehensive information on various conditions affecting runners.

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