The Achilles’ Heel of Runners: Achilles Tendinopathy

achilles injury
Achilles tendon pain can be a problem for professional and recreational athletes, as well as non-athletes, and can severely hinder activities of daily life. Physiotherapist Luke Bowman explains what it is, and what you can do if you experience Achilles pain.

Why do we get tendon pain?

More than 30% of all sports injuries involve our tendons, and this can be due to several factors depending on the sport/activity in question. When looking at problems with the Achilles (and in common with other injuries) the following factors are particularly important:

  • Overuse: This is a BIGGY! A lot of the cases I see are in large part caused by overuse. I always start by asking about training, or any increase in activity before the injury, and in a large number of cases there will have been some recent change (e.g. “I started training for a marathon 3 weeks ago in old shoes having not run for a year,” or “I thought I could go back at the same volume as before”). Although you may feel fit enough, your muscles and tendons will not be prepared and you run the risk of getting a tendinopathy (or muscle injury).
  • Muscle weakness: Weakness in the calf and reduced ability of the tendon to absorb tensile load can affect the likelihood of getting a tendon injury. Gluteal muscle weakness is another commonly seen issue when dealing with the Achilles tendon, due to its effect on lower limb positioning, leading to mechanical issues when walking/running.
  • Muscle imbalance: Altered muscular tension can also be a factor in tendon injury. For example, if your calf muscles are tight this will affect the way you walk/run and reduce the duration of heel contact during the gait cycle. If you have a tight calf and your heel lifts up before you have achieved a full stride, this will load the tendon more, potentially leading to overuse, so make sure to keep up with your strength and conditioning (and yes, that includes stretching!).
  • Malalignment: Gait analysis can reveal a host of interesting and potentially injurious positional/biomechanical abnormalities. These factors can (but don’t always) predispose you to getting aches and pains, of which Achilles tendinopathy is one.
  • Ageing: Leading to reduced tensile strength of the tendon itself.
  • Obesity: Excess loading on the tendon. In essence this is a form of oveuse.

I’m confused… What’s the difference between tendonitis, tendinosis and tendinopathy?!

The most commonly used term to describe tendon pain is ‘tendonitis’ which refers to the inflammation of a tendon. The other term that is less commonly but seemingly more appropriately used is ‘tendinosis’ which refers to a non-inflammatory degeneration of a tendon, resulting from poor healing of a tendon after injury. Tendinopathy is a more global term to encompass both of these.

Frankly, what word people use to describe tendon pain/damage is not particularly important! However, what we do and how/when we do it is important, as progressing too quickly or too slowly with tendon rehab will have an impact on recovery time.

How do we address tendon pain?

The first line of treatment for any tendon injury (unless you have fully ruptured the tendon) will be conservative in nature. We need to try to establish and address the factors and causes that can lead to the onset of pain in the first place. If we don’t address the underlying cause, the symptoms will not subside.

If overuse is one of the causes, then in order to improve the tendon you first need to change the amount of load you put through the limb, to avoid further irritatation to the tendon. Most of the time this does not mean complete rest unless the tendon is extremely irritable and in the early stages of injury. At this stage, relative rest may be of use, so as not to increase local swelling/pain.

Treating a tendon injury can be a difficult tightrope walk, because over-loading the tendon will make it worse, but in fact under-loading the tendon will not make it any better!

Most of the current research and information from clinical practice points us towards a gradual increase in ‘eccentric’ loading. Eccentric loading is the slow, controlled, lengthening movement of the tendon (i.e. the movement from tip toes to foot flat). It has been shown that if the tendon is gradually exposed to this kind of slow loading force it will start to adapt, therefore increasing the tendon’s capacity to bear load overtime. Again, if the tendon is overstressed you will see a decline in its condition, so this needs to be done in a controlled way!

For a tendon injury, surgery is extremely rare and only considered in chronic cases where a plethora of other treatments have been unsuccessful.

Other factors to consider

We also need to look back at what other issues may have contributed to the symptom onset. As explained above, these could include muscle imbalance, muscle weakness, a person’s gait (walking or running pattern) as well as that individual’s weight and level of activity. Age is also relevant and should be taken into consideration when managing a tendon injury.

achilles injury
A strength and conditioning programme is often advised for increasing strength and mobility in muscles that help or hinder the lower limb during motion (e.g. gluteals, hamstrings, calf muscles, hip flexors etc).

Your physio should be able to help identify which areas are problematic for you as an individual, and what can be done to improve the state of the tendon.

Treatments can include:

  • Muscle loosening: Massage techniques.
  • Joint mobilisation: Getting relevant joints to move better to allow for more fluidity in movement.
  • Muscle stretch and strengthen: Specific exercises to target areas of weakness and areas of immobility to improve muscular balance. This programme will be progressive and will eventually aim to put higher loads through the tendon if required. This may include more dymnamic movements (otherwise known as plyometrics).
  • Orthotics: These may be required for a period of time to help to offload tension from the Achilles tendon, allowing it to repair. This depends on individual mechanics and will not be the case for everyone.
achilles injury

Plyometric exercises may be set for you by your physio.

Physios never treat all cases in the same way! We all have different injury requirements so need this to be reflected in our rehab.

As you have hopefully seen from this article, Achilles tendinopathy can be a complex issue to manage, however with the correct management you should start to see a good change in the tendon.


phsyio focus
Luke Bowman (BSc Hons Physiotherapy, HCPC and CSP registered) is the owner and lead clinician at Reform Physiotherapy.  Luke has a wealth of experience in musculoskeletal Physiotherapy. In addition to his work at Reform Physiotherapy, he works at the University of Cambridge with a wide range of collegiate athletes and the up and coming elite in sports including rowing, cycling, running, rugby, football, swimming, golf, athletics and basketball. Luke has a special interest in the area of gait analysis and lower limb biomechanics helping to give an extremely varied approach to symptom management, addressing the underlying causes of pain and dysfunction. Contact him via the Reform Physiotheraphy website, via Facebook or Twitter, on 01799 530650 or 07399 499959, or email reformphysio@outlook.com.

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