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Achilles Tendinopathy

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Achilles tendinopathy is a painful overuse injury of the Achilles tendon most commonly seen in runners and sports that involve repetitive jumping, leading to altered tendon structure and reduced load capacity. This injury is not limited to the athletic population and is a commonly seen in patients presenting to physiotherapy.


  • Training Errors of excessive loading with inadequate recovery time between training sessions, or spikes in intensity and duration of training

  • Change is footwear

  • Anatomical abnormalities such as Haglung deformity

  • Reduced ankle range of motion especially into dorsiflexion

  • Reduced strength and endurance of the calf complex

  • Increased foot pronation

  • Increased body weight leading to excessive strain

  • Reduced stiffness of the Achilles tendon often seen in hypermobile ankle joints

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Signs & Symptoms

  • Localised pain with or without swelling of the Achilles tendon

  • Morning Pain and pain after prolonged sitting

  • Tendon warms up with exercise but worse after exercise

  • Pain with running or jumping

  • Reduced function and performance eg. Running speed, or reaction times

  • Change in recent loading, either increased load or seen after a de-load period like being sick or coming back from injury or time off

Differential Diagnosis

  • Posterior ankle Impingement

  • Os Trigonum syndrome

  • Acute Achilles rupture

  • Sural nerve irritation

  • Fat pad irritation

  • Systemic Inflammatory disease

PROmotion Assessment and Outcomes Measures

  1. Palpation of the Achilles tendon with the presence of pain; can determine a mid portion achilles tendinopathy or an insertional tendinopathy

  2. Symptom severity and Pain and can be assessed during aggravating functional tasks such as walking, hopping or running

  3. Questionaires such as the VISA -A, Foot and Ankle Outcome score (FAOS) and the Foot and ankle ability Measure (FAMM)  have been designed to evaluate function, pain and symptom severity on activity

  4. Ankle range of motion

  5. Heel rise test for calf endurance and strength

  6. Jumping ability through the single legged hop test and hop landing ability from a step

  7. Gait analysis

How to Manage

Exercise rehab and load management show the best outcomes for achilles tendinopathy. Management through an individualised Achilles tendon loading program is considered best practice.The Initial stage of rehab should focus on reducing pain / irritation and monitoring load. Pain scores should stay in the green zone of 3/10 during exercise with no lasting pain of 24 hours after load. Heel raises can be used as a tool to limit tensile load and orthotics can be used to limit contributing factors like excessive pronation.

A training diary should be used to help monitor exercise, other activities performed during the day, pain and morning irritability.

Once pain and irritability have reduced patients can focus on regaining strength and load tolerance. Strength exercises to the calf complex are progressed by increasing receptions, range of motion and speed. It is important to add in quick rebounding heel rises to help increase the tendons tolerance to fast loads in preparation for plyometric exercise and running. This phase should address any other impairments or deficits that have been picked up on assessment like hip and knee strengthening and control.

Heavier strength training of the calf muscle with external loads like the smith machine can further promote tendon recovery and strength. Plyometric training is the last phase and should involve jumping and hopping in preparation to return to sport and running.  

Recovery is very important for tendon repair and allowing adequate time between exercises is essential. Low load exercises can be performed daily but higher loaded exercises require 36-72 hours to repair the tendon. A structured plan is necessary in the later stages to avoid re injury.


Sibernagel, G., Hanlon, S., Sprogue, A. (2020). Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. Journal of Athletic Training. Vol 55, 438-227.

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