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Achilles tendinopathy is an overuse condition of the Achilles tendon that causes pain, stiffness and reduced function, most often in running and jumping athletes but also in the general population.
It is classified by site as mid-portion (2 to 6 cm above the calcaneal insertion) or insertional, and each has its own pathology and management.
The Achilles tendon is formed by the gastrocnemius and soleus and inserts on the posterior calcaneus. It transmits forces of up to 12.5 times body weight during running. The mid-portion has a relatively hypovascular zone, thought to contribute to its vulnerability to degeneration.
Tendinopathy is now understood as failed healing rather than inflammation. The continuum model (Cook and Purdam) describes 3 stages: reactive tendinopathy, tendon dysrepair and degenerative tendinopathy. Histology shows increased ground substance, collagen disorganisation and neovascularisation without true inflammation.
Remember the continuum as reactive, dysrepair, degenerative. Reactive tendinopathy is reversible with load management; degenerative tendinopathy has little capacity to reverse. Treatment depends on where the tendon sits on the continuum.
Pain comes on gradually and is localised to the tendon, often with stiffness in the morning or after rest. It is aggravated by loading such as running, jumping and hill walking, and may ease once warmed up (the warm-up phenomenon).
Same-day orthopaedic referral or admission:
Refer to a sports physician or orthopaedics when:
Achilles tendinopathy is primarily a clinical diagnosis. Imaging helps confirm it, assess severity and exclude other causes.
Blood tests are not routinely needed unless a systemic inflammatory or metabolic condition is suspected.
Management is predominantly conservative, built on load management, activity modification and a structured exercise programme, set out under Rehabilitation.
Surgery is reserved for symptoms that persist after 6 to 12 months of appropriate conservative care. Options include tendon debridement or paratenon stripping, and Haglund's resection for insertional disease. The referral criteria are in the Red Flags and Referral box under Clinical Presentation.
Rehabilitation follows progressive loading in 4 stages:
1. Isometric loading: in the reactive phase, for pain relief and to maintain capacity, commonly 5 × 45-second holds at 70% of maximum voluntary contraction.
2. Isotonic strengthening: heavy slow resistance with seated and standing calf raises, progressed over 12 weeks. The Alfredson eccentric protocol (3 × 15 repetitions, twice daily) is an equally supported alternative.
3. Energy storage: hopping, skipping and bounding to restore the tendon's capacity to store and release energy.
4. Return to sport: sport-specific drills and a graduated return to full training.
Insertional tendinopathy needs a modified approach. Load on a flat surface rather than dropping below horizontal off a step, because deep dorsiflexion compresses the insertion against the posterior calcaneus. A small heel lift during symptomatic periods reduces that compression, particularly with a Haglund deformity. Mid-portion tendinopathy, by contrast, tolerates full dorsiflexion off a step.
Return is criteria-based: pain-free repeated single-leg heel raises, symmetrical calf strength, and sport-specific loading without a symptom flare. Most patients need 3 to 6 months of rehabilitation, and athletes should be told that full recovery may take 6 to 12 months.