Achilles Tendinopathy

The purpose of this blog is to discuss Achilles Tendinopathy, dispel the most common myths associated with the diagnosis, and teach you everything you need to know about managing the condition.

Are you struggling with Achilles tendon pain? Check out our Achilles Rehab Program!

Achilles Tendon (Anatomy & Function)

Named for the Greek mythological hero, Achilles, the Achilles tendon is the strongest and thickest tendon in the human body. During walking and running, the load experienced by the Achilles tendon reaches up to 4 and 8 times your bodyweight. The primary calf muscles, the gastrocnemius and soleus, attach to the calcaneus, or heel bone, via the Achilles tendon. 

Achilles Tendinopathy (Not Tendinitis or Tendinosis)

According to an international consensus statement by Scott et al in 2020, “Achilles tendinopathy is the preferred term for persistent Achilles tendon pain and loss of function related to mechanical loading.”

Tendinitis, used to indicate an inflammatory process, is discouraged from being used as a label. Although inflammatory markers are present, inflammation is NOT believed to be the primary driver of the condition and may reflect the normal response to tendon loading and adaptation. 

Plus, people often associate inflammation with the need for ice, anti-inflammatory medication, and complete rest, which are not recommended for the management of Achilles tendinopathy. In fact, a randomized controlled trial by Malmgaard-Clausen et al in 2021 concluded that “anti-inflammatory medication does not add to the recovery process.”

Tendinosis, used to indicate a degenerative process, is also not the appropriate terminology. A systematic review by Docking et al in 2021 found that the prevalence of Achilles tendon abnormalities in people without symptoms ranged from 0% to 80%. A study by Lieberthal et al in 2019 concluded that “there is a high prevalence of tendon pathology [46%] in an asymptomatic male running population with no history of Achilles tendon pain.”

If you have Achilles tendinopathy, you’ll have changes on imaging. However, these changes are quite common in the asymptomatic population and imaging alone is unable to diagnose or guide treatment. To hammer it home, Docking et al in 2015 state “…there is no direct correlation between structural disorganization and the presence of symptoms.”

Mid-Portion vs Insertional Achilles Tendinopathy

Achilles tendinopathy is typically categorized based on the location of symptoms as either mid-portion or insertional.

Mid-portion Achilles tendinopathy is the more common diagnosis of the two, which is why there’s more research dedicated to it. For the purpose of this blog though, all education, exercise progressions, and recommendations will apply to mid-portion and insertional Achilles tendinopathy based on the significant similarities between them.

Why Did You Get Achilles Tendinopathy?

Regardless of symptom location, you might be wondering why you developed Achilles tendinopathy in the first place. 

A simplified framework is that it’s thought to occur when the intensity, frequency, and volume of Achilles tendon loading, such as during walking, running, or playing sports, exceeds your capacity to recover and adapt appropriately.

This will look different for different individuals, so it can be helpful to consider the extremes.

If you’re an active individual, such as a regular runner, it often comes down to doing too much, too soon. For example, if you normally run half marathons but suddenly increase your total running mileage in preparation for a marathon that you want to do next month, that spike in training load may exceed your current capacity.

For less active individuals, it might be related to a gradual decline in general physical activity and overall well-being, which represents a decrease in capacity that’s more easily exceeded.

Therefore, the goal of rehab is to balance out this equation, so that your capacity is greater than or equal to the various loads you’re experiencing on a day-to-day and week-to-week basis. It’s also important to point out that other lifestyle factors like sleep, stress, and nutrition can influence this equation.

Treat The Donut, Not The Hole

Many interventions are aimed at altering the structure of the Achilles tendon, but remember that these so-called abnormalities are actually quite normal.  

One of the most prolific researchers in this area, Sean Docking, coined the phrase – “treat the donut, not the hole.” The hole is referring to the disorganized portion of the tendon seen on imaging, while the donut is the rest of the healthy tendon.

What your tendon looks like on imaging is likely irrelevant to the rehab process. 

A systematic review by Murphy et al in 2018 reported that individuals with Achilles tendinopathy can have improvements in symptoms and function with exercise despite no changes in tendon structure on imaging.

And if your tendon looks or feels thickened, that’s probably a good thing. Research by Docking et al in 2020 found that abnormal Achilles tendons contain similar, if not greater, amounts of organized tendon structure as a compensatory mechanism to maintain tissue homeostasis. 

This statement from a study by Docking and Cook in 2015 summarizes this section well – “While increases in tendon thickness have previously been described as negative, the findings of this study suggest that tendon thickening might be the tendon’s method of adapting to pathology. Treatment strategies may be better served in building load capacity within the already present aligned tendon structure, rather than attempting to regenerate the area of pathology with intratendinous injections or surgery.”

Keep the goal of rehab simple – build your capacity by (1) improving your tolerance to various forms of loading and (2) restoring the function of your Achilles tendon and calf, the rest of your kinetic chain, and you, the person, in general.

Understanding & Monitoring Pain

Another fundamental component of rehab is understanding and monitoring pain. 

Do you have to avoid pain during exercise or is it safe to push into a little pain?

Many people are concerned that exercising into pain means that they’re damaging their tendon or worse.

A paper by Turner et al in 2020 interviewed individuals with Achilles tendinopathy. Here’s what 2 people had to say:

• “I’m quite certain that if I played table tennis, it would definitely be worse. I’m not even attempting that, because I’m just scared that I might rupture a tendon.”
• “If I’m overtraining or something, I don’t really know, perhaps the rubbing together of the tendons causing mini fractures?”

Silbernagel et al in 2007 helped popularize the model that’s most often used today, which involves exercising within a tolerable level of pain. This is unique to you. One person reading this blog might only be comfortable exercising with slight pain while someone else might be comfortable exercising with moderate pain. There’s not necessarily a right or wrong way to go about it, but there are some strategies that you can do to help find what works best for you.

You’re not only going to monitor symptoms during exercise, but immediately after and the following day. Ask yourself 3 questions:

1. Is my pain tolerable during exercise? If it’s helpful for you, you can rate your pain on a scale from 0-10 and determine the highest acceptable number for you. Some physical therapists might recommend staying at a 3/10 pain or less while others might suggest 5/10 pain or less. You get to decide.
2. Is my pain better, worse, or the same after exercise? Achilles tendinopathy may exhibit a warm-up phenomenon where symptoms actually improve with physical activity, so it’s possible that you feel better after exercising.
3. Is my pain better, worse, or the same the day after exercise? This is the most important question because it gives you an understanding of how you’re responding to the current dosage of exercise. If you feel fine during and immediately after exercise, but you have a significant worsening of symptoms the next day, that’s an indication that you’re doing too much and need to back off a bit.

You can assess your next-day symptoms with your normal functional activities like walking or use a specific assessment, such as a heel raise. 

For example, you rate your pain on day 1 with walking as a 2/10 pain. You then perform your exercise routine within tolerance, go about your day, and go to bed without any major issues. The next morning you go walking again, but this time you rate your pain as a 5/10. This means that even though your symptoms were tolerable during exercise, you might have done more than what you can currently recover from. You didn’t do any harm, but decreasing the volume or intensity would be recommended.

So, do you have to avoid pain during exercise? Not necessarily.

Is it safe to push into a little pain? Absolutely.

However, you’re going to have to find what works best for you. 

Load Management & Activity Modifications

Since Achilles tendinopathy is thought to occur when the intensity, frequency, and volume of Achilles tendon loading exceeds your capacity to recover and adapt appropriately, it’s important to discuss load management and activity modifications.

Let’s tie all of the previous information together by reviewing two common mistakes. Tell me in the comments if either of these scenarios sound familiar.

The first scenario relates to individuals who chronically do too little because they’re fearful of their symptoms or what their symptoms might mean. Without a structured plan, and as a way of avoiding pain, they do less and less activity over time to the point that their capacity becomes severely diminished.

The other scenario involves people who persist, or push, through their pain, which leads to a flare-up. They do too much and require a period of rest to allow that spike in symptoms to subside. Then, when they’re feeling a bit better, they try to repeat that same level of activity, but come to realize that the flare-up happens even sooner. This cycle repeats until their capacity is also severely diminished.

These are not uncommon cycles. They’re often driven by the belief that pain is bad and rest is good, while also using a reduction in pain as the primary metric for success.

But that’s not the way to approach Achilles tendinopathy because rehab can take 3 months, 6 months, or even a year or longer. Symptoms will fluctuate on a day-to-day and week-to-week basis, which is why your focus should be on function while monitoring pain to guide the appropriate amount of physical activity.

An increase in function will not always correlate with a linear decrease in pain. If you go from running 1 mile with a 3/10 pain to running 3 miles with a 3/10 pain over the course of 3 months, that’s actually significant progress. The pain may seem like it’s staying the same, but technically it’s getting better because it requires more activity to reach the same level of pain that you initially experienced.

Remember, a main component of rehab is trying to restore function. You’ll monitor your symptoms during and after exercise to ensure that you’re not exceeding your current capacity, while keeping track of your progress with the various exercises. At the same time, you’ll reduce the frequency, intensity, or volume of activities, such as running or playing sports, that are aggravating your symptoms and limiting your functional progress.

If needed, you can replace the reduction in that specific activity with a different activity that doesn’t exacerbate symptoms to maintain your fitness.

Rehab Stages

Before demonstrating the exercises, it’s helpful to understand the underlying rationale.

As I mentioned at the start, the load experienced by the Achilles tendon during walking and running reaches up to 4 and 8 times your bodyweight. A recent review by Demangeot et al in 2022 grouped exercises relative to the loads imposed on the Achilles tendon during walking and running.

On the far left side of this spectrum is a seated heel raise with 2 legs that loads the Achilles tendon very little. On the far right side is a single leg forward hop that highly loads the Achilles tendon. 

This paper presents a stepwise progression of exercises and activities that can be implemented to gradually increase your tolerance and function over time.

I’m going to present these exercises across 4 overlapping stages. You will progress from one stage to the next based on your symptoms, function, and tolerance as opposed to a given timeframe or after meeting specific criteria.

However, you should be reasonable with your approach and expectations. You shouldn’t attempt single leg hopping if walking and heel raises are painful.

Stage 0: Isometrics (Static Holds)

Most tendinopathy protocols actually have isometrics listed as stage 1, but they’re listed here as stage 0 because I don’t think there’s an isometric milestone that you need to pass before performing the next group of exercises. However, they are typically quite tolerable since little to no movement is occurring.

I am going to provide you with six examples so you can choose what works best for you based on your preference, equipment availability, tolerance, function, etc.

1. Double Leg Heel Raise
2. Single Leg Heel Raise
3. Heel Raise on Leg Press
4. Seated Heel Raise
5. Seated Barbell Heel Raise
6. Seated Smith Machine Heel Raise

These are just some options. Adjust weight, seated vs standing, and single leg vs double leg as needed.

How would you incorporate these into your routine? You can perform them as a warmup prior to your workouts or they can be used as an independent stimulus, completed 1-3 times per day.

You’d pick one option to complete for 3-5 sets of 45 second holds at a 7 out of 10 effort with a 2 minute rest between sets.

Stage 1: Heavy Slow Resistance

Heel raises are the foundation of any exercise program for Achilles tendinopathy.

Here’s a standing, knee straight progression:

Level 1 – Double Leg Heel Raises on Flat Ground. Aim for 3 sets of 25 slow and controlled reps. Use your hands for balance as needed.

Level 2 – Single Leg Heel Raises on Flat Ground. Aim for 3 sets of 15 reps.

Level 3 – Single Leg Heel Raises on a Step. Aim for 3 sets of 15 reps.

Level 4 – Single Leg Heel Raises on a Step with Weight. Aim for 3-4 sets of 6-15 reps.

Performing heel raises on a step is a progression from flat ground because research by Yeh et al in 2021 demonstrated that “maximum dorsiflexion increases Achilles tendon force during exercise.”

Other standing, knee straight variations include using a smith machine or leg press, or elevating the front foot.

Another option is a seated, knee bent progression:

Level 1 – Seated Heel Raises on Flat Ground. Aim for 3 sets of 15 slow and controlled reps.

Level 2 – Deficit Seated Heel Raises. Aim for 3-4 sets of 6-15 reps.

You can use a barbell, smith machine, dumbbells, or seated heel raise machine.

You can also do knee bent heel raises in standing, but they’re less optimal because of the balance and coordination demands, and the quads often fatigue first.

Heel raises during a wall sit or bridge are suboptimal for similar reasons. They’re not sufficiently challenging for the Achilles and calf.

In terms of programming, you should aim to perform a minimum of 1-2 exercises, 2 to 3 days per week. Make sure to complete every repetition slowly and controlled. You shouldn’t be bouncing up and down. 

Two common questions I want to address before moving on to the next stage:

1. What about stretching? You can stretch if it feels good for you, but you don’t need to stretch. If you perform the heel raises slowly and through a full range of motion while pausing at the bottom of every repetition, you’ll match or exceed any benefit of stretching.
2. Shouldn’t all heel raises be done for high repetitions? No, that’s a common myth, especially among runners. You’re better off progressing weight over the long run (pun intended).

Lastly, although the priority is restoring the function of the calf and Achilles complex, this is a good place to incorporate other aspects of leg strengthening, such as split squats, single leg deadlifts, step downs, and hip thrusts.

Stage 2: Energy Storage & Release

Along with the isometrics and resistance training, stage 2 includes jumping, landing, plyometrics, and exercises that prioritize a faster rate of loading.

These exercises should be performed 2-3 times per week with an emphasis on execution. This isn’t meant to be cardio.

There’s an infinite number of possibilities and loading schemes here, so I’m just going to provide 2 options that require no equipment.

Option #1: Hopping Progression

Start by hopping in place on 2 legs with your hands on your hips and eyes looking straight ahead. You want to spend as little time on the ground as possible. 

If this is too difficult, don’t leave the ground. Just do small bounces/rebounds in place. 

If you want to make it harder, hop higher while spending minimal time on the ground.

Progress to hopping forward and backward before moving on to hopping side to side. You’ll then work through the same progression on a single leg. 

Aim for 3 sets of 30 to 60 seconds per leg.

Option #2: Jumping Progression

Start by performing a submaximal vertical jump on 2 legs before progressing to a maximal vertical jump on 2 legs. Do your best to stick the landing. Then work on a submaximal jump on 1 leg before progressing to a maximal vertical jump on 1 leg.

You can then practice jumping forward, side to side, and diagonally. Aim for 3 sets of 6-8 reps each.

Stage 3: Return To Sport

There are no distinct exercises that need to be performed in this stage. Instead, this stage is about gradually returning to your preferred sport or activity. 

For example, if you’re a marathon runner, you’d train for that marathon over the course of several months as you build up your volume. If you’re a recreational soccer player, the same thought process applies. 

You can’t expect to just run back onto the field and play hours of soccer after doing 3 months of exercises in the gym. You have to build back up to it. 

Don’t get stuck in that boom-bust cycle (Mistake Two: Too Much, Too Soon)!

Achilles Tendinopathy Programming

How do you put all of this information together to create a structured program?

If you’re starting at stage 0, you can perform 1 isometric heel raise variation 1 to 3 times per day for 3-5 sets of 45 second holds.

Assuming you can tolerate the exercises in stage 1, you can perform heel raises 3 times per week.

For example, you might work up to doing 3 sets of single leg heel raises on a step with weight for 8 repetitions on Monday and Friday. On Wednesday, you might do deficit seated heel raises with a barbell for 3 sets of 12 repetitions.

The following week you could do the seated heel raises on Monday and Friday, while doing the single leg heel raise on a step on Wednesday. If you have the time and can tolerate it, you can continue to do the isometrics on the other days.

If you want to be more comprehensive with your training, this is the time to include other lower body exercises as well.

If you’re moving on to stage 2, you can alternate the jumping and hopping exercise progressions every training session. You can do them on the same day as the heel raises for practical reasons, but you’d want to complete them at the start of each workout.

For stage 3, you’re fitting in your runs, practices, sporting events, and other activities into your weekly calendar based on your schedule, symptoms, function, etc. You’ll have to do some experimentation to find what works best for you.

A few reminders and key points:

1. These are guidelines, not hard and fast rules. I can’t provide suggestions that will account for each person’s unique circumstances.
2. The stages are overlapping. You will progress from one stage to the next based on your symptoms, function, and tolerance as opposed to a given timeframe or after meeting specific criteria.
3. If your only goal is to lift weights in the gym or walk around your neighborhood, stages 2 and 3 might not be applicable to you.

Do You Have To Stop Running?

Not necessarily. You can incorporate your runs into this rehab framework, but you probably have to change something. You might have to do less weekly miles or fewer runs per week, but you can make up that difference with the exercises in this blog or through other forms of training. 

If you continue to run, but can’t stop yourself from consistently overdoing it and falling into that boom-bust cycle, then it might be worth considering taking a break from running.

You don’t want to be your own worst enemy here. Don’t turn a 6 month process into a 2 year process by being impatient initially.

For runners and non-runners, walking is also an important part of rehab because every step loads the Achilles tendon. Throughout the process, track your steps, adjust accordingly, and try to gradually do more over time.

Other Management Strategies

What about foam rolling, massage, or whatever else you can think of? If it’s low cost, low risk, and complements the rest of your structured program, you can pretty much try out anything for symptom reduction. However, these things aren’t the focus of rehab and shouldn’t take away from the goal of progressively improving your function.

Heel lifts or more supportive shoes can be trialed with the intention of temporarily reducing Achilles tendon load early on when you’re highly symptomatic. However, what you choose to wear will also be based on your comfort, preferences, beliefs, and other factors.

The purpose of our content is to provide you with low cost, low barrier-to-entry self-management options.

And for anyone wondering, a study by Kearney et al in 2021 found that a PRP injection is no better than a sham, or fake, injection for Achilles tendinopathy.

Achilles Tendinopathy Summary

In summary, Achilles tendinopathy is the preferred term for persistent Achilles tendon pain and loss of function related to mechanical loading.

Inflammation isn’t the primary driver of the condition, so ice and complete rest aren’t the cornerstones of rehab. Degeneration also isn’t the focus, so interventions shouldn’t be aimed at changing the structure of the tendon.

Achilles tendinopathy is thought to occur when the intensity, frequency, and volume of Achilles tendon loading, such as during walking, running, or playing sports, exceeds your capacity to recover and adapt appropriately. Therefore, the goal of rehab is to balance out this equation, so that your capacity is greater than or equal to the various loads you’re experiencing on a day-to-day and week-to-week basis.

If the onset of symptoms is from doing too much, too soon, then your first goal is to find a Goldilocks level of loading that keeps your symptoms tolerable during, immediately after, and the next day following activity. You’ll then implement exercises for 3 or more months to improve your function and tolerance to various activities.

You can incorporate adjunct treatments that alleviate pain, but they’re not the focus of rehab, especially if they’re high cost or high risk. Unfortunately, there is no quick fix. Achilles tendinopathy takes time, patience, consistency, and dedication to a structured plan.