November 9, 2022

A Guide to Physical Therapy for Achilles Tendinopathy

Achilles tendinopathy is a degenerative injury that results in pain and stiffness along the Achilles tendon. It can occur in anyone, but is most often seen in athletes.

Finding the right balance of weight bearing while also dealing with the pain is essential for reducing your risk of tear (hint: most people are actually underloading).1

Conservative treatment is the best option for Achilles tendinopathy, with the goal of restoring tissue health and reducing the risk of chronic pain and dysfunction.

Continue reading to learn what tendinopathy is, the causes and risk factors, symptoms, diagnosis, how to manage it with physical therapy.

Table of Contents

Understanding Achilles Tendinopathy

The Achilles tendon is the largest tendon in the body. It attaches the calf muscles to the back of the heel bone (calcaneus).2 This complex plays a key role in weight-bearing activities. In particular, the local muscles and connective tissue work in sync to propel the human body forward as the heel raises off the ground during walking and running.

The term "tendinopathy" refers to a group of conditions that cause degeneration of the tendon tissue matrix. Thus, it is most often a chronic condition that gets worse gradually over time if not properly addressed.

Types of Tendinopathy

There are two types of Achilles tendinopathy: insertional (where the heel connects) and non-insertional (higher up in near the calf muscle bellies). A painful tendon can essentially be in one of two phases:

  • Acute tendinopathy: Or a "reactive tendon," with new onset of symptoms following an acute injury or overload
  • Chronic tendinopathy: Or "reactive-on-late dysrepair," with a result in a downward spiral of tissue health and degeneration.3

The reality is that different areas of the tendon can being going through different phases of tendon dysfunction. Understanding what stage the tendon is in helps with creating a treatment program that adequately reloads the injured tissues.

Symptoms of Achilles Tendinopathy

The symptoms of Achilles tendinopathy can vary depending on the stage of the injury. However, the most common symptom is pain along the back of the heel and tendon. This pain is often worse with activity and relieved with rest.

Other symptoms can include:

  • First step morning pain
  • Swelling in the ankle or calf
  • Stiffness of the ankle, foot, and/or calf
  • Difficulty walking, descending stairs, or running
  • Tenderness to the touch along the heel and tendon

What Causes Achilles Tendinopathy?

At the most basic level, tendinopathy is caused by persistent overloading of local tissues that causes decreased ability to absorb and produce force through the tendon. However, determining the cause of Achilles tendinopathy is typically quite complex. It tends to be multifactorial and affects each individual differently. Regardless of the cause, symptoms ensue and the integrity of the tendon is gradually compromised.

Risk factors that can contribute to the onset of Achilles tendinopathy include:

  • Overuse or overloading of the tendon: Most common with loads that are eccentric (when the muscle is lengthening)
  • Aging: As we age, our tendons become less elastic and more susceptible to injury (and poor healing)
  • Biomechanics: Abnormal foot mechanics, calf tightness, and/or calf weakness can all place extra stress on the Achilles tendon and lead to injury
  • Training errors: Too much training volume too soon, or a sudden change in training surface or intensity can increase your risk of developing Achilles tendinopathy
  • Inappropriate footwear: Wearing shoes that do not support the foot can increase stress on the Achilles tendon
  • Chronic steroid use: Can lead to decreased blood flow and poor collagen production, both of which can contribute to a tendon injury
  • A previous foot or ankle injury: Such as a sprain or fracture
  • Obesity: Excess weight places extra stress on the Achilles tendon, particularly with weight-bearing activities
  • Chronic inflammatory disease: Including diabetes and heart disease which impact blood flow to the tendon

Diagnosing an Achilles Injury

If you are experiencing any of the symptoms mentioned above, it's important to see your healthcare provider for an accurate diagnosis. A CityPT physical therapist can help determine the root cause of your pain and how to get on track with tissue healing and pain relief.

If your physical therapist has any concerns about the presence of other foot and ankle conditions, they can refer you to an orthopedic specialist for more diagnostic testing. Although not typically needed for an Achilles injury, the diagnostic test of choice for an ankle injury is ultrasound.3

For an in-depth diagnosis and the creation of a treatment plan, here's what you can expect at your first visit with your CityPT physical therapist:

  • A review of clinical history and lifestyle
  • Symptoms review — such as when they started, what makes them better or worse, etc.
  • A physical examination to assess the range of motion, flexibility, tissue quality, and strength of your lower body
  • Special tests (orthopedic tests) to help determine the source of your pain
  • Functional movement testing to assess your ankle and foot motion during activities

Treating Achilles Tendinopathy Conservatively

The primary goal of treatment is to address the pain associated with Achilles tendinopathy while reducing the load on the local tissues to allow healing. This is done through a combination of treatments, including:

  • Education: This is key for understanding what to expect and how to properly heal. It will help you to set realistic expectations and feel empowered throughout the recovery process.
  • Activity modification: This involves reducing the amount or intensity of activities that place extra stress on the Achilles tendon. For example, if you’re a runner, you may need to cut back on your mileage.
  • Biomechanical training: Adjusting any dysfunction in alignment or muscle coordination with daily activities can effectively reduce local tendons rain. Tool for building awareness might include an exercise program, taping, and other forms of biofeedback.
  • Functional exercise: This is a crucial component of Achilles tendon rehabilitation. Exercises are aimed at strengthening the muscles and improving flexibility around the ankle and calf to help take the stress off the Achilles tendon and increase its tolerance for activity.
  • Manual therapy: This may include soft tissue mobilization or manipulation, joint mobilization, and dry needling to provide short-term pain relief and promote blood flow to the injured area for healing.
  • Pain managing modalities: Ice, heat, ultrasound, shockwave (ECSW), and electrical stimulation (specifically iontophoresis) are all examples of modalities that can be used to decrease pain around the Achilles tendon.

Do I Need Surgery for Achilles Tendinopathy?

If you are in the early stages of Achilles tendinopathy, your symptoms will most likely resolve with conservative treatment. However, if you are later stages of Achilles tendinopathy that have resulted in tendon disrepair, particularly with insertional tendinopathy, you may need more aggressive treatment. This might include corticosteroid injection or surgery — with the goal of promoting blood flow for healing.3

Prevention Tips for Achilles Pathology

If you want to prevent a future flare-up or try to avoid Achilles pain altogether, keep these tips in mind.

  • Warm up before exercise and cool down afterward
  • Gradually increase the intensity and duration of your workouts
  • Choose appropriate footwear that fits well and is designed for the activity you are participating in
  • Maintain a healthy weight to minimize stress on your feet and ankles
  • Practice good foot and ankle mechanics with weight-bearing activity to reduce strain on the Achilles tendon
  • Exercise regularly, making sure to include some dynamic foot and ankle movement for calf tissue extensibility and strength
  • Make healthy lifestyle choices to reduce the body's overall inflammatory response and allow better healing mechanisms- including better (and more) sleep, a nutrient-dense diet, adequate stress management, etc.

Conservative Treatment for Your Achilles Tendon: Is it Time?

If you are struggling with Achilles pain of any sort — whether acute or chronic — it’s time to see a physical therapist. In most cases, Achilles tendinopathy can be resolved with conservative treatment and get back to what you love to do most pain-free.

Book an appointment with one of our CityPT orthopedic specialists to get started immediately on your road to an effective recovery.

This guide is intended for informational purposes only. We are not providing legal or medical advice and this guide does not create a provider-patient relationship. Do not rely upon this guide (or any guide) for medical information. Always seek the help of a qualified medical professional who has assessed you and understands your condition.



  1. Zhang, Haining et al. The Risk of Achilles Tendon Rupture in the Patients with Achilles Tendinopathy: Healthcare Database Analysis in the United States. BioMed Research International Hindawi. Volume 2017. Published April 30, 2017. https://doi.org/10.1155/2017/7021862

  2. Medina Pabón MA, Naqvi U. Achilles Tendonitis. [Updated 2022 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK538149/

  3. Physiopedia. Achilles Tendinopathy. Physiopedia.com. Accessed August 31, 2022. https://www.physio-pedia.com/Achilles_Tendinopathy 2 3

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