Achilles Tendinopathy Treatment: A Recovery Guide By Dr. Gavine, DC
Medically Reviewed By: Adam Gavine, BHK, M.Chiro https://www.backtofunction.com.au/about
Original Published: March 2022
Updated On: September 2026
Pain at the back of the ankle can turn an ordinary walk, run or trip up the stairs into an uncomfortable experience.
Achilles tendon symptoms frequently begin with morning stiffness or discomfort at the start of exercise. The pain may improve as you warm up, only to return later that day or the following morning.
This warm-up effect can make the condition easy to ignore. You may continue training because the tendon feels better after several minutes, while its ability to tolerate the overall workload gradually declines.
Achilles tendinopathy treatment should do more than temporarily reduce pain. A complete plan needs to identify the activities exceeding the tendon’s current capacity and progressively prepare it for walking, running, jumping or sport.
What Is Achilles Tendinopathy?
The Achilles tendon connects the calf muscles to the heel bone. It transfers force from the calf to the foot and plays an important role in:
walking
running
climbing stairs
jumping
changing direction
rising onto your toes
Achilles tendinopathy is a clinical condition characterized by tendon pain, stiffness and reduced capacity during activities that load the lower leg.
The term “tendinitis” is still commonly used, but it implies that inflammation is the central problem. Persistent Achilles tendinopathy involves more complex changes in tendon structure, load tolerance and pain sensitivity.
It is not accurately described as a tendon that has simply failed to heal. Tendons remain capable of adapting, although recovery can take time.
Midportion and Insertional Achilles Tendinopathy
The location of pain matters because the two main presentations may require different exercise modifications.
Midportion Achilles tendinopathy
Midportion symptoms occur within the tendon, usually several centimetres above its attachment to the heel.
Common features include:
pain or stiffness in the middle portion of the tendon
localised thickening
morning discomfort
pain during running or repeated heel raises
symptoms that ease temporarily after warming up
Insertional Achilles tendinopathy
Insertional symptoms occur where the Achilles tendon attaches to the heel bone.
Features may include:
pain directly at the back of the heel
sensitivity to pressure from shoes
discomfort during uphill walking
pain when the ankle bends deeply
difficulty lowering the heel below the level of a step
Insertional symptoms can be aggravated by compression between the tendon and heel bone. This means some exercises used for midportion tendinopathy may need to be modified.
For example, lowering the heel below a step can increase compression at the insertion. Early insertional rehabilitation may therefore begin with heel raises performed from the floor.
What Causes Achilles Tendinopathy?
Achilles tendinopathy rarely has one isolated cause. It commonly develops when tendon load increases faster than the body can adapt.
Rapid changes in training
Examples include:
increasing running distance
adding hill sessions
beginning sprint training
returning to sport after a break
adding more weekly training days
changing from road running to trails
introducing skipping or jumping
playing several matches in a short period
The tendon can tolerate substantial force when it has been prepared gradually. The problem is often the size and speed of the workload change.
Work and daily activity
Achilles pain is not limited to athletes. Standing, walking, climbing and carrying at work all contribute to the tendon’s total load.
A new job, extended shift or walking holiday may be enough to provoke symptoms, particularly if combined with exercise.
Reduced calf capacity
The calf muscles and Achilles tendon work together. Reduced strength, endurance or power can make a familiar activity relatively more demanding.
Assessment may identify difficulty with:
repeated heel raises
single-leg control
hopping
absorbing force
producing force quickly
maintaining strength under fatigue
Footwear and terrain changes
A rapid change to flatter shoes, minimalist footwear, hard surfaces or steep terrain may alter Achilles load.
There is no single perfect shoe for everyone. The important consideration is whether the change was gradual and whether the footwear is comfortable for the intended activity.
Health and medication factors
Achilles tendon health may also be influenced by:
age
previous tendon injury
metabolic health
smoking
certain inflammatory conditions
some medications
Fluoroquinolone antibiotics and corticosteroid exposure have been associated with tendon problems. Do not stop prescribed medication without medical advice. Speak with your doctor if tendon pain begins while taking medication or shortly afterwards.
Common Achilles Tendinopathy Symptoms
Symptoms may include:
morning stiffness
pain during the first steps after sitting
tenderness or thickening
discomfort during heel raises
pain at the beginning or end of exercise
reduced running or jumping capacity
pain that increases after hills or faster running
symptoms that are worse the day after increased activity
Pain intensity alone does not reveal the extent of structural change. A painful tendon is not automatically torn, and an abnormal-looking tendon on imaging may not be painful.
How Is Achilles Tendinopathy Diagnosed?
Diagnosis is usually based on your history and physical examination.
The assessment may include:
locating the painful area
examining tendon sensitivity and thickening
assessing ankle movement
measuring calf strength and endurance
observing walking or running
performing heel raises or hopping where appropriate
reviewing recent training and work changes
screening for other sources of pain
Ultrasound or MRI is not routinely needed for every patient. Imaging may be considered when:
the diagnosis is uncertain
a partial tear or rupture is suspected
symptoms followed significant trauma
progress is not occurring as expected
another condition needs to be investigated
Imaging findings should be interpreted alongside symptoms and function.
When Achilles Pain May Be an Emergency
Seek prompt medical assessment if you experience:
a sudden snap or popping sensation
a feeling that you were kicked in the back of the leg
rapid swelling or bruising
an inability to push off the foot
an inability to perform a heel raise
sudden loss of ankle strength
These symptoms may indicate an Achilles tendon rupture.
Calf swelling, redness, heat, shortness of breath or chest pain also require urgent medical attention because they may indicate a blood clot or another serious condition.
Imaging is not always required. Ultrasound or MRI may be considered if the diagnosis is uncertain, a tear is suspected or symptoms are not progressing as expected.
Structural changes can be present without pain, so scan results should be interpreted alongside symptoms and function.
Evidence-Based Achilles Tendinopathy Treatment
The updated 2024 clinical practice guideline for midportion Achilles tendinopathy supports individualised assessment, education and progressive tendon-loading exercise.
1. Modify the aggravating load
Complete rest is not routinely required. It may reduce symptoms temporarily but does not prepare the tendon for future demands.
Activity can often be adjusted by changing:
running distance
speed
hills
training frequency
jumping volume
walking duration
recovery between sessions
Alternative activities such as cycling or swimming may help maintain fitness if they are comfortable.
Monitor how the tendon responds during activity, later that day and the following morning. A substantial or lasting increase may indicate that the session exceeded its current capacity.
2. Begin progressive tendon-loading exercise
Exercise is a central component of rehabilitation. Eccentric heel drops are one option, but they are not the only effective approach.
A program may progress through:
isometric calf holds
seated heel raises
standing double-leg heel raises
single-leg heel raises
loaded calf raises
heavier resistance exercises
faster calf work
hopping and jumping
running-specific drills
Both the gastrocnemius and soleus muscles should generally be considered. This may involve exercises with both a straight and bent knee.
Exercise selection, resistance, repetitions and frequency should reflect the person’s symptoms and goals. A runner preparing for hills requires a different end-stage program from someone returning to comfortable community walking.
3. Distinguish insertional rehabilitation
Insertional Achilles pain may be aggravated by deep ankle dorsiflexion.
Early adjustments may include:
performing heel raises from the floor
temporarily limiting steep hills
avoiding aggressive calf stretching
reducing exercises that place the heel below the toes
reviewing shoes that press on the painful area
Deeper loading positions may be introduced later if appropriate.
4. Progress towards energy-storage activities
Slow strengthening is important, but running and sport require the tendon to store and release energy quickly.
Later rehabilitation may include:
faster heel raises
skipping
pogo jumps
single-leg hopping
acceleration and deceleration
changes of direction
graded running
These activities should be introduced after adequate strength and symptom control have been established.
How Long Does Achilles Tendinopathy Take to Heal?
Recovery varies considerably.
Some recent cases improve within several weeks. Persistent cases may require several months of progressive rehabilitation. Tendon symptoms can fluctuate during that period.
Factors influencing recovery include:
how long symptoms have been present
the location of the condition
current calf capacity
consistency with rehabilitation
work and sporting demands
health and medication factors
the ability to modify excessive load
confidence returning to activity
Pain reduction is only one milestone. Recovery should also include improved strength, endurance and tolerance of the activities that matter to you.
Can You Keep Running?
Running does not always need to stop completely.
A modified program may be appropriate if:
pain remains manageable
your movement is not substantially altered
symptoms settle after the session
the following morning is not significantly worse
strength is being maintained or improved
Possible modifications include:
reducing distance
running less frequently
slowing the pace
avoiding hills
replacing intervals with easy running
alternating running with lower-impact exercise
More significant symptoms may require a temporary break from running while capacity is rebuilt.
Does Shockwave Therapy Help?
Shockwave therapy delivers mechanical acoustic pulses to the treatment area. It is sometimes considered for persistent Achilles tendinopathy.
Research has produced mixed results. Earlier studies suggested possible benefit for some midportion cases, particularly when shockwave was combined with exercise. Other studies and reviews have found uncertain or limited effects.
A 2026 systematic review and meta-analysis concluded that shockwave therapy should not currently be considered a routine treatment for either midportion or insertional Achilles tendinopathy.
This does not mean shockwave can never be discussed. It means that:
it should not replace progressive loading
benefit cannot be guaranteed
evidence uncertainty should be explained
tendon location matters
cost and alternatives should be considered
progress should be measured
treatment should stop if it is not providing meaningful value
Shockwave can cause temporary discomfort, redness, bruising or tenderness. Suitability should be established through an individual assessment.
Other Treatment Options
Manual and soft-tissue therapy
Manual treatment may provide short-term symptom relief or address relevant movement restrictions. It does not independently restore the tendon’s ability to tolerate running or jumping.
It should support an active rehabilitation plan rather than become the sole intervention.
Kinesio taping
Taping may alter symptoms temporarily for some people, but evidence for meaningful long-term improvement in Achilles tendinopathy is limited.
It should be considered an optional adjunct.
Heel lifts and orthoses
A temporary heel lift may reduce ankle dorsiflexion and alter Achilles loading. Orthoses may be considered when there is a specific clinical reason.
Neither is automatically required. Expensive custom devices should not be prescribed simply because the foot does not appear perfectly aligned.
Stretching
Stretching may be useful when calf or ankle mobility is relevant. It is not mandatory for every case.
Aggressive stretching can increase compression at the insertion and may aggravate insertional symptoms.
Injections
Injection options should be discussed with a suitably qualified medical practitioner. Corticosteroid injection into or around the Achilles requires particular caution because of concerns about tendon weakening and rupture.
No injection should be presented as a substitute for rebuilding physical capacity.
Surgery
Surgery is generally considered only after a substantial period of appropriate conservative management has not produced an acceptable result. Specialist assessment is required.
Returning to Running and Sport
A return-to-sport plan may consider:
morning stiffness
walking tolerance
repeated calf raises
calf strength compared with the other side
hopping ability
running response
sport-specific drills
symptoms during the following 24 hours
A graded sequence may move from walking to walk-jog intervals, continuous easy running, longer runs, hills, speed and competition.
Avoid progressing every variable at once.
Practical Steps You Can Take
Record recent changes in running, walking and gym activity.
Reduce the most provocative load rather than stopping everything.
Wear shoes that do not press directly on insertional symptoms.
Avoid aggressive heel drops from a step if insertional pain is present.
Begin calf strengthening at an appropriate level.
Monitor the following morning, not only the exercise session.
Maintain other comfortable forms of physical activity.
Seek assessment if symptoms persist or the diagnosis is uncertain.
What to Expect at Back To Function
At Back To Function, Dr Adam Gavine begins by identifying the type of Achilles presentation and the physical demands that may be contributing to it.
Detailed history
Your consultation may cover:
symptom location and duration
morning stiffness
running and walking volume
recent changes in speed or hills
work demands
medication
footwear
previous tendon injuries
treatments already attempted
return-to-activity goals
Physical assessment
Adam may evaluate:
Achilles tenderness
ankle mobility
calf strength and endurance
heel-raise capacity
walking or running mechanics
balance
hopping ability where appropriate
related foot, knee and hip function
signs suggesting another condition
Individualised management
Depending on your findings, care may include:
education and load modification
progressive calf and Achilles rehabilitation
Active Release Techniques®
myofascial treatment
chiropractic or joint-based care where relevant
kinesio taping
footwear guidance
shockwave therapy following a discussion of the evidence and alternatives
referral for imaging or medical assessment where indicated
Progress should be evaluated through function, strength and activity tolerance, not only tenderness or pain.
Rebuild the Tendon’s Capacity
Achilles tendinopathy can be persistent, but that does not mean the tendon is beyond recovery.
The most important steps are identifying excessive load, modifying it without unnecessary inactivity and completing a progressive strengthening program. Passive treatments may support selected patients, but they should not displace exercise and gradual return to activity.
If Achilles pain is affecting your walking, running or sport, contact Back To Function on 0468 749 223, email adam@backtofunction.com.au, or arrange an assessment at Suite 36/38, 12–14 Waratah Street, Mona Vale.
Dr Adam Gavine provides Achilles assessment and rehabilitation for patients from Sydney’s Northern Beaches and the Central Coast.
AUTHOR BIO
Dr Adam Gavine, BHK, M.Chiro, is the Director and Chiropractor at Back To Function. He has more than 19 years of clinical experience and a special interest in sports rehabilitation and soft-tissue health.
Adam is a full-body certified Active Release Techniques® (ART) provider, one of only a handful in Australia. He is also co-founder of the Wasabi Method, a shockwave therapy partnership. Adam is currently completing a PhD at the University of Sydney and services patients across Sydney’s Northern Beaches and the Central Coast.
READ MORE
What Is Tendinopathy and How Do You Manage It?: Understanding tendon pain and progressive loading
Shockwave Therapy: How It Works and When It May Help: A balanced introduction to shockwave treatment
Plantar Fasciitis Treatment: A Practical Guide: Understanding another common source of heel pain
