Written by Adam White, Clinical Lead Physiotherapist — Whittlesea Physiotherapy & Clinical Pilates
That familiar tightness in your heel when you take your first steps in the morning. The ache that creeps back in after a run, even when the first kilometre felt fine. The nagging pain at the back of your ankle that just will not settle — no matter how much you rest.
If this sounds familiar, you may be dealing with Achilles tendinopathy. It is one of the most common lower limb injuries we see at Whittlesea Physiotherapy & Clinical Pilates — and it is one that responds very well to the right approach.
What Is Achilles Tendinopathy?
The Achilles tendon is the largest and strongest tendon in the body. It connects the calf muscles to the heel bone and is responsible for every push-off you make — walking, running, climbing stairs, jumping. It handles enormous loads daily.
Achilles tendinopathy occurs when the tendon is exposed to more load than it can manage and adapt to. This leads to structural changes within the tendon — a process that involves both tissue degeneration and a pain response. The term tendinopathy is now preferred over the older term tendonitis, because current evidence shows that true inflammation is not always present. The pain is more often driven by tendon structure change and load-related sensitisation (Cook & Purdam, 2009).
There are two main types, classified by where the pain occurs:
- Mid-portion Achilles tendinopathy — pain located 2–7 cm above the heel. This is the most common type and is strongly linked to overuse and load management.
- Insertional Achilles tendinopathy — pain at the point where the tendon meets the heel bone. This type can involve the nearby bursa and tends to be more sensitive to compression-based movements (such as stretching into a deep heel drop).
Who Gets It?
Achilles tendinopathy is particularly common in:
- Runners — especially those who have recently increased their training distance, pace, or surface
- Active adults who have started a new sport or exercise routine
- People returning to activity after a period of rest
- Older adults, where tendon capacity naturally declines with age
- Women during and after menopause, when hormonal changes affect tendon health
Research suggests that up to 24% of runners will experience Achilles tendinopathy at some point (Rowe et al., 2012), and it accounts for approximately 11% of all running injuries.
What Does It Feel Like?
Achilles tendinopathy has a recognisable pattern of symptoms. You may experience:
- Morning stiffness and pain — often worst in the first few steps after rest
- Pain that warms up — eases during activity, then worsens afterwards
- Heel or lower leg pain during running, jumping, or walking uphill
- Swelling or thickening of the tendon
- Tenderness when pressing on the tendon
- In more severe cases: pain during normal walking, or an inability to weight-bear comfortably
One of the hallmarks of Achilles tendinopathy is its load-dependent nature — symptoms are often manageable at rest but flare with activity. This pattern can tempt people to push through, which often delays recovery and worsens the condition.
What Causes It?
Achilles tendinopathy almost always involves a mismatch between the load placed on the tendon and the tendon’s capacity to absorb and adapt to that load. This mismatch can build gradually or occur more suddenly.
Common contributing factors include:
- Rapid increase in training volume or intensity (too much, too soon)
- Starting a new exercise program or sport
- Poor calf and lower limb strength or endurance
- Reduced ankle joint mobility
- Inadequate recovery between sessions
- Flat feet, high arches, or poor foot biomechanics
- Inappropriate or worn footwear
- Excess body weight, which increases tendon load
- Age-related reduction in tendon strength and flexibility
From a physiotherapy perspective, it is rare for one factor alone to cause tendinopathy. A thorough assessment — looking at your load history, movement patterns, strength, flexibility, and contributing factors — helps us identify what is driving your symptoms and what needs to change.
The Evidence Behind Treatment
Current best-practice evidence is clear: progressive tendon loading is the cornerstone of Achilles tendinopathy rehabilitation (Beyer et al., 2015; Alfredson et al., 1998). Rest alone does not rehabilitate the tendon — in fact, complete rest can reduce tendon capacity further.
A well-structured rehabilitation program progresses through three key phases:
Phase 1: Isometric Loading
Isometric exercises involve contracting the calf muscle without movement — for example, holding a calf raise at the top position. Research shows that isometric exercises provide meaningful short-term pain relief and help maintain tendon and muscle function during the early stages of management (Rio et al., 2015). This is typically where we start.
Phase 2: Isotonic Loading (Heavy Slow Resistance)
This phase involves progressively loaded calf raise exercises — both with a straight knee (targeting gastrocnemius) and with a bent knee (targeting soleus). The landmark Alfredson heavy-load eccentric protocol, and more recent heavy slow resistance (HSR) protocols, demonstrate significant improvements in tendon structure, pain, and function over 12 weeks (Beyer et al., 2015). Slow, controlled repetitions are key — speed matters as much as load.
Phase 3: Plyometric Loading and Return to Sport/Activity
Once a solid strength base is established, the program advances to energy-storage activities — such as jump training, running progressions, and sport-specific drills. This phase prepares the tendon to manage the fast, explosive loads required for running, sport, and activities of daily life. Skipping this phase is a common reason for re-injury.
A note on stretching: For mid-portion tendinopathy, aggressive calf stretching (particularly with the heel dropped below a step) is not recommended in the early stages. Compression of the tendon in this position can aggravate symptoms (Cook & Purdam, 2009). Your physiotherapist will guide what is appropriate for your specific presentation.
what about other treatmeants
In addition to a structured loading program, your physiotherapist may also use:
- Manual therapy — soft tissue techniques and joint mobilisation to address contributing stiffness or tightness
- Activity and load modification — adjusting your training to allow the tendon to recover while staying active
- Footwear and orthotic advice — heel raises and supportive footwear can reduce tendon load in the short term
- Gait retraining — for runners, small modifications to running form can significantly reduce Achilles load
- Education — understanding how to monitor your symptoms and progress load safely is one of the most powerful tools in tendinopathy management
In some cases, imaging (ultrasound or MRI) may be recommended to assess tendon structure and rule out other contributing factors. However, imaging findings do not always correlate with symptom severity — a tendon can look abnormal on scan and cause minimal pain, or appear relatively normal and be very symptomatic.
Extracorporeal shockwave therapy (ESWT) has emerging evidence, particularly for chronic or insertional Achilles tendinopathy that has not fully responded to loading programs alone.
how long does recovery take?
Recovery from Achilles tendinopathy varies. For mild to moderate cases with early, appropriate treatment, significant improvement is typically seen within 6–12 weeks. For longstanding or severe cases, recovery may take 3–6 months or longer.
The most important factor in recovery is not avoiding pain entirely — it is managing your load appropriately and staying consistent with your rehabilitation. Tendons respond slowly but reliably to the right stimulus.
Why Early Treatment Matters
Many people with Achilles tendinopathy try to push through, rest completely, or self-treat with stretching — and find the problem persists or worsens. The longer tendinopathy is left unmanaged, the more the tendon structure can deteriorate, and the longer recovery tends to take.
Getting a clear diagnosis and starting a structured program early gives you the best chance of a faster, more complete recovery — and reduces the risk of re-injury down the track.
How We Can Help at Whittlesea Physiotherapy
Our team has extensive experience managing tendon conditions across a wide range of patients — from recreational walkers and weekend athletes to competitive runners and returning post-surgery clients.
When you come in for an Achilles assessment, we will:
- Take a thorough history of your symptoms and activity levels
- Conduct a detailed physical assessment of the tendon, calf strength, ankle mobility, and movement patterns
- Identify contributing factors specific to you
- Design a progressive loading program tailored to your goals and current capacity
- Guide you back to the activities you love — safely and confidently
We also work closely with our Clinical Pilates team where additional core stability, hip, and lower limb strength work can support your recovery and long-term resilience.
Next steps
Our If you have been dealing with heel or Achilles pain that is not settling, do not wait it out. Early, targeted physiotherapy makes a real difference.
Book an appointment online at whittleseaphysiotherapy.com.au or call us on 03 9716 2250.
Our clinic is open Monday to Saturday — we are here to help you get back to moving well.
Whittlesea Physiotherapy & Clinical Pilates has been serving the Whittlesea community since 2005. Our team of experienced physiotherapists provides evidence-based, patient-centred care for musculoskeletal conditions, sports injuries, and chronic pain.
references
- Alfredson H, Pietila T, Jonsson P, Lorentzon R. (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine, 26(3), 360–366.
- Beyer R, Kongsgaard M, Hougs Kjaer B, Ohlenschlaeger T, Kjaer M, Magnusson SP. (2015). Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy. American Journal of Sports Medicine, 43(7), 1704–1711.
- Cook JL, Purdam CR. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409–416.
- Rio E, Kidgell D, Purdam C, et al. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine, 49(19), 1277–1283.
- Rowe V, Hemmings S, Barton C, et al. (2012). Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning. Sports Medicine, 42(11), 941–967.
This blog is intended as general health information only. It does not replace individualised professional advice. Please consult a qualified physiotherapist for assessment and management of your specific condition.