Achilles Tendonitis

Understanding Achilles Tendonitis

The Achilles tendon—the thick band of tissue running down the back of your lower leg to your heel—is the largest and strongest tendon in your body. Yet despite its impressive strength, it’s also one of the most commonly injured tendons, particularly among athletes and active individuals. Achilles tendonitis can progress from a minor nuisance to a debilitating condition that sidelines you from activities you love, and in severe cases, can lead to tendon rupture. Understanding this condition and, more importantly, seeking early diagnosis and treatment can mean the difference between quick recovery and months of frustration.

What Is Achilles Tendonitis?

Achilles tendonitis (also called Achilles tendinopathy in chronic cases) is inflammation and degeneration of the Achilles tendon. This condition develops when the tendon is subjected to repetitive stress or overuse that exceeds its capacity to heal and adapt.

Achilles Tendon Anatomy and Function

The Achilles tendon:

• Connects your calf muscles (gastrocnemius and soleus) to your heel bone (calcaneus)
• Enables you to point your foot downward (plantarflexion)
• Provides the power for walking, running, and jumping
• Bears forces 2-3 times your body weight during walking
• Bears forces up to 12 times your body weight during running
• Is essential for nearly all lower body athletic movements

Why it’s vulnerable:

• Limited blood supply, especially in the middle portion
• Subjected to repetitive, high forces
• Must be both strong and elastic
• Decreases in elasticity with age
• Can’t rest—used with nearly every step

Two Types of Achilles Tendonitis

Insertional Achilles Tendonitis:

• Affects the lower portion where the tendon attaches to the heel bone
• Often involves bone spurs or calcification
• Can develop at any age
• More common in less active individuals but also in athletes
• May cause visible bump at the back of the heel

Non-Insertional (Midportion) Achilles Tendonitis:

• Affects the middle portion of the tendon (2-6 cm above heel)
• More common in younger, active individuals
• Often associated with sports and overuse
• May show thickening of the tendon
• Better blood supply than insertional type, potentially better healing

The Distinctive Symptoms

Achilles tendonitis has characteristic symptoms that distinguish it from other conditions:

Classic presentation:

• Pain and stiffness along the Achilles tendon, especially in the morning
• Pain that decreases with mild activity but worsens with increased intensity or duration
• Tenderness when squeezing the tendon
• Swelling along the tendon
• Thickening of the tendon (chronic cases)
• Feeling of sluggishness or weakness in the affected leg
• Tightness in the calf muscles
• Pain with rising on toes or pushing off while walking/running

Warning signs:

• Sharp, sudden pain may indicate partial tear
• Inability to rise on toes suggests significant tendon damage
• “Popping” sensation may indicate rupture (medical emergency)
• Severe pain and inability to walk requires immediate evaluation

Progression pattern:

• Stage 1: Pain only after activity, resolves quickly
• Stage 2: Pain during activity but doesn’t affect performance
• Stage 3: Pain during activity that affects performance
• Stage 4: Chronic pain even at rest, severely limited function
• Stage 5: Complete tendon rupture

Why Early Diagnosis and Treatment Are Critical

Unlike some conditions that may resolve with rest alone, Achilles tendonitis has a strong tendency to become chronic if not properly addressed early. Here’s why early intervention is absolutely essential:

The Degenerative Cascade

When Achilles tendonitis goes untreated:

1. Initial inflammation becomes chronic degeneration
2. Normal tendon structure deteriorates into disorganized, weakened tissue
3. Small areas of damage expand and coalesce
4. Tendon thickens but becomes weaker (scar tissue, not functional tendon)
5. Blood vessels grow abnormally into the tendon, causing pain
6. Nerve ingrowth creates chronic pain signals
7. Tendon becomes increasingly brittle, raising rupture risk

The critical window: The first few weeks of symptoms represent your best opportunity for complete healing. During this time, appropriate treatment can:

• Reverse inflammatory processes
• Promote proper tissue healing and remodeling
• Prevent degeneration
• Restore normal tendon structure
• Avoid chronicity

After chronic degeneration sets in (typically after 2-3 months of symptoms):

• Healing becomes much more difficult
• Treatment takes significantly longer
• Complete structural recovery is less likely
• Risk of rupture increases substantially
• May require more aggressive interventions

Why Achilles Injuries Are Particularly Dangerous

The tendon can’t truly rest:

• Used with every step you take
• Difficult to completely offload
• Even “rest” involves some tendon stress
• Continued micro-trauma can prevent healing

Poor blood supply to critical areas:

• Middle portion of tendon has watershed area with limited circulation
• Reduced blood flow means slower healing
• Makes the tendon more vulnerable to degeneration

High forces during activity:

• Running, jumping create enormous loads
• Even modified activity can exceed healing capacity
• Easy to re-aggravate during recovery

Progression to rupture:

• Chronic tendonitis significantly increases rupture risk
• Rupture often occurs after period of chronic pain
• Rupture requires surgery and 6+ months recovery
• May never regain full pre-injury function

The Cost of Delayed Treatment

Addressing Achilles tendonitis early (within 2-4 weeks):

• Resolution in 6-12 weeks typical
• Conservative treatment highly effective
• Full return to activity expected
• Low risk of reinjury with proper rehabilitation

Delaying treatment (months of symptoms):

• Recovery takes 6-12+ months
• More aggressive treatments required
• Incomplete recovery more likely
• Higher reinjury rates
• Substantially increased rupture risk
• Possible need for surgical intervention
• Chronic limitations in athletic performance

The message is clear: Don’t wait. Act early.

What Causes Achilles Tendonitis?

Understanding causes helps with both treatment and prevention:

Training Errors (Most Common in Athletes)

• Sudden increase in training volume or intensity: “Too much, too soon”
• Inadequate rest between sessions: Insufficient recovery time
• Change in training surface: Switching from soft to hard surfaces
• Hill running or speed work: Increased eccentric load on tendon
• Inadequate warm-up: Starting intense activity with cold tissues
• Poor progression: Jumping into advanced training without base

Biomechanical Factors

• Overpronation: Excessive inward foot roll during walking/running
• Tight calf muscles: Reduces flexibility and increases tendon stress
• Weak calf muscles: Inadequate strength for demands placed on them
• Leg length discrepancy: Creates asymmetric forces
• Poor running mechanics: Inefficient movement patterns
• Foot structure: Flat feet or high arches can contribute

Footwear Issues

• Worn-out shoes: Lost cushioning and support
• Inappropriate shoes for activity: Wrong shoe type for your sport
• Inadequate heel cushioning: Increases impact on tendon
• Sudden change in footwear: Altering mechanics or support

Age-Related Factors

• Natural tendon changes with age: Decreased elasticity and vascularity
• More common in 30s-50s: “Weekend warrior” phenomenon
• Reduced recovery capacity: Takes longer to adapt to training stress

Medical Factors

• Fluoroquinolone antibiotics: Known to increase tendon injury risk
• Inflammatory conditions: Rheumatoid arthritis, ankylosing spondylitis
• Metabolic conditions: Diabetes, obesity
• Steroid use: Weakens tendon tissue

Activity-Specific Risks

• Running (especially distance running, trail running with hills)
• Basketball, tennis, soccer: Repetitive jumping and cutting
• Dancing: Particularly ballet and jumping disciplines
• CrossFit or plyometric training: High-intensity eccentric loading

Our Comprehensive Diagnostic Approach

When you visit our office with Achilles pain, we conduct a thorough evaluation to confirm diagnosis, assess severity, and identify contributing factors:

Detailed History

1. Symptom onset: Sudden or gradual? Related to training change?
2. Pain pattern: When is it worst? What activities aggravate it?
3. Training history: Recent changes in volume, intensity, or activities?
4. Previous Achilles problems: History of tendon issues?
5. Medical history: Medications, systemic conditions?
6. Footwear: What shoes for training? How old are they?

Physical Examination

1. Visual inspection: Swelling, thickening, redness
2. Palpation: Locating exact area of tenderness, feeling for thickening or nodules
3. Range of motion testing: Ankle dorsiflexion (bringing toes toward shin)—often limited
4. Strength testing: Calf raises (single and double leg), toe walking
5. Functional testing: Hopping (if appropriate), running gait analysis
6. Biomechanical assessment: Foot posture, pronation, leg alignment
7. Calf flexibility: Almost always tight in Achilles tendonitis
8. Thompson test: If rupture is suspected (squeezing calf produces no foot movement)

Differentiating from Similar Conditions

• Achilles bursitis: Inflammation of bursa between tendon and heel bone
• Haglund’s deformity: Bony prominence irritating tendon
• Calcaneal stress fracture: Heel bone injury
• Sural nerve entrapment: Nerve pain mimicking tendonitis
• Soleus or gastrocnemius strain: Muscle injury above tendon

When Imaging Is Indicated

• Ultrasound:
  • Visualizes tendon structure and thickness
  • Identifies tears, degeneration, or inflammation
  • Can assess blood flow
  • Dynamic imaging during movement
  • Often first-line imaging for Achilles problems
• MRI:
  • Detailed view of tendon structure
  • Identifies partial tears or significant degeneration
  • Rules out other conditions
  • Pre-surgical planning if needed
• X-ray:
  • Shows bone spurs or calcification
  • Rules out fractures or bone abnormalities
  • Less useful for soft tissue assessment

Our Evidence-Based Treatment Approach

Treatment for Achilles tendonitis must be comprehensive, addressing both symptoms and underlying causes:

Focused Shockwave Therapy: FDA-Approved Treatment

Extracorporeal Shockwave Therapy (ESWT) is FDA-approved specifically for chronic Achilles tendonitis and represents one of the most effective treatments available.

How shockwave therapy works for Achilles tendonitis:

• Delivers focused acoustic waves directly to the damaged tendon
• Stimulates cellular regeneration and tissue remodeling
• Breaks down abnormal blood vessels and nerve ingrowth causing chronic pain
• Increases growth factor production
• Promotes formation of new, healthy blood vessels
• Reactivates healing in chronic, degenerative tendons
• Reduces pain through neurological mechanisms

Research on shockwave therapy for Achilles tendonitis:

• 70-80% success rates in chronic cases
• Significantly more effective than traditional conservative care alone
• Particularly beneficial for tendinopathy that hasn’t responded to other treatments
• Provides lasting results, not temporary relief
• Reduces or eliminates need for surgery
• FDA-approved specifically for this condition

Treatment protocol:

• Typically 3-6 sessions over several weeks
• Each session takes 10-15 minutes
• Some discomfort during treatment (well-tolerated)
• Gradual improvement over 8-12 weeks
• Combined with rehabilitation exercises for optimal results

Shockwave therapy is especially beneficial for:

• Chronic Achilles tendonitis (lasting more than 3 months)
• Cases showing signs of tendon degeneration on imaging
• Athletes needing to return to high-level activity
• Patients who haven’t responded to conservative care
• Those wanting to avoid prolonged downtime or surgery

This FDA-approved treatment has revolutionized Achilles tendonitis care, offering hope for cases that previously might have required surgery.

Traditional Rehabilitation Therapies

Manual Therapies:

• Instrument-assisted soft tissue mobilization (IASTM): Breaking down scar tissue and adhesions in the tendon and surrounding tissues
• Myofascial release: Addressing tightness in the calf complex
• Deep tissue work: Releasing chronic muscle tension
• Joint mobilization: Improving ankle and foot mechanics
• Graston or similar techniques: Specific fascial and tendon work

Eccentric Strengthening (Cornerstone of Rehabilitation):

• Eccentric heel drops (Alfredson protocol)—the gold standard exercise
• Slow, controlled lowering from raised position
• Loads the tendon in lengthened position
• Proven highly effective in research
• Performed daily, even with mild discomfort
• Progressive resistance added over time

Additional Strengthening:

• Calf raises (both straight knee and bent knee)
• Toe walking
• Resisted plantarflexion
• Functional strength exercises
• Single-leg balance work

Flexibility Work:

• Calf stretching (gastrocnemius and soleus)
• Performed multiple times daily
• Held 30-60 seconds
• Both static and dynamic stretching
• Ankle mobility exercises

Laser Therapy:

• Reducing inflammation in the tendon
• Accelerating tissue healing and remodeling
• Decreasing pain
• Promoting healthy tissue formation
• Can be used frequently without side effects

Load Management:

• Modifying training volume and intensity
• Cross-training with low Achilles-load activities (swimming, cycling)
• Progressive return to running/jumping
• Activity modification during healing phase

Footwear and Orthotics

Proper footwear:

• Adequate heel cushioning (reduces tendon stress)
• Good arch support
• Avoid completely flat shoes or minimalist footwear during acute phase
• Replace worn-out athletic shoes
• Heel lifts (temporary) may reduce strain during acute phase

Orthotics (when indicated):

• Custom or over-the-counter arch supports
• Correcting excessive pronation
• Improving foot mechanics
• Reducing abnormal stress on Achilles

Activity Modification Strategies

During acute phase:

• Reduce or temporarily stop aggravating activities
• Maintain fitness with alternative exercises:
  • Swimming (avoid aggressive kicking)
  • Cycling (lower resistance initially)
  • Upper body strength training
  • Core work
  • Rowing (with caution)

Gradual return to activity:

• Progressive loading protocol
• Short intervals initially
• Flat surfaces before hills
• Walking before running
• Slower speeds before faster
• Monitoring response (some discomfort acceptable, should not worsen significantly)

Expected Recovery Timeline

With early, appropriate treatment (including shockwave therapy):

Weeks 1-2:

• Begin treatment and load management
• Start eccentric exercises
• Initial shockwave sessions if chronic
• Pain may initially persist

Weeks 2-6:

• Gradual pain reduction
• Improved function in daily activities
• Progressive strengthening
• Continued shockwave sessions
• May begin modified return to sport

Weeks 6-12:

• Substantial improvement
• Progressive return to full activity
• Continued eccentric exercises
• Most patients significantly improved by 12 weeks

Beyond 12 weeks:

• Complete or near-complete resolution typical
• Full return to sport
• Maintenance program for prevention
• Long-term strengthening continued

Important note: Chronic tendonitis (present for months before treatment) takes longer than acute cases addressed early.

Advanced Interventions for Resistant Cases

While most Achilles tendonitis responds to conservative care including shockwave therapy, rare severe cases may require:

PRP (Platelet-Rich Plasma) Injections

• Using your own concentrated platelets
• Injected into areas of degeneration
• Stimulates healing response
• Typically combined with rehabilitation
• Evidence mixed but promising in some studies
• Considered when conservative care including shockwave has failed

Corticosteroid Injections

• Generally NOT recommended for Achilles tendonitis
• Significantly increases risk of tendon rupture
• May provide temporary pain relief but doesn’t heal tissue
• Should be avoided in almost all cases
• Only extremely rare circumstances might warrant consideration

Surgical Intervention

• Reserved for severe cases unresponsive to comprehensive conservative care (including shockwave therapy) for 6+ months
• Procedures include:
  • Debridement (removing degenerative tissue)
  • Tendon repair if significantly damaged
  • Transfer of other tendons if needed
• Recovery time 4-6+ months
• Not guaranteed success
• Should be absolute last resort

Our philosophy: Surgery should only be considered after exhausting all appropriate conservative treatments, including FDA-approved shockwave therapy.

Prevention: Protecting Your Achilles

Once recovered, focus on preventing recurrence:

Training Principles

• Gradual progression: Increase mileage/intensity no more than 10% per week
• Adequate recovery: Rest days between hard efforts
• Varied training: Mix surfaces, speeds, intensities
• Proper warm-up: Never start intense activity with cold muscles
• Listen to your body: Address early warning signs immediately

Strengthening and Flexibility

• Continue eccentric heel drops: 2-3 times per week for maintenance
• Regular calf stretching: Daily
• Ankle mobility work: Maintaining dorsiflexion range
• Hip and core strength: Supporting overall mechanics
• Progressive loading: Maintaining tendon’s capacity to handle stress

Equipment

• Replace shoes regularly: Every 300-500 miles for running shoes
• Appropriate footwear: Match shoe to activity and foot type
• Gradual transitions: When changing shoe types
• Consider orthotics: If biomechanical issues present

Lifestyle Factors

• Maintain healthy weight: Reduces stress on tendons
• Stay hydrated: Supports tissue health
• Adequate nutrition: Protein and nutrients for tissue maintenance
• Manage overall training load: Account for all activities, not just primary sport

Early Warning System

If you feel any Achilles discomfort:

• Reduce activity immediately
• Increase stretching and mobility work
• Apply ice after activity
• Schedule evaluation if doesn’t resolve in 2-3 days
• Don’t push through developing tendonitis

Don’t Gamble with Your Achilles

The Achilles tendon is too important and too vulnerable to take chances with. Early diagnosis and treatment aren’t just recommended—they’re essential.

Schedule evaluation if you experience:

• Any pain along the Achilles tendon lasting more than a few days
• Morning stiffness in the Achilles
• Pain during or after running/jumping activities
• Tenderness when squeezing the tendon
• Swelling or thickening along the tendon
• Any change in your athletic performance related to calf or heel pain

Don’t wait for:

• Pain to become severe
• Inability to train at all
• Chronic degeneration to set in
• Risk of rupture to increase
• Simple problem to become complex

Your Path to Recovery

If you’re experiencing Achilles tendon pain, schedule a comprehensive evaluation so we can:

1. Accurately diagnose your specific condition and assess severity
2. Determine the stage: Acute inflammation vs. chronic degeneration
3. Identify contributing factors: Training errors, biomechanics, footwear, muscle tightness
4. Create a targeted treatment plan: Including FDA-approved shockwave therapy for chronic cases
5. Implement evidence-based rehabilitation: Eccentric exercises and progressive loading
6. Modify training appropriately: Maintaining fitness while allowing healing
7. Address biomechanical issues: Correcting problems that caused the injury
8. Monitor progress closely: Adjusting treatment based on response
9. Guide safe return to sport: Ensuring readiness before full activity
10. Establish prevention strategies: Protecting against recurrence

The Bottom Line on Achilles Tendonitis

Key points to remember:

• The Achilles is the largest, strongest tendon in your body—but also highly vulnerable
• Early diagnosis and treatment are absolutely critical
• Untreated Achilles tendonitis progresses to chronic degeneration
• Chronic tendonitis dramatically increases rupture risk
• Conservative care is highly effective—especially when started early
• Shockwave therapy is FDA-approved specifically for Achilles tendonitis with excellent success rates
• Eccentric exercises are the cornerstone of rehabilitation
• Complete recovery is expected with appropriate early treatment
• Delayed treatment leads to prolonged disability and possible surgery
• Prevention through proper training and maintenance is possible

The window for optimal treatment is limited. Don’t miss it.

Achilles tendonitis is not a condition to “wait and see” about or try to push through. The stakes are too high, and the consequences of delayed treatment too severe.

With accurate early diagnosis, FDA-approved shockwave therapy, comprehensive rehabilitation, and attention to contributing factors, most people achieve complete resolution and return to full activity.

Protect your Achilles. Seek evaluation early. Get back to the activities you love—without chronic pain or risk of rupture.

Schedule your Achilles tendonitis evaluation today. Your tendon—and your athletic future—will thank you.