Achilles Tendinopathy

The tendon that announces itself in the morning

Achilles tendinopathy usually introduces itself the same way: stiffness and pain in the back of the heel with the first steps out of bed, easing as you warm up, returning after you sit, and flaring after runs rather than during them. Early on, the warm-up phenomenon fools people — if it loosens up, how bad can it be? — and the tendon quietly loses ground for months before it starts interrupting training.

It is common in runners, but also in people who simply ramped up walking, started a jumping sport, or gained load faster than the tendon adapted. Like tennis elbow and most tendon problems, this is degeneration under a failed healing response, not inflammation — which reorders the entire treatment plan.

Location matters: midportion vs. insertional

Where the tendon hurts changes what we do, so this distinction is worth two minutes.

Midportion tendinopathy — pain and often a tender, spindle-shaped thickening 2 to 6 centimeters above the heel bone. This is the more common pattern and the more treatment-responsive one.

Insertional tendinopathy — pain right at the heel bone, where the tendon attaches. Often accompanied by a bony prominence (a Haglund deformity) and a bursa that joins the protest. This version dislikes stretching and dislikes having the heel dropped below level — which means the standard rehab program for midportion disease, applied here, makes it worse. It's a common reason "I tried the exercises and they didn't work."

Ultrasound in the office shows us which one we're dealing with, how thickened the tendon is, whether there's a partial tear, and whether the neighboring bursa is involved.

Why rest backfires

A tendon's strength is earned and maintained by load. Rest a degenerated Achilles for six weeks and you get a weaker degenerated Achilles that hurts again on the second run back. The evidence on this is unusually consistent: the treatment that rebuilds tendons is progressive mechanical loading, applied for months, at intensities that feel meaningful.

The flip side: some pain during rehab is expected and acceptable. The working rule is pain up to about 3–4 out of 10 during exercise that settles within 24 hours. Waiting for a pain-free tendon before loading it means waiting forever.

How we approach it

Confirm what it is. Exam plus ultrasound. Posterior heel pain has mimics — plantar fasciitis referring up, the bursa alone, a stress reaction of the calcaneus, and in older patients a partial tear that changes the aggressiveness of loading. And a sudden pop with immediate weakness is a rupture, which is a different conversation entirely and an urgent one.

Progressive loading, matched to the location. For midportion disease: heavy, slow calf work — loaded heel raises progressing in weight, done consistently for twelve or more weeks. For insertional disease: the same idea, but loading only to floor level, no stretching into dorsiflexion, and often a temporary heel lift to calm the insertion while it adapts. The details are the difference between a program that works and one that flares.

Look upstream. Calf strength asymmetry, a stiff ankle, a hip that doesn't extend, running mechanics that overload the calf — these determine how much stress the tendon absorbs on every stride. Osteopathic treatment addresses the restrictions; motion analysis quantifies the asymmetries and tracks whether they're actually changing.

Shockwave therapy for tendons that have plateaued. The evidence for extracorporeal shockwave in Achilles tendinopathy — particularly insertional — is respectable, and it pairs naturally with the loading program: shockwave provokes a healing response, loading organizes it.

PRP selectively. The trial evidence for PRP in midportion Achilles tendinopathy is honestly mixed — less favorable than in tennis elbow. We reserve it for carefully selected chronic cases, with a frank conversation about the odds, and we say so plainly rather than selling it.

What to avoid: cortisone injection into or around the Achilles. Steroid weakens tendon, and this is one of the tendons in the body that can rupture as a consequence. The convenience is not worth the risk, and we don't do it.

What you can do right now

Put a small heel lift in both shoes — it reduces load on the tendon with every step while you set up the real plan. Keep walking and keep training at whatever level leaves the tendon no worse the next morning.

Start isometric holds: a heel raise held partway up, 30 to 45 seconds, several times, most days. Then begin slow heel raises — both legs up, one leg down — adding load as tolerated. If the pain is at the bone rather than above it, work only from floor level up.

Skip aggressive calf stretching, especially for insertional pain. Compression against the heel bone is part of the problem, and stretching adds compression.

When to come in

Come in if morning stiffness and heel pain have persisted more than a few weeks, if the tendon is visibly thickened, if pain is forcing changes to training, or if a previous round of "rest and stretch" failed — that failure is usually the program's fault, not yours. Come in urgently if you felt a sudden snap in the calf with immediate weakness pushing off: that needs same-week evaluation to sort rupture from everything else, and ultrasound answers it in minutes.