Achilles Tendonitis

Written by Tele Demetrious, Physiotherapist, BPhysio(Hons)
Reviewed by Brett Harrop, APA Sports Physiotherapist, BPhysio(Hons), MPhysio(Sports Physio)

Injuries > Achilles & Heel > Achilles Tendonitis

(Also known as Achilles Tendinitis, Achilles Tendinopathy, Achilles Tendinosis)

N.B. Although recent research suggests that ‘Achilles tendinopathy’ is the more appropriate term to describe overuse injuries to the Achilles tendon, we will use the term ‘Achilles tendonitis’ in this document as it is more widely known.

What is Achilles tendonitis?

Achilles tendonitis is a relatively common condition characterized by tissue damage and pain in the Achilles tendon.

The muscle group at the back of the lower leg is commonly called the calf. The calf comprises of 2 major muscles, one of which originates from above the knee joint (gastrocnemius), the other of which originates from below the knee joint (soleus). Both of these muscles insert into the heel bone via the Achilles tendon (figure 1).

Achilles Tendonitis Anatomy

Figure 1 – Relevant Anatomy for Achilles Tendonitis

During contraction of the calf, tension is placed through the Achilles tendon. When this tension is excessive due to too much repetition or high force, damage to the tendon occurs. Achilles tendonitis is a condition whereby there is damage to the tendon with subsequent degeneration and inflammation. This may occur traumatically due to a high force going through the tendon beyond what it can withstand or, more commonly, due to gradual wear and tear associated with overuse.

Causes of Achilles tendonitis

Achilles tendonitis most commonly occurs due to repetitive or prolonged activities placing strain on the Achilles tendon. This typically occurs due to excessive walking, running or jumping activities. Occasionally, it may occur suddenly due to a high force going through the Achilles tendon beyond what it can withstand. This may be due to a sudden acceleration or forceful jump. The condition may also occur following a calf or Achilles tear, following a poorly rehabilitated sprained ankle or in patients with poor foot biomechanics or inappropriate footwear. In athletes, this condition is commonly seen in running sports such as marathon, triathlon, football and athletics.

Signs and symptoms of Achilles tendonitis

Patients with this condition typically experience pain in the region of the heel and back of the ankle. In less severe cases, patients may only experience an ache or stiffness in the Achilles region that increases with rest (typically at night or first thing in the morning) following activities which place stress on the Achilles tendon. These activities typically include walking or running excessively (especially uphill or on uneven surfaces), jumping, hopping, performing heel raises or performing calf stretches. The pain associated with this condition may also warm up with activity in the initial stages of injury. As the condition progresses, patients may experience symptoms that increase during sport or activity, affecting performance. Pain may also increase when performing a calf stretch or heel raise (i.e. rising up onto tip toes). In severe cases, patients may walk with a limp or be unable to weight bear on the affected leg.

Patients with Achilles tendonitis may also experience swelling, tenderness on firmly touching the Achilles tendon, weakness and sometimes palpable thickening of the affected Achilles tendon when compared with the unaffected side.

Diagnosis of Achilles tendonitis

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose an Achilles injury such as Achilles tendonitis. Occasionally, further investigations such as an Ultrasound, X-ray or MRI scan may be required to assist with diagnosis and assess the severity of the condition.

Prognosis of Achilles tendonitis

Most patients with this condition heal well with appropriate physiotherapy. This, however, can be a lengthy process and may take up to 6 months in those who have had their condition for a long period of time. Early physiotherapy treatment is vital to hasten recovery in all patients with this condition.

Treatment for Achilles tendonitis

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Contributing factors to the development of Achilles tendonitis

There are several factors which can predispose patients to developing this condition. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:

  • joint stiffness (particularly the ankle)
  • muscle tightness (particularly the calfs)
  • inappropriate or excessive training
  • poor biomechanics
  • poor foot posture (i.e. flat feet or high arches)
  • inappropriate footwear
  • inadequate warm up
  • muscle weakness
  • poor proprioception or core stability
  • being overweight

Physiotherapy for Achilles tendonitis

Physiotherapy treatment for patients with an Achilles injury is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of recurrence. Treatment may comprise:

  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • the use of crutches
  • the use of heel wedges
  • the use of a protective boot or night splint
  • stretches
  • joint mobilization
  • ice or heat treatment
  • exercises to improve strength, flexibility, core stability and balance
  • education
  • anti-inflammatory advice
  • activity modification advice
  • hydrotherapy
  • biomechanical correction (e.g. the use of orthotics)
  • footwear advice
  • a gradual return to activity program
  • a gradual return to running program

Other intervention

Despite appropriate physiotherapy management, some patients with this condition do not improve. When this occurs the treating physiotherapist or doctor will advise on the best course of management. This may include pharmaceutical intervention, corticosteroid injection, autologous blood injection or referral to appropriate medical authorities who will advise on any interventions that may be appropriate to improve the condition. A review with a podiatrist for possible orthotics may also be indicated.

Exercises for Achilles tendonitis

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 2 – 3 times daily and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate and advanced exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.

Initial Exercises

Calf Stretch with Towel

Begin this stretch in long sitting with your leg to be stretched in front of you. Your knee and back should be straight and a towel or rigid band placed around your foot as demonstrated (figure 2). Using your foot, ankle and the towel, bring your toes towards your head until you feel a stretch in the back of your calf, Achilles tendon or leg. Hold for 5 seconds and repeat 10 times at a mild to moderate stretch provided the exercise is pain free.

Calf Stretch with Towel for Achilles Tendonitis

Figure 2 – Calf Stretch with Towel

Resistance Band Calf Strengthening

Begin this exercise with a resistance band around your foot as demonstrated and your foot and ankle held up towards your head (figure 3). Slowly move your foot and ankle down against the resistance band as far as possible and comfortable without pain, tightening your calf muscle. Very slowly return back to the starting position. Repeat 10 – 20 times provided the exercise is pain free.

Resistance Band Calf Strengthening for Achilles Tendonitis

Figure 3 – Resistance Band Calf Strengthening (left calf)

Intermediate Exercises

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Advanced Exercises

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Other Exercises

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Rehabilitation Protocol for Achilles Tendonitis

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Physiotherapy Products for Achilles Tendonitis

Physiotherapy products for Achilles tendonitis

Some of the most commonly recommended products by physiotherapist for patients with this condition include:

  1. Wobbleboards (to improve proprioception and balance)
  2. Massage Balls & Foam Rollers (for self massage)
  3. Night Splint

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