Achilles Tendonitis

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

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

Most patients with this condition heal well with appropriate physiotherapy. The success rate of treatment is largely dictated by patient compliance. One of the key components of treatment is that the patient rests from any activity that increases their pain until they are symptom free (the use of crutches, Achilles tendon taping and / or heel wedges are often required). Activities which place large amounts of stress on the Achilles tendon should also be minimised, particularly walking or running excessively (especially up hills or on uneven surfaces), jumping, hopping and performing excessive calf stretches or heel raises. Rest from aggravating activities allows the body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.

Ignoring symptoms or adopting a ‘no pain, no gain’ attitude is likely to lead to the problem becoming chronic. Immediate, appropriate treatment in patients with Achilles tendonitis is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence.

Patients with this condition should follow the R.I.C.E. Regime in the initial phase or injury or following injury aggravation. The R.I.C.E. regime is beneficial in the first 72 hours following injury or when inflammatory signs are present (i.e. morning pain or pain with rest). The R.I.C.E. regime involves resting from aggravating activities (the use of crutches, Achilles tendon taping or heel wedges may be required), regular icing, the use of a compression bandage and keeping the affected leg elevated (above the level of the heart). Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.

Manual “hands-on” therapy from the physiotherapist such as massage, trigger point releases, joint mobilisation, dry needling, stretches and electrotherapy can hasten healing and assist with improving flexibility, pain and function. This can generally commence once the physiotherapist has indicated it is safe to do so.

Patients should also undergo a graduated flexibility and eccentric strengthening program (particularly of the calf muscles) to ensure an optimal outcome. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they can commence. Careful assessment by the physiotherapist to determine which factors have contributed to the development of the condition with subsequent correction of these factors is also important to ensure an optimal outcome.

In the final stages of rehabilitation, a gradual return to running program is required for those patients who wish to return to running or running sports. This is essential to recondition the Achilles tendon to running in a safe and effective manner and should include the implementation of progressive acceleration and deceleration running drills before returning to sport.


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

Calf Stretch

With your hands against the wall, place your leg to be stretched behind you as demonstrated (figure 4). Keep your heel down, knee straight and feet pointing forwards. Gently lunge forwards until you feel a stretch in the back of your calf / knee. Hold for 15 seconds and repeat 4 times at a mild to moderate stretch pain free.

Calf Stretch

Figure 4 – Calf Stretch (left leg)

Heel Raises

Begin this exercise standing at a bench or chair for balance (figure 5). Keep your feet shoulder width apart and facing forwards. Slowly move up onto your toes, raising your heels as far as possible and comfortable without pain, then very slowly lower your heels back to the starting position. Repeat 10 – 20 times provided the exercise is pain free. Once you can perform 20 repetitions of this exercise consistently without pain progress to performing the exercise over a step (figure 6). Begin with only a few repetitions over the step initially and then build up to 20 repetitions gradually over a number of days provided there is no increase in pain.

Heel Raises

Figure 5 – Heel Raises

Heel Raises Over Step

Figure 6 – Heel Raises Over Step


Advanced Exercises

Calf Stretch (Soleus)

Begin this stretch with your hands against the wall and your leg to be stretched in front of you as demonstrated (figure 7). Keep your heel down. Gently move your knee forward over your toes until you feel a stretch in the back of your calf or Achilles tendon (figure 7). Hold for 15 seconds and repeat 4 times at a mild to moderate stretch pain free.

Calf Stretch (Soleus)

Figure 7 – Calf Stretch (Soleus) (right leg)

Calf Stretch over Step (Gastrocnemius)

Begin this stretch standing with your heels over the edge of a step and holding onto a rail for balance as demonstrated (figure 8). Keeping your knees straight slowly let your heels drop down below the step until you feel a stretch in the back of your calf, Achilles tendon or knee (figure 8). Hold for 15 seconds and repeat 4 times at a mild to moderate stretch pain free. This exercise can be progressed by placing more weight through the leg to be stretched provided it is pain free and eventually progressing to one leg (figure 9).

Calf Stretch Over Step (Gastrocnemius)

Figure 8 – Calf Stretch Over Step (Gastrocnemius)

Single Leg Calf Stretch Over Step

Figure 9 – Single Leg Calf Stretch Over Step (right leg)

Single Leg Heel Raises

Begin this exercise standing on one leg at a bench or chair for balance (figure 10). Keeping your foot facing forwards, slowly move up onto your toes, raising your heel as far as possible and comfortable without pain. Then very slowly lower back down. Repeat 10 – 20 times provided the exercise is pain free. Once you can perform 20 repetitions of this exercise consistently without pain progress to performing the exercise over a step (figure 11). Begin with only a few repetitions over the step initially and then build up to 30 repetitions gradually over a number of days provided there is no increase in pain.

Single Leg Heel Raises

Figure 10 – Single Leg Heel Raise (right leg)

Single Leg Heel Raises Over Step

Figure 11 – Single Leg Heel Raises Over Step (left leg)


Other Exercises

Foam Roller Calf Releases

Place the foam roller under your calves as demonstrated (figure 12). Using your arms, slowly move your body forward and backwards allowing the foam roller to massage the back of your lower legs. Breathe normally keeping your legs relaxed. Repeat this process for 15 – 90 seconds provided it is comfortable and does not cause pain. This exercise can be progressed by crossing your legs and massaging one calf at a time (figure 13).

Foam Roller Calf Release

Figure 12 – Foam Roller Calf Release

Foam Roller Calf Release (Legs Crossed)

Figure 13 – Foam Roller Calf Release (Legs Crossed)

Massage Ball Calf Release

Place the massage ball under your calf as demonstrated (figure 14). Using your arms and opposite leg, slowly move the spikey ball forwards, backwards and side to side allowing the spikey ball to massage the back of your lower leg. Breathe normally keeping your calf relaxed. Repeat this process for 15 – 90 seconds provided it is comfortable and does not cause pain. You can also apply sustained pressure to a particular tight spot for periods of 15 – 60 seconds or until the soft tissue relaxes.This exercise can be progressed by crossing your legs and placing more pressure through the chosen calf (figure 15).

Massage Ball Calf Release

Figure 14 – Massage Ball Calf Release

Massage Ball Calf Release (Legs Crossed)

Figure 15 – Massage Ball Calf Release (Legs Crossed)


Rehabilitation Protocol for Achilles Tendonitis

The following is a general rehabilitation protocol for patients with Achilles tendonitis. This needs to be tailored to each individual and should be discussed with your treating physiotherapist prior to commencing. Progression through this program can vary from weeks to many months depending on injury severity and quality of treatment:

  • See your physiotherapist as soon as possible to confirm diagnosis, establish the likely prognosis, identify the contributing factors to injury and begin appropriate treatment.
  • Follow the R.I.C.E. Regime for the first 48 – 72 hours. This should primarily comprise:
    • Rest from any activity that increases pain (if walking is painful or causing a limp, the use of crutches, Achilles tendon taping or heel wedges are usually required)
    • Ice the sore area for 20 minutes and repeat every 2 hours
    • Elevate the affected leg above the level of your heart whenever possible
    • Anti-inflammatory medication may be beneficial (discuss this with your doctor and/or pharmacist)
  • If using crutches, walk normally, but take enough weight off the injured leg so walking is pain free and limp free. Sometimes smaller steps may be required for a period of time. Gradually increase weight through the injured side as tolerated provided there is no increase in pain or limp.
  • If using heel wedges or Achilles tendon taping, gradually reduce the period of time you are using these during weight bearing activity provided there is no increase in pain or limp.
  • Aim for pain free rehabilitation (i.e. gradually increase strength, flexibility and activity, provided there is no increase in symptoms during activity or upon rest following activity. This should take place over a number of weeks).
  • Begin “Initial Exercises” 72 hours following injury provided there is no increase in symptoms.
  • Heat treatment can usually commence 72 hours following injury provided there is no inflammation (i.e. night-time pain, morning ache/stiffness or pain at rest). Apply a heat pack to the injured area at a comfortable warmth for 20 – 30 minutes before exercises. If inflammation is still present (i.e.night-time pain, morning ache / stiffness or pain at rest) continue to use ice instead of heat.
  • Increase walking distance, and eventually speed, gradually, and, provided there is no increase in pain or limp (this should take place over a number of weeks).
  • Progress to the “Intermediate Exercises” once the “Initial Exercises” can be performed pain free and to the same extent on the injured side as the non-injured side. Ensure all new exercises do not increase symptoms. The ‘Intermediate Exercises’ should replace the ‘Initial Exercises’.
  • ‘Other Exercises’ may be added provided they do not cause or increase pain.
  • Progress to the “Advanced Exercises” once the “Intermediate Exercises” can be performed pain free and to the same extent on the injured side as the non-injured side. Ensure all new exercises do not increase symptoms. The ‘Advanced Exercises’ should replace the ‘Intermediate Exercises’.
  • Assessment with a podiatrist may be required for possible orthotics or footwear advice, particularly in patients with flat feet or high arches.
  • A gradual Return to Running Program should be implemented for individuals who aim to return to running following injury provided there is no increase in symptoms.
  • A gradual return to sport and activity can occur provided there is no increase in symptoms.
  • Ensure your physiotherapist has identified the contributing factors to your injury and appropriate intervention has taken place to address these issues to minimize the likelihood of injury recurrence.

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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

To purchase physiotherapy products to assist with rehabilitation of an Achilles injury click on one of the above links or visit the PhysioAdvisor Shop.


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