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• The Achilles is the tendon found at the bottom of the calf and joins the calf muscles (Gastrocnemius and Soleus) to the heel bone. The Achilles tendon has to tolerate the highest loads in the body – up to 10 times your body weight during running and jumping.
• Achilles heel pain is now called Achilles tendinopathy. There are cellular changes to the tendon and to the arrangement of collagen fibres, as well as its supporting system, the matrix. With Achilles tendinopathy the tendon does not become weak, but it does make it difficult for the Achilles to tolerate loads. Correcting this that is at the heart of treatment.

You can get Achilles tendinopathy through a specific injury or by overuse. The tendon can deteriorate gradually over a period of time

What are the symptoms?

• Classic features of Achilles tendinopathy are the gradual onset of morning stiffness, which may resolve within 5-10 minutes, and stiffness when walking after sitting for long periods. The morning stiffness is often worse on days after a run.
• You may also notice some swelling.
• Your Achilles tendon might feel tender when you touch it. There may be a grating noise or creaking feeling (crepitus) when you move your ankle.
• Sudden pain in your heel or calf, which quickly becomes swollen, bruised and sore, can mean you’ve torn the tendon. You may actually hear it snap. This is called an Achilles tendon rupture. You should get urgent medical attention if this happens.
• The pain/stiffness will typically “warm-up” during the first 5-10 minutes of a run. This often means people don’t seek help as they can initially run through the pain. But the earlier you seek help, the more likely you will be able to get away with adjusting your load rather than stopping running altogether.

 
What causes Achilles Tendinopathy?
 
There are certain risk factors that may lead some people to developing Achilles tendinopathy, many of which relate to changes in load through the tendon rather than to a person’s biomechanics.

• More men are affected than women
• It is more common in your 30s or 40s.
• Some individuals also have a genetic predisposition to developing tendon pain.
• Other risk factors can include changes to your exercise regime.

 
There are three questions that should be considered:

• What – Have I changed in my training/exercise in some way e.g. more hilly terrain for running/cycling, increased distance/speed?
• Where – Have I changed where I train e.g. cross country to road running?
• With – Have I changed what I train with e.g new footwear, altered bike set up etc?

How to treat it

• Diagnosis can occur at different points: the onset of pain may be quite sudden and a reaction to overload – referred to as a reactive tendinopathy and may be severely painful. Or it might be more chronic (longstanding as opposed to severe) – referred to as tendon disarray or degeneration. The treatment will therefore depend on the individual, but ultimately it involves improving the tendons tolerance to load.

 
Physiotherapy principles
 
The key areas that physiotherapy focuses on are as follows:

• Improving how well the tendon tolerates load
• Biomechanical correction read here about orthotics/insoles
• Manual therapy (Soft tissue and joint mobilisation to relax tight areas within the calf muscles and reduce any stiffness in surrounding joints)
• Strength training and correcting training errors

There may be a need to cut running initially, but the general consensus is that off-loading the tendon for too long is unhelpful. So the ideal is to calculate the amount of running that can be done without affecting the symptoms – which are mostly latent. So morning stiffness following a training day can be a good indication of how the tendon is coping with load.
There is good evidence that slow, heavy load-strength training can improve a tendon’s tolerance to load and this is one of the gold standards for treatment. It is important, though, to avoid overload through other aspects of training while strength training, otherwise it may fail.
 
While there may also be specific biomechanical factors feeding into the tendinopathy.
Your Physiotherapist will consider the whole chain when assessing, including looking at the hips and knees any spinal involvement.
 
More common than biomechanical problems are training errors. Most people we see present with Achilles tendon problems when they have radically changed their training load. All the evidence points towards load management as the best way to treat Achilles tendinopathy. And it is important to give it time before considering other options – we suggest three to six months.

Try this diagonal movement pulley exercise for shoulder stability and core strength.
Our team are always happy to help if our exercise tips don't resolve your issues!