Achilles tendinopathy is one of the most common and challenging overuse injuries, affecting athletes and non-athletes alike. Understanding the nature of this condition and following evidence-based treatment can lead to successful recovery. At M.O. Therapy in Markham, we help patients overcome Achilles tendinopathy through comprehensive rehabilitation.
Understanding Achilles Tendinopathy
Anatomy of the Achilles Tendon
The Achilles tendon is the largest and strongest tendon in the body:
- Connects calf muscles (gastrocnemius and soleus) to heel bone
- Transmits forces of 4-8 times body weight during running
- Lacks a true tendon sheath
- Has relatively poor blood supply (especially 2-6 cm above insertion)
Tendinitis vs Tendinopathy
Tendinitis:
- Implies active inflammation
- Acute phase terminology
- May respond to anti-inflammatory measures
Tendinopathy:
- More accurate term for chronic conditions
- Degenerative changes predominate
- Collagen disorganization
- Failed healing response
- Different treatment approach needed
Types of Achilles Tendinopathy
Midportion (Non-Insertional):
- Located 2-6 cm above heel
- Most common type (55-65%)
- Area of poorest blood supply
- Often has nodular thickening
- Generally responds well to loading programs
Insertional:
- At attachment to heel bone
- Associated with bony changes
- May involve retrocalcaneal bursa
- More challenging to treat
- Compression component involved
Causes and Risk Factors
Training Factors
Overload:
- Rapid increase in activity
- Too much too soon
- Inadequate recovery
- Hill training and speed work
Common Patterns:
- Increasing mileage too quickly
- Adding hill running
- Returning from time off too fast
- Year-round training without breaks
Biomechanical Factors
Lower Limb:
- Decreased ankle dorsiflexion
- Overpronation
- Leg length discrepancy
- Forefoot varus
Calf Weakness:
- Insufficient calf strength
- Weakness relative to load demands
- Asymmetry between legs
- Poor endurance
Individual Factors
Non-Modifiable:
- Age (risk increases with age)
- Male sex (higher incidence)
- Previous Achilles injury
- Genetic factors
Modifiable:
- Obesity
- Diabetes
- High cholesterol
- Certain medications (fluoroquinolone antibiotics, statins)
- Smoking
Environmental Factors
- Hard training surfaces
- Inappropriate footwear
- Cold weather training
- Inadequate warm-up
Symptoms and Diagnosis
Symptom Progression
Early Stage:
- Morning stiffness in Achilles
- Pain at start of activity
- Improves with warming up
- Minimal pain during activity
Moderate Stage:
- Pain during activity
- Pain may limit activity
- Stiffness persists longer
- Tenderness to touch
Severe Stage:
- Pain with daily activities
- Difficulty walking
- Night pain
- Visible swelling or nodule
Physical Examination
Inspection:
- Swelling (fusiform thickening)
- Nodular changes
- Redness (acute cases)
- Asymmetry compared to other side
Palpation:
- Tenderness location (midportion vs insertional)
- Crepitus (sometimes present)
- Nodules or thickening
- Pain reproduction
Functional Tests:
- Single-leg heel raises (strength and endurance)
- Hop test
- Squat test
- Running assessment
Imaging
Ultrasound:
- First-line imaging
- Shows tendon thickening
- Identifies tears
- Assesses neovascularization
- Can be done dynamically
MRI:
- Detailed tissue visualization
- Shows extent of degeneration
- Identifies partial tears
- Helpful for surgical planning
X-Ray:
- Shows bony changes (insertional)
- Calcifications
- Heel spur
- Rules out other pathology
Treatment Approaches
Load Management
Relative Rest:
- Modify activity, don't stop completely
- Reduce loading to tolerable level
- Maintain some tendon loading
- Avoid complete rest (leads to further weakness)
Activity Modification:
- Reduce running volume and intensity
- Avoid hills and speed work initially
- Cross-train with low-impact activities
- Gradually reintroduce load
Exercise-Based Treatment
Exercise therapy is the cornerstone of Achilles tendinopathy treatment.
Heavy Slow Resistance (HSR):
- Slow concentric and eccentric contractions
- 3 seconds up, 3 seconds down
- Heavy load (6-15 RM)
- 3 sets, 3 times per week
- 12-week program
Eccentric Exercise Protocol:
- Traditional Alfredson protocol
- Eccentric loading only
- 3 sets of 15, twice daily
- Both straight knee and bent knee
- Progress load with backpack or weighted vest
Isometric Exercise:
- Useful for pain management
- 45-second holds
- Heavy load (70% max)
- Can reduce pain for 45+ minutes
- Use before activity
Manual Therapy
Soft Tissue Mobilization:
- Calf muscle release
- Address trigger points
- Improve muscle flexibility
- Reduce compensatory tension
Joint Mobilization:
- Ankle joint mobility
- Subtalar joint mobility
- May improve dorsiflexion
Dry Needling:
- Trigger points in calf
- May stimulate healing response
- Reduces muscle tension
Addressing Contributing Factors
Footwear:
- Assess current shoes
- Heel lift may help temporarily
- Appropriate cushioning
- Replace worn shoes
Ankle Mobility:
- Improve dorsiflexion if limited
- Stretching program
- Joint mobilization
- May reduce tendon stress
Calf Strength:
- Build strength systematically
- Address asymmetries
- Include both gastrocnemius and soleus
- Progress to high-load activities
Other Treatments
Shockwave Therapy:
- May help chronic cases
- Stimulates healing response
- Often used when exercises alone insufficient
Injection Therapies:
- PRP (platelet-rich plasma) - emerging evidence
- Avoid corticosteroids (risk of rupture)
- High-volume injection (specialist procedure)
Nitroglycerin Patches:
- Some evidence for benefit
- Promotes collagen synthesis
- Used adjunctively
Exercise Program
Phase 1: Isometrics and Pain Management
Single-Leg Isometric Heel Raise:
- Hold at top of heel raise
- 45 seconds, heavy load
- 4-5 repetitions
- 2-3 times daily
Goals:
- Reduce pain
- Maintain muscle activation
- Build tolerance to loading
Phase 2: Heavy Slow Resistance
Seated Calf Raise:
- Slow 3 seconds up, 3 seconds down
- Start with 15 RM
- Progress to 6-8 RM
- 3 sets, 3 times per week
Standing Calf Raise:
- Same tempo
- Progress load with weights or machine
- Include single-leg when ready
- 3 sets, 3 times per week
Phase 3: Energy Storage Loading
Hopping Progression:
- Start with small bilateral hops
- Progress to single-leg hops
- Increase height and distance
- Jump rope progression
Running Progression:
- Walk-run intervals
- Gradual increase in running
- Add hills when ready
- Progress speed work last
Recovery Timeline
Typical Timeline
Weeks 1-4:
- Pain management focus
- Isometric exercises
- Begin heavy slow resistance
- Activity modification
Weeks 4-12:
- Progressive loading
- Strength building
- Gradual activity increase
- Address contributing factors
Months 3-6:
- Return to sport activities
- Energy storage exercises
- Full strength restoration
- Prevention strategies
Important Notes:
- Recovery typically takes 3-6 months
- Some cases take longer (12+ months)
- Patience and consistency are key
- Rushing return often leads to relapse
Factors Affecting Recovery
Positive Factors:
- Shorter symptom duration
- Compliance with exercises
- Addressing contributing factors
- Patience with progression
Negative Factors:
- Long symptom duration before treatment
- Insertional type
- Previous episodes
- Systemic factors (diabetes, etc.)
Prevention Strategies
Training Principles
- Follow 10% rule for increasing load
- Include rest days
- Periodize training
- Listen to early warning signs
Strength Maintenance
- Regular calf strengthening
- Include heavy loading
- Single-leg exercises
- Address any asymmetry
Flexibility
- Maintain ankle dorsiflexion
- Regular calf stretching
- Address calf tightness early
Frequently Asked Questions
How long does Achilles tendinopathy take to heal? Most cases improve significantly within 3-6 months of consistent treatment. However, some chronic cases may take 12 months or longer. Early treatment and compliance with exercise programs lead to better outcomes.
Should I stretch my Achilles tendon? Gentle stretching may be beneficial, but heavy stretching can aggravate the condition. Focus on strengthening rather than aggressive stretching, especially for insertional tendinopathy.
Can I run with Achilles tendinopathy? It depends on severity. Mild cases may allow modified running, while more severe cases require rest from running. Pain should not exceed 3-4/10 during or after activity, and symptoms should settle within 24 hours.
Will my Achilles tendinopathy come back? Recurrence is possible, especially if contributing factors aren't addressed. Maintaining calf strength, following training principles, and addressing early warning signs can reduce recurrence risk.
Book Your Assessment
If you're dealing with Achilles pain, M.O. Therapy in Markham can help. Our team will assess your condition and develop a comprehensive treatment plan for recovery.
Call (905) 201-5827 or book online for your assessment. We offer direct billing and same-day appointments.