Achilles Tendinopathy
Pain and stiffness in the big tendon at the back of the heel, worst first thing in the morning. An overloaded tendon, not an inflamed one. The fix is gradual calf strengthening, and patience.
Typical signs: pain and stiffness at the back of the heel or a few centimetres above it, worst on waking or when you start moving after rest. It often warms up during exercise, then bites back later. The tendon may look thickened and feel tender to squeeze.
Why it happens: the tendon gets more load than it can adapt to: a sudden jump in running, hills or sport, tight or weak calves, extra body weight, or getting older. Some antibiotics (such as ciprofloxacin) can weaken tendons.
Diagnosis: usually from your story and an examination, often including a hop or tiptoe test. Scans are rarely needed unless a tear is suspected or it isn’t improving.
The Achilles ladder
Exercise is the treatment, not the warm-up act. Expect 3 months to feel real change and 6–9 months to get fully back to sport.
- Step 1 · Self-careChange your load, don’t stop movingCut back on running, hills, jumping and speed work. Keep fit with cycling or swimming. Keep pain during activity to a mild level (about 3–5 out of 10) that settles by the next morning.
- Works
- Carrying on with sport within a pain limit did no harm compared with resting in a Swedish trial
- Cost
- Free
- How long
- Weeks to months, alongside exercises
- Watch for
- Pain that’s worse each morning is the tendon saying you overdid it yesterday.
Complete rest weakens the tendon. Sulking on the couch is not rehab.
- Step 2 · Self-careCalf-strengthening programHeel raises that build up from two legs to one leg, then add weight and speed. Either daily slow-lowering (“eccentric”) heel drops or heavy, slow heel raises 3 times a week.
- Works
- About 6 in 10 were recovered or much improved at 4 months with a calf-loading program, vs about 2.5 in 10 with wait-and-see. Heavy slow raises worked as well as daily drops, and people stuck with them better
- Cost
- Free (a step and a backpack)
- How long
- 12 weeks to judge; keep a maintenance version going for 3–6 months
- Watch for
- Some discomfort is fine; sharp or rising pain the next day means back off a level.
The tendon only reads what you do, not what you meant to do.
- Step 3 · PharmacyHeel lift, footwear and simple pain reliefA small heel raise or cushioned shoes with a bit of heel height; paracetamol or a short course of anti-inflammatories for flare-ups.
- Works
- Little trial evidence; may make walking comfier while the exercises do the work
- Cost
- About $10–40
- How long
- Short term
- Watch for
- Anti-inflammatory tablets: stomach, kidney and blood pressure cautions.
Painkillers are for comfort, not for running 10 km on it.
- Step 4 · Allied healthPhysio or podiatristTo stage your program, add weight safely and plan a return to running or sport.
- Works
- Supervision helps people progress the load properly; the exercises are what work
- Cost
- About $90–130 a session; Medicare rebates with a GP care plan
- How long
- Usually 6–12 weeks of visits, mostly home exercise
- Watch for
- Massage, needling or machines instead of exercise: nice, but not the main course.
Your physio is a coach. You still have to do the reps.
- Step 5 · Allied healthShockwave therapyPulses of sound energy to the tendon, for pain lasting months despite good exercise.
- Works
- About 5 in 10 were recovered or much improved at 4 months vs 2.5 in 10 with wait-and-see in one trial; best added to exercise, not instead of it
- Cost
- About $60–120 a session, usually 3–5 sessions
- How long
- A few weeks
- Watch for
- Uncomfortable during treatment; bruising.
Noisy add-on, not a substitute for heel raises.
- Step 6 · SpecialistSports physician or surgeonFor pain lasting 6 months or more despite a well-done program, or if a tear is suspected.
- Works
- Surgery is rarely needed; evidence for it comes mostly from small, uncontrolled studies
- Cost
- Specialist fees vary; Medicare rebates with a GP referral
- How long
- Months of rehab after any procedure
- Watch for
- A sudden “kick” or snap in the heel is a different problem: see a doctor the same day.
Nearly everyone gets better without the scalpel.
Save your money
Popular, heavily marketed or often asked about, but the evidence is weak or says no.
- PRP (platelet-rich plasma) injectionsNo better than a fake (sham) injection in a 240-person UK trial, plus more pain and bruising. Pricey disappointment.
- Steroid (cortisone) injectionsLittle evidence of lasting benefit, and doctors worry they can weaken the tendon. Most tendon experts steer clear.
- Routine scansUltrasound or MRI rarely changes treatment for typical Achilles pain. The tendon’s photo doesn’t predict how you’ll do.
- Stretching aloneCalf stretches feel nice, but strengthening is what changes the tendon.
- Total rest in a bootUnless a doctor suspects a tear, immobilising a sore tendon makes it weaker, not better.
What you can do
- Follow our Achilles exercise handout: a staged heel-raise program with sets, reps and pain rules.
- Use the morning test: if pain and stiffness are worse the next morning, drop back a level. If not, carry on.
- Change one training thing at a time. Big jumps in distance, hills, speed or new flat shoes are classic triggers.
- Build back running gradually over weeks, on flat ground first.
- If you’re above a healthy weight, losing some reduces load on every step.
- Tell any doctor prescribing antibiotics that you have Achilles problems.
See your GP if
- No improvement after 12 weeks of a proper exercise program
- Pain at rest or at night, or both heels and other joints are sore
- Pain started while taking an antibiotic such as ciprofloxacin
- You’re limping or can’t do your job
See a doctor the same day if you felt a snap, a pop or a “kick” at the back of the heel, can’t stand on tiptoe, or your calf is suddenly swollen, red, warm or tender. These can mean a torn tendon or a clot.
Common questions
How long does Achilles tendinopathy take to get better?
Usually months. Most people need 3 months of exercise to feel a clear change and 6 to 9 months to get fully back to sport without pain. Flare-ups along the way are normal.
Can I keep running with Achilles pain?
Often yes, if pain stays mild during the run (about 3 to 5 out of 10) and is no worse the next morning. If it is, cut back, swap some runs for cycling and keep up the calf exercises.
Will the tendon rupture?
Rupture is uncommon in tendinopathy. Doing the strengthening program makes the tendon stronger. A sudden snap or being unable to push off needs a same-day check.
Do I need a scan?
Usually not. Scans rarely change the treatment for typical Achilles pain. They’re useful if a tear is suspected or it isn’t improving.
Helpful resources
- Achilles exercise handoutPrintable staged calf-loading program with sets, reps and pain rules. Free, from us.
- Guy’s and St Thomas’ NHS: Achilles tendinopathyClear patient guide with early and later-stage exercises. Free, UK.
- Find a podiatristSearch for a podiatrist near your postcode, from the Australian Podiatry Association. Australia.
Evidence and more information
- Healthdirect: Achilles tendon injuries
- Guy’s and St Thomas’ NHS: Achilles tendinopathy
- Rompe et al, AJSM 2007: eccentric loading, shockwave or wait and see
- Beyer et al, AJSM 2015: heavy slow resistance vs eccentric training
- Silbernagel et al, AJSM 2007: continued sports activity using a pain-monitoring model
- Kearney et al, JAMA 2021: PRP vs sham injection (ATM trial)
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