Achilles pain
Tendinopathy

Achilles Tendinopathy
(pain behind ankle above the heel bone)

Who gets it?

Common in runners and active people, especially after suddenly increasing running, hills, jumping or sport. It also occurs in middle-aged and less-active people, particularly when tendon capacity has reduced.
It is particularly common in middle-aged adults, roughly 30–55 years, although the exact peak varies between athletic and non-athletic populations. 

What does it feel like?

Pain and stiffness at the back of the ankle/heel. Often worse with the first steps in the morning, after sitting/resting, running, jumping, stairs or calf raises. It may initially improve as the person warms up and return afterwards.

Where is the pain?

Midportion: usually 2–6 cm above the heel.
Insertional: directly where the Achilles attaches to the heel bone.

What might look similar?

Achilles rupture/partial tear, retrocalcaneal bursitis, heel-bone/Haglund irritation, calf injury, referred pain from the lumbar spine or nerve, and less commonly inflammatory conditions.

What should we check?

Location of tenderness, swelling/thickening, calf strength, single-leg heel raise, walking/running load and recent changes in activity. A sudden snap/pop with weakness or inability to push off requires assessment for Achilles rupture.

Best recommendation?

Do not completely rest the tendon. Reduce the aggravating load temporarily and then progressively strengthen it.

Main treatment

Progressive calf/Achilles loading is the key evidence-based treatment. Start at a tolerable level → calf raises → heavier/slower strengthening → faster/elastic loading → gradual return to running/sport.

Eccentric exercise?

Useful, but not the only option. Heavy slow resistance and combined concentric/eccentric calf exercises can also work.

How long?

Improvement takes time. A structured programme is usually continued for at least 12 weeks, with gradual progression according to symptoms and function.

A very simple message for patients is:

Pain → Reduce excessive load → Build calf/Achilles strength → Gradually increase load → Return to running/activity

The important concept is load versus capacity: the Achilles becomes painful when the demand being placed on the tendon is greater than what it can currently tolerate. Treatment therefore aims to build its capacity again, rather than simply trying to eliminate pain with passive treatments.

One important distinction: with insertional Achilles pain, deep heel-drop exercises below the level of the step can increase compression at the tendon insertion, so loading often starts on a flat surface with limited dorsiflexion.