Achilles Tendinitis? Tendinosis? Tendinopathy?

An in-depth look at Achilles tendinitis, otherwise known as tendinosis or tendinopathy

The Achilles tendon is the thickest and strongest tendon in the human body. That being said, this doesn’t mean you can’t injure it, on the contrary injury to this tendon is quite common. Injury extent can range from mild Achilles ‘tendinitis’ all the way to a ruptured Achilles!


The Achilles Tendon

The Achilles tendon is amazing, Maffulli et al (2004)  found that 1 square centimetre of the Achilles tendon is capable of taking between 500kg to 1000kg! Just look at how much load it takes in running:

Achilles load in running

Achilles tendon Anatomy

When you think of your Achilles you think that it’s right down by your heel and although this is true it actually starts much higher up in the calf at about halfway and it essentially attaches the Gastrocnemius and Soleus muscles to the Calcaneus (heel bone). The proportion of each muscle varies from person to person but it is around 50-50 but can be up to 60% more Gastrocnemius in a small number of people (Doral et al 2010). The average length of the Achilles is 15cm but has been found as short as 11cm and as long as 26cm, obviously, height will play a part in its length. The thinnest part is at the mid-portion and this is also the most commonly injured spot too (Apaydin et al 2009).

Blood supply of the tendon is not great and decreases with age, the worst area is the mid-portion of the tendon, which is supplied but the Peroneal artery and again this could be why this is the most injured part (Chen et al 2009).


Why do you hear so many terms for an Achilles injury?

So what is tendinitis, tendinosis or tendinopathy?


This is a broad term encompassing painful conditions occurring in and around tendons, which includes tendinitis and tendinosis. ‘Opathy’ means pathology of something and so pathology of a tendon.


This basically means inflammation of a tendon as ‘itis’ means inflammation of something.


This means degeneration of tendon as ‘osis’ means degeneration of something.

So which is it then?

You will be most familiar with the term Achilles tendinitis and for a long time, tendinitis was the term that we all used as it was considered that injured tendons were simply inflamed. Then the thinking shifted to the thought that there was little or maybe no inflammation present in these conditions (Andres & Murrell 2008). Rees et al (2013) suggest that although it is predominantly tendinosis there may be an inflammatory response associated with chronic tendinopathy, even though recent opinions had decided it to be non-inflammatory. To add to the debate, D’Addona et al (2017) found that most inflammation in the Achilles happens before the injury phase as a normal repairing process so you can’t really call it tendinitis at this point. When you don’t allow recovery between loading of the tendon then this then causes dis-repair and degeneration of the tendon, which is tendinosis by definition. So it would appear that both tendinitis and tendinosis can be present but not at all points of the process so Achilles tendinopathy would be the more appropriate term to play it safe.

Other causes of symptoms other than inflammation or degeneration?

Even more recently there has been more emphasis placed on other factors in tendon pain, neurovascular (nerves & blood vessel) ingrowths into the tendon (neovascularisation) are thought to play a role in Achilles tendon pain (Alfredson 2007).  There is also a possibility of central sensitisation in tendon pain and it has been suggested there may be an association between persistent tendon pain and sensitisation of the nervous system but this is still emerging evidence (Plinsinga et al 2015). This is important to note as your approach to management will have to differ to typical rehab methods. To gauge whether there may be central sensitisation, Nijs et al (2014) recommend the following criteria:

  • Disproportionate perception of pain or disability to the nature or extent of the injury or pathology.
  • Diffuse wider spread pain, allodynia (pain with a light touch) and hyperalgesia (pain with crude touch).
  • Hypersensitivity of other senses such as bright lights, smells, sounds and temperature.

What types of Achilles injury can you have?

Achilles tendinitis

Mid portion:

This is the most common type, accounting for about 75% of cases of Achilles injury and it affects the area at about 2–6 cm above its insertion on the calcaneus (heel bone).


This is less common and is around 25% of cases affecting the insertion of the Achilles tendon on the posterior calcaneum (heel bone).


This is when the tendon actually tears to varying extents from a partial rupture to a full rupture, which is where the tendon has snapped completely. Luckily 98% of Achilles ruptures occur in a pathological tendon and so healthy tendons don’t just snap in most cases (Cook & Purdam 2009).


How common is Achilles tendinopathy?

150,000 people in the UK every year are known to suffer from Achilles tendinopathy (Kearney et al 2013).

Dancers: 9%

Gymnasts: 5%

Tennis players: 2%

Football players less than 1%

(Wilson et al 2010)

In runners, the incidence ranges from 9.1% to 10.9% according to Lopes et al (2012) but this is not just a problem for active individuals as was found by De Jong et al (2011), where they found that 75% of mid-portion Achilles tendinopathy was in people who didn’t participate in any sport.


How common is an Achilles rupture?

Rupture of the Achilles tendon is getting more common according to Jones et al (2012) and it has an annual incidence of approximately 2 per 10,000 people (Singh 2015). Achilles ruptures occur more in men than women and the common ages are between 30 and 50 years of age, especially in intermittent participation of recreational sport (Khan & Carey Smith 2010).


How do you diagnose an Achilles injury?


Clinical examination with subjective and objective assessment is the easiest way to diagnose your Achilles tendinitis and although diagnostic ultrasound and MRI scans can be accurate they are not practical and expensive. This means that Achilles tendinopathy is usually a clinical diagnosis and imaging is not routinely needed or performed. With tendinopathy and ruptures, pain is usually only in the tendon and nowhere else. For rupture diagnosis, look for an abnormal angle of declination lying on your front with your feet overhanging the bed, as a rupture of the Achilles tendon often has more resting dorsiflexion than the normal side. A gap can sometimes be felt in the tendon but not always due to haematoma in new cases or fibrous tissue in older chronic cases.

Bruising is sometimes seen in acute new cases but obviously not in chronic cases. The common test is the Thompson squeeze test, which is basically squeezing of the calf muscles with the foot overhanging the bed lying face down. A positive test indicating a rupture will find that your foot remains in the neutral position when your calf is squeezed but this is not 100% accurate especially in chronic cases with wasting (Maffulli & Ajis 2008).


Other conditions or problems to consider:

Plantaris tendinopathy — the Plantaris muscle is deep underneath the gastrocnemius muscle, it’s not found in everybody but is present in 7–20% of people. Injury to this can be very similar to Achilles tendinopathy.

Retrocalcaneal bursitis — Inflammation of the retrocalcaneal bursa, which lies between the calcaneum and the Achilles tendon.

Ankle osteoarthritis.

Dislocation of the Peroneal tendons or other plantar flexor tendons.

Posterior ankle impingement — Pain on forced plantar flexion when jumping etc.

Tendon xanthoma — A rare problem that is associated with severe hypercholesterolemia causing fatty deposits and immune cells in the Achilles tendon causing a thickened appearance like Achilles tendinitis.

Haglund’s deformity — a posterolateral (back/ outer side) calcaneal (heel) prominence, which can become inflamed.

Calcaneal apophysitis aka Sever’s disease – Only occurs in children and adolescents and pain in the heel at the growth plate.

Os Trigonum syndrome — a floating bone just behind the ankle joint causing pain on plantar flexion.

Calcaneal stress fracture.

Irritation or neuroma of the sural nerve or sacral root pain from the back.

Systemic inflammatory disease, such as rheumatoid arthritis

(Carcia et al 2010)


What causes Achilles tendinopathy?

This can be split into categories: Things about you that you can control, things about you that you can’t control and things that you do or are exposed to (ONeil et al 2016).


Things about you that you can control:


Due to the fact that Achilles loading is relative to your body weight then the loading demand placed on the tendon will be higher in obese individuals and the secondary correlation of lack of exercise means that tendons will also be weaker due to disuse.


This is a similar argument to obesity, as tendon loading in relative to bodyweight. Remember some people have a more muscle, which weighs a lot and are generally bigger in stature irrespective to body fat so although the tendon may be stronger than in obese groups it still could be overloaded with greater body weight in general.

High Cholesterol and high blood pressure:

These are unknown as true causes in isolation but they are very much linked along with other systemic problems that cause an increased risk such as obesity and type 2 diabetes.


Both type 1 and 2 are linked here, obviously, type 2 is affected by you and so is understandably in the ‘can control’ group and type 1 is genetic so you could easily say that it is not controllable but remember type 1 is still controlled with diet and medication and so it is how well you manage this.


feet and ankle with diagram over the top

So with anything, there will always be debate and biomechanics this is definitely a hotly debated area. That being said the NICE guidelines to include factors such as leg length discrepancy, overpronation, shortened or weak hamstrings, lateral instability of the ankle and high-arched (pes cavus) feet.


Local Achilles and calf strength: Weakness of the Achilles and Calf muscles is a known risk factor for developing Achilles injury. We even saw this in the NBA with Kevin Durant, who ruptured his Achilles after rushing back to playing after a calf strain.

Strength higher up the body: The body works as a unit in synchronicity so any areas of weakness will create excessive loads or abnormal movements elsewhere. For example, it was found that the Gluteus Medius & Maximus had a delay in onset & a shorter duration of activity in Achilles tendinopathy sufferers (Smith et al 2014).


Poor endurance leads to more fatigue and when the muscle is fatigued the contraction strength is not as strong or fast, leading to more load or stretch being passed to the tendon. Exercise can disturb proprioception through fatigue, this has implications for musculoskeletal injuries (Proske & Gandevia 2012). Obviously when you fatigue your movement alters, which will change the way that your tendon is loaded. For example, when running, if your gluteus medius tires then the pelvis will drop on the opposite side, the hip will internally rotate on your weight-bearing leg, causing overpronation in the foot. This alignment in the foot will change the angle of load through the Achilles from an ideal vertical direction to a lateral one. The reason that this is significant is down to the structure of the tendon (The fibres line up vertically and not laterally, so it is very strong in the vertical plane but weak in the lateral one).

Restricted ankle dorsiflexion:


If the calf muscles and the Achilles are too short for the activity at hand then it is easier to potentially overload them and if you don’t warm the tissue up before activity then the tissue is not as pliable making it tighter and more likely to injure.

Interestingly excessive flexibility could also be another factor as some people who are hypermobile (double-jointed) or people who have overlengthened their tendon are more likely to have problems as the tensile strength of the tendon is reduced, making it easier to overload too.

Stress and other psychological issues:

Stress seems to crop up with nearly all injuries now but you can’t argue with the evidence. Stress certainly can lower pain thresholds and psychological issues such as fear about the injury can create avoidance and lead to not rehabbing the problem correctly.


Things about you that you can’t control:


The older you get the more that the tendon loses resilience & strength (Asplund and Best 2013). The average age for Achilles tendinopathy is 43.4 years & in 34.6% of cases in which sport was involved (De Jonge 2011).


Do men of women have a better pain threshold?

Men are more likely to have Achilles problems than women.

Antibiotical disease:

Taking fluoroquinolones (antibiotics) increases the risk of Achilles tendinopathy (van der Linden et al 2002). Achilles tendon rupture is also more likely too, with a three times higher risk within 90 days after taking fluoroquinolones (Sode et al 2007).

Rheumatological disease:

Rheumatoid arthritis and inflammatory joint diseases have been found to link to insertional tendinopathy.

Recent injury:

The compensation effect, if you are injured then you will move differently and place load elsewhere through compensation and this abnormal loading can overload other areas of the body such as the Achilles.

Steroid exposure:

Corticosteroid injections weaken tendons but steroid abuse in sport or bodybuilding is definitely a big risk factor due to the same effect systemically.


Achilles tendinopathy has been reported to be five times higher in person with a family history of Achilles issues and they have even found the gene that minimises the risk too! Individuals with an A2 allele of the COL5A1 gene are less likely of developing Achilles tendinopathy (Mokone et al 2006).

Previous lower limb tendinopathy:

This is the same as a recent injury but also due to likely genetic risk too.


Things that you do or are exposed to:

Training errors:

woman posing in exercise gear

Recovery time: If you don’t allow enough recovery between loading activities then the tendon hasn’t got enough time to repair and training again on it too soon could build up cumulative damage. A tendon is slow to recover and heal due to poor vascularisation (blood flow). Some people believe just to recover the microtrauma from a run takes at least 24 hours on average to repair. So if you do more than the average distance or heal slower than the average person then you will need 48 hours between the sam training session types.

Poor technique: In running, for example, it has been shown that an increase in cadence by 5-10% reduces pressure & force variables in the heel and metatarsal regions (Wellenkotteret al 2014).

Too much training volume: Athletes with less than 2 rest days per week have a 5.2 times higher risk of injury (Ristolainen et al 2014).


Due to nicotines direct toxic effects on osteoblasts/osteoclasts activity and the indirect actions on sex and adrenocortical hormones, vitamin D, intestinal calcium absorption, vessels and oxygen supply smoking will increase the likelihood of developing Achilles injury (Abate et al 2013).

Change in loading:

The body is amazing and can adapt to almost anything, the issues arise when we do too much too soon and don’t give our bodies time to adapt to the loading. So any abrupt change in loading either one-off or cumulative can be an increase in risk.

Footwear and environment:

Inappropriate or worn-out footwear are known to increase injury risk, as too, is training on hard surfaces or hills, and in cold weather but remember these can be affected positively with progressive training and rotation of footwear and although you can’t change the weather you can warm-up thoroughly beforehand making sure the tendon is warm and pliable with progressive loading and dynamic stretches rather than static ones.

Does alternating the use of running trainers lower injury risk


How long does Achilles injury last for?

The good news is that most people with Achilles tendinopathy improve with conservative treatment and this is expected for most within 12 weeks. However, early treatment is key because it has been found to become more resistant to treatment if not dealt with early (Paavola et al 2000).

It is still considered that the injury has three phases from the onset. The first phase is an acute inflammatory phase which lasts a few days but as we have mentioned previously this inflammation element has been overplayed. The next phase is the proliferative phase, which is generally 3 weeks and this phase is where fibroblasts produce new collagen and new blood vessels form. The final phase is the remodelling phase, which is up to a year. Essentially, where tendon injury goes wrong, is mostly in this final phase with the creation of disorganised blood vessels and collagen creating a painful and weakened structure (Sussmilch-Leitch et al 2012).

Now just because the structure is changing for a year after the onset of the injury doesn’t mean that symptoms last for a year. Pain can completely resolve and function restores without full recovery but as re-organisation of the tissue is slow then rehab should be long and continue after symptoms resolve. This was shown by De Jonge (2011), where it was found that the average duration of symptoms in Achilles tendinopathy in the general population was 11.3 weeks (range 1 to 52 weeks) but we know this doesn’t mean completely recovered in a structural sense.

It has also been proposed that rather than heal the tendon just makes new tendon based on demand and the ‘damaged’ area may always remain. This was shown but this study by Heinemeier et al (2013):


What are the signs and symptoms of Achilles tendon injury?

Mid portion:

The obvious one is a pain in Achilles a few centimetres up from the heel and this is usually intermittent rather than constant. It is classically worse in the morning and is aggravated by activity or exercise. The tendon will commonly feel stiff and this is usually worse in the morning or after a period of immobility and so this will ease as you get moving.

Swelling and thickening can be seen or felt along the tendon and it is often tender and warm with crepitus sometimes being present on palpation.

Any tendon-loading activity is painful in most people and a simple single-leg heel raise can bring on pain but certainly, a hop on the spot should reproduce pain (Carcia et al 2010).



Very much the same but pain is lower down on the attachment to the Calcaneus (Heel bone).



This is characterised by a sudden intense pain in the back of the leg that some people describe like being hit in the back of the calf. Afterwards, you might struggle to walk and push off with any power, people also describe an audible snap or pop at the time of rupture and after the initial pain one-third of people don’t have pain (Singh 2015).


What are the best treatments for the Achilles?

Like any injury, you need to know the causes of the injury and plan to correct as many as possible. If you can correct these causes then the Achilles has the best chance to recover. That being said there is plenty of research out there showing the best ways of treating it outside of this vital aspect.

Early treatment:

Dubois et al (2020), advocates P.E.A.C.E. & L.O.V.E for acute injury, but this is a general concept and needs some modification for this specific injury

This stands for the following: Protect, elevate, Avoid ice and anti-inflammatory drugs, Compression, Education (For the first 48 to 72 hours). Then, load it, Optimism, Vascularisation, Exercise. (After the P.E.A.C.E phase).

So, what does this all mean exactly?

  • Protect – Avoid anything that irritates the injury. This doesn’t mean absolute rest though either. You need to move the area within its tolerance. So after or the next day, there are no signs or symptoms increasing. You may find heel wedges to take some load off the Achilles can help to settle pain in the short term. If your shoes are not ideal then wear good supportive shoes as you feel helps the pain.
  • Elevate – Obviously this only applies to areas that you can and this is done in between your movement and activities. In the case of the Achilles tendinopathy, this isn’t that important but for a rupture, this would be useful.


  • Avoid ice and anti-inflammatory drugs – New thinking is moving away from the icing of acute injuries as it doesn’t help and may even hinder. The reasoning here is based on when you apply ice you get vasoconstriction in the skin and superficial area, which is designed to stop the blood from cooling too much. This blood has to go somewhere else and that place is deeper. meaning you have to vasodilate deeper, which will increase blood flow to the injury site, hence worsening the bleeding and swelling. It’s obvious when you consider that cryochambers are used by athletes to speed up recovery from injury and training and how does this work? It INCREASES blood flow!

Why no anti-inflammatory medication?

Now remember this is a rough guide, but inflammation is what essentially heals your body so why would you want less? Surely this will slow down the healing process? However, here is the caveat, if the pain is impeding your ability to progress your rehab then it may be worth taking them to lower pain and improve function but you shouldn’t use them for long and avoid them if you can.

Specifically for tendons, Ibuprofen has been shown to inhibit tendon cell proliferation, therefore has a negative effect on tendon healing (Tsai et al 2006).

The Control group who didn’t take nonsteroidal anti-inflammatory drugs (NSAIDS) demonstrated progressively increasing collagen organization during the course of the study, whereas the NSAIDs group did not. This basically means NSAIDS were worse than doing nothing. (Cohen et al 2006).


  • Compression – Using compression creates back pressure to the injury site, making bleeding and swelling difficult to enter the area. This would be advised for a rupture more than tendinopathy.
  • Education – this is more about your physio. This is giving you all the help and guidance to get through the first phases of injury.

After the first couple of days, you should start the L.O.V.E. phase

  • Load it – The biggest issue with injury is deconditioning or how to minimise it. No better is this illustrated by Bayer et al (2017). They found that patients with calf and thigh strains who started to rehab their injury at 2 days after their injury, got back to sport 3 weeks earlier than if rehab was started at 9 days after injury. They also found no increased risk of re-injury too. So this obviously doesn’t mean just hammer things on day two. You need to work is within its tolerance levels, monitoring after and next day effects on pain and swelling. As long as no negative effects occur then you are rehabilitating things at the correct level. Loading is a vital component of Achilles tendinopathy but has to be more protocol led for ruptures.
  • Optimism – Be optimistic about your recovery. Research clearly find having high expectations of your recovery leads to better outcomes and the reverse can be said about negative thinking.
  • Vascularisation – The rest of your body isn’t injured remember! Train your upper body and the other leg as this is not a problem. Plus there is a phenomenon called the cross over effect, which is where you can actually increase strength in the untrained limb (Andrushko et al 2018). So why not! Don’t forget Cardio too! So because you can’t train your lower body for a cardio workout then train your upper body with things such as swimming or a hand bikes. So again, why let this deteriorate for no good reason!
  • Exercise – Build up your exercises slowly for the injured area. Gradually stretch and load progressively up, while monitoring signs and symptoms.


Start Physiotherapy

If after 7-10 days you are not improving then you need to access Physiotherapy to assess you and get you onto treatment and a loading program. The type of loading that is key is particularly eccentric loading. This is when a muscle contraction is the tensioning/ contracting a muscle as it is being lengthened and stretched at the same time. An example is in controlled lowering of the heel using a step.

The curious story of Alfredson and eccentric loading in Achilles tendinitis

Back in the mid-1990’s Dr Alfredson had chronic Achilles tendon pain and it wasn’t going well with conservative treatment. He decided to ask his boss for surgery but he was refused this as he thought that it wasn’t serious enough and the clinic couldn’t afford for Alfredson to be off sick.

So what was he to do?

Amazingly, Alfredson decided to try to make it worse so that there would be no option than surgery. So he proceeded to load his Achilles aggressively by performing eccentric heel drops off the back of a step but instead of making things worse they actually resolved the injury fully! So Alfredson was amazed and started to use it and research it more, hence the Alfredson protocol was devised.

What is the Alfredson protocol?

It involves two different exercises, a straight-leg and a bent-leg heel drop loading exercise. So simply you start on your tiptoes with your heel overhanging the edge of a step, next you gradually lower your heel down to a stretch, then you need to use the other leg (or your arms on something) to raise yourself back to the starting position so that your injured leg doesn’t work on the way up. You do three sets of 15 reps of each exercise, twice a day (yes, that’s 180 reps per day) for 12 weeks. When you feel no discomfort or next-day soreness from the program, add some weight and keep adding more and more gradually over time.

They work on the basis of the fact that loading of tendon creates an upregulation of insulin-like growth factor (IGF-I) and so stimulate the growth of tendon tissue to strengthen and improve load tolerance of the Achilles (Khan & Scott 2009).

So eccentric loading of tendon became the cornerstone of Achilles rehabilitation the research backs this up as we can see with the following:

Painful eccentric calf-muscle training showed good clinical results in chronic mid-portion Achilles tendinosis (Jonsson 2008).

Eccentric exercises are superior to wait and see for Achilles tendinopathy (Magnussen et al 2009).


So do you have to isolate the eccentric only component though?

So when you think about a normal single leg calf raise, as shown below, you are doing the same amount of eccentric loading here that you would in an eccentric only version and it is less confusing to patients too, which is vital! The good thing is that this isn’t just common sense, one of the leading experts in Achilles injury agrees too. Malliaras et al (2013), found that there is little clinical evidence for isolating the eccentric component, in Achilles tendinopathy exercise so just go up and down.


So knowing this, I would just recommend progressive calf raises with control, where you go up and down. Don’t bounce at the bottom. In fact, it may be worth starting with them from the floor rather than a step, to begin with, and this would be especially true of insertional Achilles tendinopathy.

I would monitor the pain and symptoms after and the next day and if they are minimal and short in duration then wait for them to reduce and then advance the load of the exercise. This could be going from 2 legs to holding a weight, to single-leg to weights and then moving onto performing them on the edge of the step. Beyond this, I would look at progressing to more plyometric loading activities ao develop more tolerance to faster loading, which will prepare you for return to sport for example.

Also, you may have noticed that the Alfredson protocol involves high-frequency training, which is not at all practical for most people and this is why I would give my patients much less frequency, maybe about 3 times per week and this is supported by Kongsgaard et al (2009).

All of this will need guidance and monitoring otherwise you may simple re-irritate the problem and set yourself back.


Other than loading what other treatments can help?


Extracorporeal shock-wave therapy (ESWT):

Shock wave therapy is when sound waves are passed through the skin to the tendon. It is still up for debate in terms of its effectiveness and even The National Institute for Health and Care Excellence (NICE) recommends that this uncertainty of effect should be explained to people who are offered this treatment. (NICE 2009).


Scott et al (2011) stated that even mild biomechanical abnormalities of lower limb kinetics are important to improve in Achilles tendinopathy. Examples are overpronation or poor movement patterns in the whole body or even leg length discrepancies.

Night splints:

Although eccentric exercises are superior to night splints for Achilles tendinopathy they do work as an addition in some cases (Magnussen et al 2009). However, they are usually poorly tolerated and would only be indicated if there is definitely restricted dorsiflexion of the ankle.

Soft tissue mobilisation:

The research support for things like deep transverse frictions just isn’t there, however, there may be anecdotal support for its use. For me, I might include some soft tissue focus on the calf so something like sports massage in this area may reduce localised tension and spasm present in the muscles above the Achilles, which can prove beneficial as an adjunct.

Low-level laser therapy:

This is thought to increase collagen production and reduce blood flow in the new vessels forming and the evidence does support its use as an adjunct to eccentric exercises (Sussmilch-Leitch et al 2012).


In this systematic review by Cox et al (2016), they found that acupuncture may be beneficial for Achilles Tendinopathy but the evidence is inconsistent.


Injection Achilles

Do not inject corticosteroids into or around the tendon! Coombes et al  (2010) looking at the safety and effectiveness of corticosteroid injections and other injections in the management of Achilles tendinopathy. They concluded that corticosteroid injections did not help pain and they found adverse effects including atrophy and tendon rupture. In 2013, Roche et al agreed with Coombes and found that adverse effects occur in up to 8% of corticosteroid trials one of with is Achilles tendon rupture.


What if it doesn’t respond to conservative treatments?

If your Achilles tendinopathy is not improving by 6 weeks then consider a referral to orthopaedics for assessment and further treatment.

Surgery for Achilles tendinopathy:

This is an option it no progress is being gained by 6 months and the surgery can be either open or minimally invasive. The aim of the surgery is to remove fibrotic tissue and adhesions in and around the tendon, excise and remove any areas that have healed abnormally then normal healing can effectively hopefully more normally and so plenty of post-op Physio will be needed (DTB 2012).


Do I need surgery for an Achilles rupture?

Surgery is not always needed and conservative treatment does work well in the right cases. Surgical repairs appear that have less re-rupture rates but not by much, however, complications are obviously higher with surgery. The main benefit from Percutaneous surgical tendon repair to full open repair is simply complication rates are lower (Jones at el 2012).

(Check out the video below on a study by Ochen et al 2019:)

What is the Post-op Achilles repair process?

Early but carefully planned and progressive mobilisation and loading are key in Achilles rupture repair. The common fear is that loading and moving too soon may over-elongate the tendon and this is obviously not great and has bee shown to have a negative outcome. However, in this study by Kangas et al (2007), they found better outcomes and slightly less elongation in the early mobilisation group compared to the later mobilisation one.

This makes sense because mobilisation doesn’t mean dorsiflexion it means Plantarflexion and this movement wouldn’t lengthen the tendon and may even improve tendon stiffness, hence less likelihood of over lengthening. This early mobilisation view is also supported by Ajis et al (2007) due to early loading encouraging better maturation of collagen fibres in the Achilles.

Controlled mobilisation phase:

0-8 weeks:

Boot with heel lifts to allow weight-bearing

Exercises with limited dorsiflexion: Isometrics in the boot, Seated Heel raises, Exercise banded work and foot/ toes exercise to get intrinsic foot muscle working (All in a plantarflexed position)

Early mobilisation phase:

6-11 weeks

Physiotherapy sessions

Exercise bike, Ankle range of movement exercises, progress loading with exercise band work, 25-50% of body weighted seated calf raises, standing calf raises off two legs, balance exercise and gait re-education training.

Also, train other parts of the legs with leg extensions and hamstring curls and progress into leg presses too.

Once you can do 90% of the height of a single leg calf raise off one leg compared to the good leg then you can begin some two-legged plyometric heel raises and then hopping on two legs and finally some very light jogging.

Late mobilisation phase:

10-15 weeks

This phase is simply a progression of your range and loading capacity. So exercises such as single-leg calf raises on a step, a squat with more depth and weight gradually. Next single-leg squats and more plyometric exercises such and single-leg hopping can be worked up to and Jogging speed can advance through this phase too and even build in some incline work too.

Return to sport phase:

3-12 months

By this point, you should have full range and excellent basic strength and stability from the previous phases. Obviously this phase will vary depending on your sport but the aim is to start to gradually focus more into the demands of this to prepare you body for returning to sport. So drill-based work, for example, zig-zag running and hopping, directional change work and more.

(Brumann et al 2014)


In summary, for Achilles tendinopathy things may at first seem simple but even the terminology is complicated and even the source of the symptoms is not all that you would expect, especially with the role of the central nervous system and differential diagnoses. Everybody is different so you can’t assume the same mechanisms and managements for all, ideally, you should be assessed and screened to highlight your individual issues to formulate a plan for you. Not all reasons for the condition are correctable but many are so you can always make a difference but not everybody will succeed.

Still to this day, progressive loading is the most important and effective treatment but there are plenty of treatments to supplement this approach, so whether you know it as Achilles tendinitis or another name there is plenty to get things improving and back to full fitness.

In summary for Achilles ruptures, surgery isn’t always the best approach but if this is the solution then you need to get moving and loading it early in the carefully planned ways as previously described.


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  • Abate, Michele, et al. “Cigarette smoking and musculoskeletal disorders.” Muscles, ligaments and tendons journal 3.2 (2013): 63.
  • Ajis, Adam, and Nicola Maffulli. “Management of acute tendo Achillis ruptures.” Foot and ankle surgery 13.3 (2007): 132-135.
  • Andres, Brett M., and George AC Murrell. “Treatment of tendinopathy: what works, what does not, and what is on the horizon.” Clinical orthopaedics and related research 466.7 (2008): 1539-1554.
  • Andrushko, Justin W., Layla A. Gould, and Jonathan P. Farthing. “Contralateral effects of unilateral training: sparing of muscle strength and size after immobilization.” Applied Physiology, Nutrition, and Metabolism 43.11 (2018): 1131-1139.
  • Apaydin N, Bozkurt M, Loukas M, Vefali H, Tubbs RS, Esmer AF. Relationships of the sural nerve with the calcaneal tendon: an anatomical study with surgical and clinical implications. Surg Radiol Anat. 2009;31(10):775–780. doi: 10.1007/s00276-009-0520-0.
  • Asplund, C. and Best, T. (2013) Achilles tendon disorders. BMJ 346, f1262.
  • Bayer, M. L., Magnusson, S. P., & Kjaer, M. (2017). Early versus delayed rehabilitation after acute muscle injury. New England Journal of Medicine, 377(13), 1300-1301.
  • Brumann, Mareen, et al. “Accelerated rehabilitation following Achilles tendon repair after acute rupture–Development of an evidence-based treatment protocol.” Injury 45.11 (2014): 1782-1790.
  • Carcia, C., Martin, R., Houck, J., et al. (2010) Achilles pain, stiffness, and muscle power deficits: achilles tendinitis. Journal of Orthopaedic and Sports Physical Therapy. 40(9), 1-26
  • Chen TM, Rozen WM, Pan WR, Ashton MW, Richardson MD, Taylor GI. The arterial anatomy of the Achilles tendon: anatomical study and clinical implications. Clin Anat. 2009;22:377–385. doi: 10.1002/ca.20758.
  • Cohen, David B., et al. “Indomethacin and celecoxib impair rotator cuff tendon-to-bone healing.” The American journal of sports medicine 34.3 (2006): 362-369.
  • Cook, J. L., and Craig R. Purdam. “Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy.” British journal of sports medicine 43.6 (2009): 409-416.
  • Coombes, B., Bisset, L. and Vicenzino, B. (2010) Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 376(9754), 1751-1767
  • Cox, Jocelyn, et al. “Effectiveness of acupuncture therapies to manage musculoskeletal disorders of the extremities: a systematic review.” journal of orthopaedic & sports physical therapy 46.6 (2016): 409-429.
  • D’Addona, Alessio, et al. “Inflammation in tendinopathy.” The Surgeon 15.5 (2017): 297-302.
  • de Jonge, S., van den Berg, C., de Vos, R., et al. (2011) Incidence of midportion Achilles tendinopathy in the general population. British Journal of Sports Medicine. 45(13), 1026-1028.
  • Doral MN, Alam M, Bozkurt M, et al. Functional anatomy of the Achilles tendon. Knee Surg Sports Traumatol Arthrosc. 2010;18:638–643. doi: 10.1007/s00167-010-1083-7.
  • DTB (2012) Management of chronic Achilles tendinopathy. Drug and Therapeutics Bulletin. 50(8), 93-96.
  • Dubois, Blaise, and Jean-Francois Esculier. “Soft-tissue injuries simply need PEACE and LOVE.” (2020): 72-73.
  • Heinemeier, Katja Maria, et al. “Lack of tissue renewal in human adult Achilles tendon is revealed by nuclear bomb 14C.” The FASEB Journal 27.5 (2013): 2074-2079.
  • Jones, Matthew P., Riaz JK Khan, and Richard L. Carey Smith. “Surgical interventions for treating acute Achilles tendon rupture: key findings from a recent Cochrane review.” JBJS 94.12 (2012): e88.
  • Jonsson, Per, et al. “New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study.” British journal of sports medicine 42.9 (2008): 746-749.
  • Kangas, Jarmo, et al. “Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative regimens.” The American journal of sports medicine 35.1 (2007): 59-64.
  • Kearney, R., Parsons, N. and Costa, M. (2013) Achilles tendinopathy management: a pilot randomised controlled trial comparing platelet-richplasma injection with an eccentric loading programme. Bone and Joint Research. 2(10), 227-232
  • Khan, Karim M., and Alex Scott. “Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair.” British journal of sports medicine 43.4 (2009): 247-252.
  • Kongsgaard, M., Kovanen, V., Aagaard, P., Doessing, S., Hansen, P., Laursen1, A., Kaldau, N., Kjaer, M., Magnusson, S. (2009). Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy, Scandinavian Journal of Medicine & Science in Sports, 19(6):790-802.
  • Lopes, Alexandre Dias, et al. “What are the main running-related musculoskeletal injuries?.” Sports medicine 42.10 (2012): 891-905.
  • Maffulli, N. and Ajis, A. (2008) Management of chronic ruptures of the Achilles tendon. Journal of Bone and Joint Surgery (American) 90(6), 1348-1360
  • Maffulli, Nicola, Pankaj Sharma, and Karen L. Luscombe. “Achilles tendinopathy: aetiology and management.” Journal of the Royal Society of Medicine 97.10 (2004): 472-476.
  • Magnussen, Robert A., Warren R. Dunn, and A. Brian Thomson. “Nonoperative treatment of midportion Achilles tendinopathy: a systematic review.” Clinical Journal of Sport Medicine 19.1 (2009): 54-64.
  • Malisoux, L., Ramesh, J., Mann, R., Seil, R., Urhausen, A., & Theisen, D. (2015). Can parallel use of different running shoes decrease running‐related injury risk?. Scandinavian journal of medicine & science in sports, 25(1), 110-115.
  • Mokone, G. G., et al. “The COL5A1 gene and Achilles tendon pathology.” Scandinavian journal of medicine & science in sports 16.1 (2006): 19-26.
  • NICE (2009) Extracorporeal shockwave therapy for refractory Achilles tendinopathy (NICE interventional procedure guidance 312). National Institute for Health and Clinical Excellence.
  • Nijs, Jo, et al. “Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain.” Pain physician 17.5 (2014): 447-457.
  • Ochen, Yassine, Reinier B. Beks, Mark van Heijl, Falco Hietbrink, Luke PH Leenen, Detlef van der Velde, Marilyn Heng, Olivier van der Meijden, Rolf HH Groenwold, and R. Marijn Houwert. “Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis.” bmj 364 (2019).
  • O’Neill, Seth, Paul J. Watson, and Simon Barry. “A delphi study of risk factors for Achilles tendinopathy-opinions of world tendon experts.” International journal of sports physical therapy 11.5 (2016): 684.
  • Paavola, M., Kannus,P. and Paakkala,T. et al. (2000) Long-term prognosis of patients with achilles tendinopathy: an observational 8-year follow-up study. American Journal of Sports Medicine 28(5), 634-642.
  • Plinsinga, Melanie L., et al. “Evidence of nervous system sensitization in commonly presenting and persistent painful tendinopathies: a systematic review.” journal of orthopaedic & sports physical therapy 45.11 (2015): 864-875.
  • Proske, Uwe, and Simon C. Gandevia. “The proprioceptive senses: their roles in signaling body shape, body position and movement, and muscle force.” Physiological reviews 92.4 (2012): 1651-1697.
  • Ristolainen, L., et al. “Training-related risk factors in the etiology of overuse injuries in endurance sports.” The Journal of sports medicine and physical fitness 54.1 (2014): 78-87.
  • Roche, A. and Calder, J. (2013) Achilles tendinopathy: a review of the current concepts of treatment. Bone and Joint Journal 95(10), 1299-1307.
  • Scott, A., Huisman, E. and Khan, K. (2011) Conservative treatment of chronic Achilles tendinopathy. Canadian Medical Association Journal. 183(10), 1159-1165.
  • Singh, D. (2015) Acute Achilles tendon rupture. BMJ 351, h4722.
  • Smith, Melinda M. Franettovich, et al. “Neuromotor control of gluteal muscles in runners with achilles tendinopathy.” Medicine & Science in Sports & Exercise 46.3 (2014): 594-599.
  • Sode, J., Obel, N., Hallas, J. and Lassen, A. (2007) Use of fluroquinolone and risk of Achilles tendon rupture: a population-based cohort study. European Journal of Clinical Pharmacology. 63(5), 499-503.
  • Sussmilch-Leitch, S., Collins, N., Bialocerkowski, A., et al. (2012) Physical therapies for Achilles tendinopathy: systematic review and meta-analysis. Journal of Foot and Ankle Research. 5(1), 15
  • Tsai, Wen‐Chung, et al. “Ibuprofen inhibition of tendon cell migration and down‐regulation of paxillin expression.” Journal of Orthopaedic Research 24.3 (2006): 551-558.
  • Van der Linden, P. D., et al. “Fluoroquinolones and risk of Achilles tendon disorders: case-control study.” Bmj 324.7349 (2002): 1306-1307.
  • Wellenkotter, J., et al. “The effects of running cadence manipulation on plantar loading in healthy runners.” International journal of sports medicine 35.09 (2014): 779-784.
  • Wilson, M. and Stacy, J. (2010) Shock wave therapy for Achilles tendinopathy. Current Reviews in Musculoskeletal Medicine. 4(1), 6-10.

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Online Physiotherapy

Put simply this is Physio done via either telephone or video over the internet. Skype and facetime are examples of this.

Contrary to popular belief online physiotherapy can be very effective and it can help the same injuries that face to face physio can help. I have helped many people with injuries such as disc prolapses, tennis elbow, neck pain and much more).