| What We Treat
Achilles Tendinopathy
Stiff, painful Achilles for the first few steps each morning that eases as you warm up? This is one of the most treatable tendon problems there is — provided the loading is progressed properly.
Overview
What Is Achilles Tendinopathy?
The Achilles is the strongest tendon in the body, transmitting forces of several times body weight during running and jumping. Tendinopathy occurs when the load asked of it repeatedly exceeds what it has been prepared for, producing thickening, disorganisation and pain. It is not primarily inflammatory, which is why rest and anti-inflammatories disappoint while progressive loading works reliably.
Tap a stage to see how tendon tissue responds to load over time.
A Healthy Tendon
Densely packed collagen fibres aligned along the line of pull, giving the tendon extraordinary tensile strength and the ability to store and return elastic energy with each stride.
Symptoms
How It Tends to Feel
Achilles tendinopathy has a highly characteristic pattern, particularly first thing in the morning:
Morning Stiffness
Marked stiffness and pain for the first steps out of bed, easing over the first few minutes. The classic feature.
Warms Up With Activity
Often eases within the first ten minutes of running, then returns worse afterwards.
Worse the Next Day
Symptoms the morning after loading are the most reliable guide to whether the dose was right.
Localised Tenderness
Either in the mid-portion of the tendon a few centimetres above the heel, or right at the heel bone insertion.
Thickening
A palpable nodule or general thickening compared with the other side.
Worse Uphill or in Flat Shoes
Both increase the range and load through the tendon and commonly provoke symptoms.
Causes & Risk Factors
What Drives It
This is a load and capacity problem, and there is nearly always an identifiable change behind it.
A Spike in Running Load
Increased mileage, added hill or speed work, or a return to running after a break is the most common trigger.
Change in Footwear
Moving to a lower-drop shoe, or a sudden change in training shoes, alters the load distribution through the tendon.
Reduced Calf Capacity
Weak calf muscles mean the tendon absorbs proportionally more of each stride.
Age
Peak incidence between 30 and 50. Tendon structure changes with age while activity levels often remain high.
Systemic Factors
Diabetes, raised cholesterol, raised BMI, and fluoroquinolone antibiotics all affect tendon health and recovery.
The Programme
The Loading Ladder
Tendons need progressively demanding types of load introduced in the right order. Skipping stages is the most common reason rehabilitation fails.
Isometrics
Reduce pain, maintain capacity
- Sustained calf raise holds, typically five holds of 45 seconds
- Often provides useful short-term pain relief and lets you keep active
- Reduce provocative running volume but do not stop moving
- For insertional pain, avoid dropping the heel below level early on
Tap through the stages. Morning symptoms are the best guide to whether the dose is right.
How We Can Help You
Treatment & Management
Achilles tendinopathy responds reliably to progressive loading. The skill lies in setting the right entry point and keeping the progression going through the middle months.
What the evidence says
Progressive loading programmes have consistently good outcomes in mid-portion Achilles tendinopathy across multiple randomised trials, with heavy slow resistance and eccentric protocols performing similarly. Heavy slow resistance tends to show better adherence.
Insertional tendinopathy responds less well to programmes involving dropping the heel below level, since that position compresses the tendon against the heel bone. Loading within a reduced range, with a heel lift, produces better results.
When to Seek Help
Red Flags — Don’t Ignore These
Achilles pain is usually tendinopathy. These features suggest something else:
⚠ Seek prompt medical assessment if you notice:
- A sudden pop or the sensation of being kicked in the back of the leg, with difficulty pushing off (possible rupture — attend A&E)
- Inability to rise onto tiptoes on that leg alone
- Calf pain, swelling, warmth or redness, particularly after immobility or travel (possible clot — seek same-day assessment)
- A hot, red, swollen area with fever or feeling generally unwell (possible infection — seek emergency care)
- New tendon pain after a recent course of fluoroquinolone antibiotics
Achilles rupture is frequently missed initially because people can often still walk. If you felt a sudden pop and cannot rise onto tiptoes on that leg, please attend A&E.
Common Questions
Frequently Asked Questions
Should I rest it?
No. Complete rest reduces the tendon’s capacity, so the same running hurts more when you return. Reducing provocative load while continuing to load the tendon progressively is what works, and it’s well supported by evidence.
Why is it worse first thing in the morning?
Because the tendon stiffens overnight and the first loading of the day is applied to a cold, stiff tendon. Morning stiffness is the classic feature, and its severity is actually a useful day-to-day marker of whether yesterday’s loading was appropriate.
Is it different if the pain is right at my heel?
Yes, importantly. Insertional tendinopathy, where the tendon meets the heel bone, is aggravated by compression — so exercises that drop the heel below level often make it worse. Loading within a reduced range, plus a heel lift, works far better.
How long will it take?
Three to six months for full resolution is realistic, with noticeable improvement usually within six to eight weeks. The most common reason for recurrence is stopping the strengthening once the pain settles rather than continuing it as maintenance.
Load It Properly and It Improves
A clear diagnosis of which type you have, the right loading programme, and a graded return to running that holds.
Book Your Initial AssessmentThis page is for general information only and isn’t a substitute for individual medical advice. If you’re experiencing any of the warning signs above, contact your GP or seek emergency medical care as appropriate.