Also called: Achilles tendinitis; heel cord pain
Exercise is the main treatment
Strength
Stretch
Massage
Pain and stiffness in the Achilles tendon, worst first thing in the morning. The old advice to rest it was exactly wrong: the tendon needs progressive load to reorganise, and rest weakens it further while the pain waits.
How common: Lifetime ~6% in sedentary adults and up to 24% in athletes
What it is
Achilles tendinopathy is a failed healing response to repeated load. The tendon's collagen becomes disorganised, new blood vessels and nerves grow into it, and it thickens - a process of degeneration rather than inflammation, which is why the name tendinitis has largely been dropped.
The treatment that works is loading. Progressive heavy exercise - eccentric or heavy slow resistance - reorganises the tendon and restores its capacity, with good evidence across decades. Rest reduces pain temporarily and reduces tendon capacity permanently, so the pain returns the moment activity does.
What it feels like
- Pain and stiffness in the tendon, worst with the first steps in the morning
- Warms up during activity and hurts more afterwards and the next day
- Tender to squeeze, and often a palpable thickening a few centimetres above the heel
- Worse on hills, stairs and after a hard session
- Sometimes a creaking sensation with movement
What causes it
Most people have more than one of these at once, and they feed each other. Read the
list looking for the two or three that sound like your week rather than for the one
true answer — the ones that describe you are the ones worth acting on.
- A sudden increase in load
- More running, faster running, more hills, a new sport, a return after a break. The tendon adapts slowly and this is the commonest precipitant by a wide margin.
- A failed healing response
- Repeated loading without adequate recovery produces disorganised collagen rather than repair. The tendon becomes thicker and weaker at the same time, which is the core pathology.
- Calf weakness
- The calf and the tendon are one unit. A weak calf means the tendon takes proportionally more of every push-off, and calf strength deficits are consistently found in this condition.
- Restricted ankle dorsiflexion
- A stiff ankle increases the strain in the tendon during the loading phase of each step. It is a very common contributor and easily addressed.
- Age-related tendon change
- Tendon blood supply and collagen turnover decline with age, which is why this is most common in people between about thirty and sixty rather than in the young.
- Footwear changes
- Dropping suddenly from a heeled shoe to a flat one increases tendon strain considerably. It is a classic trigger and it is preventable by making the change gradually.
- Insertional versus mid-portion
- Pain at the very bottom, at the heel bone, behaves differently: compression against the bone matters, so full dorsiflexion stretching and deep heel drops make it worse. The distinction changes the treatment.
- Fluoroquinolone antibiotics
- Ciprofloxacin and related antibiotics are associated with tendinopathy and, rarely, rupture. It is worth knowing about if symptoms began around a course of them.
- Metabolic factors
- Diabetes, obesity and high cholesterol are all associated with tendinopathy, probably through effects on collagen and blood supply. It is not purely a mechanical condition.
Who tends to get it
- Runners, particularly middle-aged recreational runners
- Anyone increasing running volume, speed or hill work quickly
- People with weak calves or stiff ankles
- Anyone who recently changed to flatter shoes
- People with diabetes, obesity or high cholesterol
What makes it worse, and what settles it
Makes it worse
- Complete rest, which reduces pain and reduces tendon capacity
- Continuing at the same load and hoping it settles
- Deep heel-drop stretching in insertional tendinopathy, where compression is the problem
- Steroid injection into the tendon, which is associated with rupture
- Increasing load again as soon as the pain eases, which is where relapses come from
Settles it
- Progressive heavy calf loading - eccentric heel drops or heavy slow calf raises - which is the treatment with the strongest evidence
- Working within an acceptable pain level rather than avoiding pain entirely
- Ankle mobility work to reduce the strain on the tendon
- Reducing aggravating volume temporarily while capacity is built
- A small heel raise in insertional cases, which removes the compression
What actually helps
The short version: Failed tendon healing response to repeated load; the tendon needs progressive load, not rest
Strength work: Legs: Calves: Gastrocnemius; Legs: Calves: Soleus - slow heavy eccentric heel drops, 3x15 twice daily (Alfredson) or heavy slow resistance
Stretching: Legs: Calves; Legs: Calves: Gastrocnemius; Legs: Calves: Soleus
Massage: Legs: Calves; Massage Stick
Also worth doing: Heel lifts while acute (Physical Therapy item 863); avoid sudden volume jumps
What the evidence says: Alfredson eccentric protocol has 20+ years of support. Insertional cases need a floor-level (not step) version - stretching into dorsiflexion makes insertional pain worse.
The names above are the Targets qFIT tracks —
the Muscle Guide explains what each one does, and
Quick Add switches on the Exercises you
already have.
The qFIT routine for this
Ready-made routineAchilles Tendinopathy PT (mid-portion, insertional & retrocalcaneal)
qFIT already has this one built. It runs massage first, then stretching, then
strength — the order that works on a body that is already sore — and every
activity in it carries the reason it is there.
The button below opens your Checklist with this routine already selected, so instead
of your whole list you land on just its Categories, Targets
and Exercises, each with its checkbox, ready to tick as you work through
them.
Have more than one problem? Tick yours under My Problems on
My Profile and your Checklist's Routine list gains
Recommended for my problems — every routine for the problems you picked, merged
into one. Your picks stay private; that filter is the only thing they feed.
Get it checked if…
Sudden pop with inability to push off - suspect rupture, urgent; insertional pain behaves differently and dislikes full dorsiflexion stretching
And whatever the body part: chest pain or unusual breathlessness on
exertion; a fever alongside the pain; unexplained weight loss; pain that is constant and
unrelated to how you move; new numbness, weakness or loss of bladder or bowel control; or
one calf that is swollen, warm and painful. Any of those, stop and get assessed.
How it usually goes
This is slow. Meaningful improvement takes three to six months of consistent loading and full resolution can take longer; the morning stiffness is usually the last thing to go and is a good progress marker. The loading has to continue after the pain settles, because the pain resolves before the capacity does - stopping there is the commonest cause of relapse. Sudden severe pain with a sensation of being kicked in the calf, and an inability to push off, is a rupture and needs urgent assessment.
Prevalence basis: Tendinopathy epidemiology reviews
Others the same routine covers
These share the Achilles Tendinopathy PT (mid-portion, insertional & retrocalcaneal) routine, so the work is the same. If one of them also
sounds like you, that is a reason to expect more from it, not less.
This is general information, not a diagnosis, and it cannot examine you.
If it matches you, use it to ask better questions of a clinician rather than to replace one.