Achilles Tendinopathy Treatment for Athletes
Achilles tendinopathy is one of the most common lower-limb injuries seen in endurance runners, cricketers, footballers, and racquet sports athletes. Unlike an acute tear, this condition develops gradually due to repetitive overload, poor load management, and biomechanical inefficiencies.
One-fourth of the Achilles tendinopathies is located at lower portion of the back of the heel Middle-aged male athletes are considered to have a greater risk of developing Achilles Tendon injury, although high rates (31% of all Achilles injuries) have also been reported in people who don’t participate in sports. Often professionals are puzzled as to how to resolve this tendinopathy
In 2025, sports physiotherapy has moved beyond “just calf strengthening” to a whole-body, sport-specific and neuromuscular approach — especially for athletes aiming to return to high-level performance without recurrence.
What Is Achilles Tendinopathy?
Achilles tendinopathy is a degenerative overuse condition affecting the Achilles tendon — the structure connecting the calf muscles to the heel bone. It commonly presents as:
- Pain during or after activity
- Morning stiffness
- Reduced push-off strength
- Thickening or tenderness of the tendon
Contrary to older beliefs, current research shows it is not primarily inflammatory, but rather a load-related tendon adaptation failure.
Anatomy and Histology
The Achilles tendon is a tendon formed from the calf muscle, which is formed from the gastrocnemius and the soleus muscles. The gastrocnemius is a 2 joint muscle, as it starts above the knee joint, and ends at the back of the heel in the form of ACHILLES tendon . Soleus, on the other hand, starts below the knee and connects to the achilles tendon .
Achilles Tendon injury
The Achilles tendon inserts not only into the calcaneus but also connects to the plantar fascia and the two structures act as a continuum. The tendon’s fibers rotate in its insertion into the calcaneal bone at approximately 90 degrees, with the medial fibers coming posteriorly and the lateral fibers coming inferiorly .
The insertion of the tendon is protected by two fluid filled sacs called BURSA , the retrocalcaneal, which is between the Achilles and the skin, and the retro Achilles, which is between the Achilles and the calcaneus. The area of the Achilles insertion, the calcaneus, and the two bursas are known as the enthesis organ.
The Achilles tendon does not have a true sheath, but it is covered instead by a loose, fatty sheath called paratendon. The paratendon provides vascular supply to the achlles tendon and helps it to glide with minimal friction within the sheath. Deeper to the peritendon is the endotendon, which encloses the collagen fibers of the tendon, its small blood and lymph vessels, and its nerves.
Blood supply to the tendon is also provided by the musculotendinous junction and through its attachment to the bone.
“The area 2-6cm above the tendons insertion has been proposed to have poor vascularity, which explains why it is prone to injury
As far as the histology is concerned, the tendon consists of cells and extracellular matrix . Approximately 95% of the tendon’s cells are tenocytes and tenoblasts, with the rest 5% being chondrocytes, vascular cells, synovial cells and smooth muscle cells.
Pathology behind the Tendon Injury?
Achilles Tendon injury can be an acute and overuse injury.
An acute Achilles Tendon injury follows the same healing principles as every other area of soft tissues, starting with inflammation and eventually healing into a scar tissue.
Chronic Achilles Tendon injuries, though, do not seem to follow the same procedure . The microtrauma caused to the tendon does not produce inflammation, thus there is poor healing of the tissues. This condition is described as “failed healing response”.
There are four basic elements seen in the majority of the patients with degenerative Achilles:
1) Altered cell function. The metabolism of the cells increases in order to produce more collagen and ground substance
2) The amount of proteoglycans in the ground substance increases
3) Microrupture of the collagen type I fibers and production of the thinner type III- which makes the tendon fragile
4) Appearance of new vessels and nerves into the tendon as a result the tendon is more sensitive than normal
The degenerative Achilles tendon does not have macroscopically a normal white shape and it rather looks grey and unstructured . Instead of parallel orientation, there is a random orientation of the collagen (especially type III), of the ground substance and of the vessels, which makes the tendon less capable to withstand loads .
Although, there is not true tissue inflammation in Achilles tendinopathy, evidence of neurogenic inflammation exists . Substance P, CRGP and glutamate have been found in symptomatic chronic tendinopathies .
Research states that chronic tendinopathies could be in fact caused by nerve tissue dysfunction, rather than being the result of repetitive overload of the tendon. considers it possible that local nerve damage in the Achilles area could be produced by long distance running due to the repetitive load, in a similar way that vibration causes trauma to the tissues. may be thats the reason, the tendon takes upto 12 months to reverse back to normalcy post rehab??
Moreover, a potential nerve pinch in the lower back region, the buttock area or between the two heads of calf could have a similar impact on the tendon.
Why Achilles Tendinopathy Is Common in Specific Sports
🏃 Marathoners & Long-Distance Runners
Marathon running exposes the Achilles tendon to thousands of repetitive loading cycles. Sudden mileage increases, speed work, or hill training often exceed the tendon’s capacity.
Common contributing factors:
- Poor calf-soleus endurance
- Reduced ankle dorsiflexion
- Fatigue-induced altered running mechanics
🏏 Cricketers
Cricket involves repeated short sprints, sudden stops, bowling load, and prolonged standing, all of which strain the Achilles — especially in fast bowlers and all-rounders.
Key risks include:
- Asymmetrical loading
- Poor posterior chain strength
- Inadequate recovery between matches
⚽ Footballers
Football places high eccentric and plyometric demands on the Achilles tendon through sprinting, cutting, and jumping.
High-risk factors:
- Frequent acceleration/deceleration
- Multi-directional stress
- Inadequate tendon load progression during preseason
🎾 Racquet Sports Athletes (Badminton, Tennis, Squash, Pickleball)
Explosive lunges, rapid push-offs, and lateral movements make racquet sports a high-risk category for Achilles tendinopathy.
Common issues:
- Poor foot-ankle control
- Over-reliance on calf muscles
- Inadequate eccentric loading capacity
Clinical Findings:-
- A careful subjective examination of the patient will reveal that the area of the symptoms in the midportion tendinopathy is along the main body of the tendon , while in the insertional the pain is experienced at the tendon’s insertion .
- Achilles tendinopathy pain does not usually refer to other areas .
- The pain can vary from minor to severe and may be accompanied by swelling, thickening and crepitus . If crepitation coexists, the paratendon is involved in the pathology too , although it is not common in chronic cases .
- The pain at the first stage of the disease appears at the beginning of the training and immediately after it, with no symptoms in-between.
- If it progresses it may not allow the patient to participate in sports and pain may be even present during his daily living activities .
- Running and hoping usually aggravate symptoms , while rest, slow walking and heat relieve them .
- Morning stiffness is one of the main complains of the patients .
- The history reveals a sudden onset of symptoms after an increase in the intensity, the frequency or the duration of training .
The objective examination we check for the following:-
observation of the patient for
- muscle bulk wasting,
- swelling of the tendon as well as for
- malalignments of the foot .
- Single-leg heel raises (are useful as pain provocation test, but also to assess the muscle-tendon unit strength and endurance .)
- hopping .(In athletes that might need a more challenging test for pain reproduction)
The palpation will reveal any possible
- thickening,
- increased heat,
- areas of tenderness or
- crepitus
Finally, we believe. it is very important to assess the whole kinetic chain of the lower limb and pelvis for possible impairments that might contribute to the problem .
The calf squeeze test is a quick test done in clients who might be suspected for tendon rupture
The “painful arc sign”, is uded for differential diagnosis of paratendonitis in clients to understand the type of achilles tendinopathy. If the area of maximum tenderness is palpated, then the foot is moved from plantar to dorsiflexion and the area of tenderness remains in the same position, in that case the paratendon is the source of symptoms .
The retrocalcaneal bursitis
Usually presents as a prominent warm area of the back and the outer part of the heel. In the retro-Achilles bursitis on the other hand, pain presents as very superficial and the area of the back of the heel is warm
while in the insertional tendinopathy the pain is around the central part of the back of the heel .
Lastly, our physiocure clinicians always remember that enthesopathy is a common symptom of rheumatoid arthritis and spondyloarthropathy so the diagnosis is made accordingly.
2025 Research Trends in Achilles Tendinopathy
🔬 1. Tendinopathy Is a Neuromuscular Problem Too
Recent research shows athletes with Achilles tendinopathy demonstrate altered nervous system control, including reduced muscle recruitment efficiency and increased cortical inhibition.
👉 This explains why strength alone isn’t enough.
🏋️ 2. Progressive Loading Still Remains the Gold Standard
Eccentric, isometric, and heavy slow resistance training continue to show strong evidence in improving tendon capacity — but now with sport-specific dosing and progression models.
🧠 3. Whole-Body Biomechanics Matter
2025 studies emphasize the role of:
- Hip and glute strength
- Core control
- Foot mechanics
- Running and sport-specific movement patterns
Achilles load is influenced by the entire kinetic chain, not just the calf.
📊 4. Early Detection & Load Monitoring
Advanced imaging and workload monitoring tools are increasingly used in elite sport to detect early tendon changes — reinforcing the importance of early physiotherapy intervention.
The Sports Physio approach at Physiocure
✅ Stage 1: Load Management & Pain Control
- Activity modification (not complete rest)
- Isometric loading for pain modulation
- Soft tissue and myofascial techniques when indicated
✅ Stage 2: Progressive Tendon Loading
- Eccentric & heavy slow resistance calf training
- Soleus-specific strengthening (crucial for runners)
- Controlled plyometric preparation
✅ Stage 3: Kinetic Chain Correction
- Hip, glute, and core strengthening
- Foot-ankle control drills
- Gait or movement pattern retraining
✅ Stage 4: Sport-Specific Return to Play
Return to sports
A short recovery time and an early return to sports without a gradual loading of activities is a recipe for reinjury or repeated tendoachilles strains. we do not recommend our players to stop playing while they are undergoing rehab for 8 to 12 weeks , but instead we recommend them to perform activities that will promote healing and restrict activities that will worsen the tendon. after a certain point in rehab the players do not have nay symptoms and hence they may be tempted to return to playing early.
Under a guided rehab program symptoms like pain, swelling, stiffness are monitired and give an idea on wether to further increase the activity level or not.
Here is a small table explaining how a runner will feel when he starts running and what should it feel like. for instance, if walking for 70 minutes causes pain more that 2 (as per the pain scale) you have not recovovered yet to pursure walking . you need to take it easy.
AS PER THIS RESEARCH BASED PROOF, WE RECOMMEND AN ATHLETE TO START WITH RUNNING OR JUMPING ACTIVITY ONLY IF ACTIVITIES OF DAILY LIVING ARE PAIN FREE
| Classification of activities | |||
| Light | moderate | Heavy | |
| Pain level during activity , NPRS (0-10) | 1-2 | 2-3 | 4-5 |
| Pain level after activity (next day) | 1-2 | 3-4 | 5-6 |
| Athletes’s RPE in regards to the Achilles tendon | 0-1 | 2-4 | 5-10 |
| Recovery days needed in between activities | 0 | 2 | 3 |
| Examples of activities for a runner | Walking for 70 mins | Jogging on flat surface for 30 minutes | Running at 85% of preinjury speed for 20 minutes |
| Abbreviations:- NPRS- numeric pain rating scale, RPE- rate of perceived exertion | |||
The return to sport program is introduced, within few weeks of the start of the rehab program. the athlete is educated even if they do not wish to follow a return to sports phase. for atheletes who do sign up a training diary is made and they are asked to note down symptoms as per the daily schedule.
Sports Specific Physio rehab points we follow:-
- Sprint mechanics for footballers & cricketers
- Running load progression for marathoners
- Lateral agility and reactive drills for racquet sports
How Long Does Achilles Tendinopathy Take to Heal?
Most athletes require 8–16 weeks of structured rehabilitation, depending on:
- Chronicity of symptoms
- Training load history
- Sport-specific demands
- Adherence to rehab protocols
Rushing return to sport is the most common cause of recurrence.
Frequently Asked Questions (FAQs)
Is Achilles tendinopathy the same as an Achilles tear?
No. Tendinopathy is a degenerative overload condition, while a tear is an acute structural rupture. Treatment strategies differ significantly.
Should I stop running or playing completely?
Not always. Modern sports physiotherapy focuses on load modification, not total rest, unless symptoms are severe.
Does shockwave therapy help Achilles tendinopathy?
Shockwave therapy can be beneficial when combined with a structured loading program, especially in chronic cases.
Why does my Achilles pain keep coming back?
Recurrence often occurs due to:
- Incomplete rehab
- Poor load progression
- Ignoring kinetic chain weaknesses
- Returning to sport too early
Can sports physiotherapy prevent surgery?
Yes. Most Achilles tendinopathy cases respond well to evidence-based physiotherapy, avoiding injections or surgical intervention.
Why Choose Physiocure: The Sports Rehab Clinic?
✔ 17+ years of sports injury experience
✔ Expertise with runners, cricketers, footballers & racquet athletes
✔ Advanced biomechanical and movement-based rehab
✔ Return-to-sport focused protocols
✔ Located in Santacruz West / Bandra / Juhu
Book a Sports Physiotherapy Consultation
If you’re an athlete dealing with persistent Achilles pain, early intervention can make the difference between full recovery and chronic limitation.
📍 Physiocure: The Sports Rehab Clinic
📞 Book your assessment today
🏃♂️ Train smarter. Recover stronger. Perform better.
References:-
- Alfredson, H & Cook, J 2007a, ‘A treatment algorithm for managing Achilles tendinopathy: new treatment options’, British Journal of Sports Medicine, vol. 41, no. 4, pp. 211-216.
- https://bjsm.bmj.com/content/50/19/1187
- Alfredson, H & Ohberg, L 2005, ‘Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: a double-blind randomised controlled trial’, Knee Surgery and Sports Traumatology Arthroscopy, vol. 13, no. 4, pp. 338-344.
- Cook, J, Khan, KM & Purdam, C 2002, ‘Achilles tendinopathy’, Manual Therapy, vol. 7, no. 3, pp. 121-130.
- https://www.researchgate.net/publication/282047223
