Achilles Tendinitis: Causes, Symptoms and How Physiotherapy Can Help

The Achilles tendon is the strongest tendon in the human body, yet it is also one of the most commonly injured. For Malaysia's growing community of runners, hikers, and recreational athletes, Achilles tendinitis (more accurately called Achilles tendinopathy) can bring your active lifestyle to a frustrating halt. Whether you are training for a marathon in KL, playing weekly badminton, or simply walking briskly to keep fit, understanding and properly treating this condition is essential for a lasting recovery.

The Achilles Tendon Explained

The Achilles tendon connects the two calf muscles – the gastrocnemius and soleus – to the heel bone (calcaneus). It transmits the force generated by the calf muscles to propel you forward during walking, running, and jumping.

During running, the Achilles tendon can experience forces of up to 12 times your body weight. This enormous load-bearing capacity also makes it vulnerable to overuse injury when the tendon is not given adequate time to adapt and recover.

Achilles tendinopathy can occur in two locations: midportion (2-6 cm above the heel bone, the most common type) and insertional (at the point where the tendon attaches to the heel). The treatment approach differs slightly for each.

Why the Achilles Tendon Breaks Down

Achilles tendinopathy develops when the tendon is subjected to load that exceeds its capacity to recover and adapt:

• Sudden increase in activity – The most common trigger. Starting a running programme, significantly increasing mileage, or switching from flat walking to hill hiking in places like Cameron Highlands without gradual progression
• Calf muscle weakness – Insufficient calf strength means the tendon absorbs more force than it should during every step
• Change of footwear or surface – Switching from supportive running shoes to minimalist footwear, or from treadmill running to road running
• Stiff ankle joint – Reduced ankle dorsiflexion places increased strain on the Achilles tendon
• Age-related changes – Tendon blood supply and collagen quality decline after age 35, reducing the tendon's resilience
• Body weight – Higher body mass increases the load transmitted through the tendon with every step

How Achilles Tendinopathy Presents

The condition typically follows a recognisable pattern:

• Pain and stiffness in the Achilles tendon area, worst first thing in the morning or after sitting for an extended period
• Pain at the start of exercise that may "warm up" and decrease during activity, only to worsen afterwards
• A tender, thickened area in the tendon that you can feel with your fingers
• Stiffness when walking upstairs or uphill
• Pain when pressing the sides of the tendon between your fingers (the pinch test)
• In advanced cases, pain during everyday walking and reduced ability to perform a single-leg heel raise

If you recognise these symptoms, it is important to seek professional assessment rather than trying to self-diagnose. Many conditions share similar symptoms, and an accurate diagnosis is crucial for effective treatment.

Struggling with Achilles Tendinitis? A physiotherapist can assess your condition and create a personalised recovery plan. Chat with a physiotherapist near you

The Science-Backed Physiotherapy Approach

Tendon loading programmes are the gold standard treatment for Achilles tendinopathy, with strong research evidence supporting their effectiveness.

Progressive Tendon Loading

The key principle is that tendons need controlled, progressive loading to heal and remodel. Complete rest is counterproductive – it causes the tendon to weaken further:

• Isometric calf raises – Holding a calf raise position for 30-45 seconds provides immediate pain relief and begins the loading process
• Eccentric heel drops (Alfredson protocol) – Slowly lowering the heel below the level of a step, which has been shown to stimulate tendon remodelling. Performed with both straight and bent knee to target both calf muscles
• Heavy slow resistance training – Progressively loaded calf raises through full range, performed slowly (3 seconds up, 3 seconds down) to maximise tendon adaptation
• Plyometric loading – Once the tendon tolerates heavy slow resistance, hopping, jumping, and running are gradually reintroduced

Adjunct Treatments

• Shockwave therapy – Particularly effective for chronic Achilles tendinopathy that has not responded adequately to exercise alone. The acoustic waves stimulate a healing response in the degenerated tendon tissue
• Manual therapy – Soft tissue massage, calf muscle release, and ankle joint mobilisation to address contributing factors
• Heel lifts – Temporary heel raises in shoes can reduce the stretch on the Achilles tendon during the early treatment phase
• Running gait analysis – Identifying and correcting running technique issues that overload the tendon, such as overstriding or excessive heel striking

Recovery: Patience Is Key

Achilles tendinopathy requires patience. Tendons take longer to adapt than muscles because of their lower blood supply. Most patients see significant improvement within 3-6 months of a consistent loading programme.

It is normal to experience some mild discomfort during exercises – pain up to 3-4 out of 10 during loading is acceptable. However, pain that worsens the following morning suggests the tendon was overloaded, and your physiotherapist will adjust the programme accordingly.

Getting Back to Running and Sport

Return to running follows a graduated approach:

• You should be able to perform 15 single-leg heel raises on the affected side without pain before attempting running
• Start with a walk-run programme, alternating walking and jogging intervals
• Increase running volume by no more than 10% per week
• Avoid hill running and speed work initially – reintroduce these gradually once flat running is comfortable
• Continue your calf strengthening programme alongside running – it should be a permanent part of your routine

Recover Stronger with Expert Guidance

Achilles tendinopathy responds well to structured physiotherapy, but the exercise programme must be individually designed and progressively adjusted. A qualified physiotherapist can assess your specific situation and create a treatment plan designed for your needs. Find a physiotherapist near you and take the first step toward getting back to the activities you love.