Achilles Tendinopathy: What to Do About a Chronic Problem

November 24, 2023

Rear view shot of the highlighted joints in a runner's foot

Chronic pain in the heel of the foot could be a sign of Achilles tendinopathy. The Achilles tendon, the largest and strongest in the body, attaches the calf muscle to the heel bone. It can withstand a lot of stress, but is susceptible to injury from intense activity or overuse.

Tendinopathy is a common injury among distance runners. But it can happen to non-athletes as well. “People who are active or who do a lot of standing can develop Achilles tendinopathy,” says Allison Schroeder, MD, a sports medicine specialist with University Hospitals Drusinsky Sports Medicine Institute.

“I have patients who do a lot of standing for work or who are walking for exercise and do a lot of hills who develop Achilles tendon problems,” Dr. Schroeder says. “It doesn’t occur just in athletes. But among athletes, it seems to be most common in runners.”

What Is Achilles Tendinopathy?

Not to be confused with tendonitis, which is an acute inflammation, tendinopathy is a spectrum of disease and includes a longer-lasting, more complex condition where healing is impaired. It’s often painful, but doesn’t necessarily involve inflammation after it becomes chronic.

Symptoms can last for years in some patients, and there is no single, definitive treatment effective for all patients. Sometimes the tendon becomes calcified, thick or inelastic – conditions that impair mobility and cause pain.

“Tendinopathy is a spectrum of problems,” says Dr. Schroeder. “By the time we see most patients, they’ve progressed from tendonitis to what’s called tendinosis, where there’s no longer inflammation, but the tendon hasn’t repaired itself like it should.”

Who Is at Risk for Achilles Tendinopathy?

Being over age 30 and male
Higher body weight
Diabetes
Weak calf muscles
Overtraining or training errors
Poor footwear
Fluoroquinolones antibiotic use

Diagnosing Achilles Tendinopathy

Diagnosis is typically based on symptoms and a physical exam, Dr. Schroeder says.

“Usually, people complain of pain, which is worse with activity or prolonged standing,” she says. “Often, patients say the pain is okay when they rest and it’s bad when they start activity. But they warm up and work through it. When they stop, it’s worse again.”

Imaging tests are not necessary for diagnosis, but can be helpful. X-rays can show if there’s calcification in the tendon or if the patient has Haglund’s deformity (a bony bump or ridge on the heel bone).

Dr. Schroeder will sometimes do an ultrasound in the office to look for signs of a tear. “If there is a little tear, I don’t want them to be putting too much weight on the tendon because it’s going to make it worse.”

Treatment for Achilles Tendinopathy

Managing tendinopathy is often challenging. “We haven’t identified a specific treatment is best for a certain type of tendon issue,” says Dr. Schroeder. “We don’t have one thing that fixes everything for everyone.”

Physical therapy has the best evidence behind it. “Tendons are used to having weight on it. What happens when we have injury is we stop loading it and the muscles that support it get weaker,” says Dr. Schroeder.

“Then, we go back to doing normal activities or trying to exercise. It’s too much load for the tendon to take. In physical therapy, the goal is to gradually build up strength through controlled loading. It’s the best proven way to help the tendon. Physical therapy also works to break up painful adhesions between the tendon and a fat pad (Kager’s fat pad) that is deep in the tendon.”

Other Treatments

In addition to physical therapy, footwear modifications such as orthotics or heel lifts often help. Dr. Schroeder also recommends a silicone compression sleeve that protects the tendon area and back of the heel.
Topical creams may help with pain.
Non-steroidal anti-inflammatory pain relievers are okay for acute pain, but aren’t recommended long-term, as they may delay healing and cause other problems.
Rest is always helpful, but rest alone will not resolve tendinopathy.
If conservative treatments don’t work, doctors may use shockwave therapy, a non-invasive therapy for overuse injuries that helps break up soft tissue adhesions and calcifications and may stimulate healing.

Several ultrasound-guided procedures are available:

Injections of biologic agents such as platelet-rich plasma.
A procedure called tendon scraping uses a needle and sterile water to break up scar tissue and adhesions to surrounding tissues.
Needle tenotomy is another technique to remove scar tissue.

To prevent Achilles tendon problems, Dr. Schroeder says it’s a good idea to keep your calf muscles and Achilles strong and flexible. Avoid putting too much pressure on the tendon too quickly.

“If you’re a runner, you want to gradually build up 10 percent a week in mileage or intensity, but not both at the same time. A rapid increase in activity can lead to many types of overuse injuries.”