Understanding Achilles Tendinopathy: What You Need to Know

Understanding Achilles Tendinopathy: What You Need to Know

When we talk about Achilles tendinopathy, many people still use terms like “tendinitis” or “tendinosis,” but those labels aren’t quite right. The term “tendinitis” suggests inflammation is the main issue, but research shows that inflammation isn’t actually the primary cause of Achilles tendinopathy. Sure, some inflammatory markers might be present, but they’re more likely part of the tendon’s natural response to loading rather than the root problem. This is important because people often think inflammation means they need to rest, use ice, or take anti-inflammatory medication, which isn’t ideal for treating this condition. In fact, a 2021 study by Malmgaard-Clausen et al. concluded that anti-inflammatory meds don’t really help the recovery process.

On the other hand, some call it “tendinosis,” which suggests degeneration of the tendon. But again, that’s not quite accurate. A 2021 review by Docking et al. found that tendon abnormalities—things you’d see on an MRI or ultrasound—are common even in people with no symptoms. In fact, another study by Lieberthal et al. in 2019 found that 46% of male runners without any Achilles tendon pain showed some form of tendon pathology. So, just because imaging shows changes in the tendon doesn’t mean that’s the whole story. This tells us that imaging alone can’t diagnose the problem or guide how we treat it. As Docking and Cook pointed out back in 2015, “there’s no direct link between structural disorganization and symptoms.”

Mid-Portion vs. Insertional Achilles Tendinopathy

Achilles tendinopathy typically falls into two categories: mid-portion or insertional, depending on where your pain is located. Mid-portion tendinopathy is more common, so you’ll find more research on it. But don’t worry—whether you’ve got mid-portion or insertional tendinopathy, the advice, exercises, and rehab strategies are largely the same for both types.

Why Does Achilles Tendinopathy Happen?

Now, the big question: why did you get Achilles tendinopathy? The simple explanation is that it happens when the load on your tendon—whether from walking, running, or sports—exceeds your tendon’s ability to adapt and recover.

For an active person, like a runner, it might happen because you did too much too soon. Let’s say you usually run half marathons but decided to ramp up your mileage for a full marathon in just a month—your tendon might not be able to handle that sudden increase in load. On the flip side, if you’re not as active, Achilles tendinopathy could develop because your general activity level has declined, and the tendon isn’t as strong as it used to be.

The goal of rehab is to restore that balance—your tendon needs to be strong enough to handle the daily and weekly loads you’re putting on it. And don’t forget, other factors like sleep, stress, and nutrition can influence how well your body handles that load.

Focus on the Donut, Not the Hole

There’s a popular saying in tendon research: “Treat the donut, not the hole.” The hole is the disorganized tissue you might see on imaging, but the donut is the rest of the healthy tendon. So, instead of focusing on trying to “fix” that disorganized part, the goal of treatment is to strengthen the rest of the tendon to handle the load.

A systematic review by Murphy et al. in 2018 found that even if the structure of the tendon doesn’t change on imaging, people with Achilles tendinopathy can still see huge improvements in their symptoms and function just by working on exercises. And if your tendon looks or feels thicker, that’s not necessarily a bad thing. Research by Docking et al. in 2020 showed that thickened tendons often contain more organized structure as part of their natural adaptation. So, think of it as your tendon’s way of coping with the stress.

Rehab: Building Capacity

So, what does rehab look like? The goal is to build your tendon’s capacity to handle load. This means gradually improving your tolerance to different kinds of exercises and restoring the function of your Achilles tendon, calf, and the rest of your body.

One key aspect of rehab is learning to manage pain. You don’t necessarily need to avoid pain altogether when exercising. Some people are comfortable with slight discomfort, while others are okay with a bit more. The important thing is finding what works for you. Keep track of your pain levels during and after exercise, and adjust your routine if pain increases significantly the next day. Remember, it’s not about pushing through severe pain, but it’s okay to experience a little discomfort as long as it’s manageable.

Load Management and Common Mistakes

Achilles tendinopathy happens when you exceed your tendon’s capacity, so managing your load is critical. Two common mistakes people make are doing too little or too much. Some people avoid activity altogether because they’re afraid of their symptoms, which only weakens their tendon further. Others push too hard, leading to flare-ups and a cycle of overloading and resting, which prevents progress. The key is finding that sweet spot where you’re challenging your tendon just enough without overdoing it.

Stages of Rehab

Rehab can be broken down into stages, and it’s important to progress through them based on your symptoms and function, rather than a set timeline.

          1.       Stage 0: Isometrics (Static Holds)

These exercises are often quite tolerable and can help with pain relief. Examples include double or single leg heel raises, or seated heel raises. You’ll do these as a warmup or independently, holding for about 45 seconds for 3-5 sets.

          2.       Stage 1: Heavy Slow Resistance

Heel raises are a core part of Achilles tendinopathy rehab. Start with double leg heel raises on flat ground and progress to single leg heel raises, eventually adding weight and using a step for more challenge.

          3.       Stage 2: Energy Storage and Release

This is where you add in exercises like jumping and hopping, which put more dynamic load on the tendon. You’ll gradually increase the speed and intensity of these movements to prepare your tendon for more demanding activities.

          4.       Stage 3: Return to Sport

Finally, you’ll begin to return to your chosen sport or activity, but it’s important to take it slow. Build your volume and intensity gradually over time, making sure not to rush back into things too quickly.

Do You Need to Stop Running?

Not necessarily. You might need to reduce your running mileage or frequency, but with the right rehab plan, many people can continue running while recovering from Achilles tendinopathy. The key is tracking your symptoms and making adjustments as needed.

Other Management Strategies

You might be wondering about treatments like foam rolling, massage, or injections. While these can provide symptom relief, they’re not the main focus of rehab. It’s all about progressively strengthening the tendon. You can also try heel lifts or more supportive shoes if needed, especially in the early stages when symptoms are more severe. However, a 2021 study by Kearney et al. found that PRP injections didn’t offer any more benefit than a placebo for Achilles tendinopathy.

Conclusion

In summary, Achilles tendinopathy happens when the tendon can’t handle the load it’s placed under. Inflammation isn’t the main issue, and focusing on tendon degeneration isn’t helpful either. The best approach is a structured rehab program aimed at increasing your tendon’s capacity to manage load. It might take time—three months, six months, or longer—but with patience and consistency, you can significantly improve your symptoms and function.