Achilles tendinopathy is pain and stiffness in the Achilles tendon caused by overload, common in runners, cricketers and badminton players. The best-proven treatment is a progressive calf-strengthening programme – not rest, not injections. Most people improve over three to six months.
This guide from the foot and ankle team at Sports Orthopedics Institute, Bengaluru explains what tendinopathy is, how it differs from a tendon tear, which exercises work, which popular treatments don't, and how to get back to sport.
Key takeaways
- It's an overload problem, not simple inflammation – which is why rest and anti-inflammatories alone rarely fix it.
- Loading exercise is the first-line treatment and the only one with the strongest recommendation in the 2024 clinical guideline.
- Heavy slow resistance and eccentric heel drops work equally well; choose the one you'll stick with.
- PRP injections don't help: a large trial found them no better than a sham injection.
- Steroid injections into the tendon should be avoided because of the risk of weakening it.
- You can usually keep running at a reduced level if pain stays mild and settles by the next morning.
What Is Achilles Tendinopathy?
When the Achilles tendon is loaded more than it can handle, its structure changes and it becomes painful. Under the microscope there is disorganised collagen rather than classic inflammation – the reason doctors now prefer “tendinopathy” to “tendinitis”.
Two types – treated differently
|
|
Mid-portion |
Insertional |
|---|---|---|
|
Where it hurts |
2–6 cm above the heel |
Where the tendon attaches to the heel bone |
|
Who gets it |
Runners and active adults |
Often older or less active people; may have a heel bump (Haglund's) |
|
Exercise tip |
Heel drops can go below step level |
Keep heel drops on flat ground – dropping below a step compresses the insertion |
Early or established?
Many clinicians describe tendon problems on a continuum: an early, reactive stage after a sudden spike in load, which settles quickly with load reduction; and a longer-standing stage with structural change, which needs months of progressive strengthening. Knowing where you are helps set realistic expectations.
Who Gets It?
- Runners – especially those training for 10Ks and half-marathons without a gradual build-up
- Fast bowlers in cricket – repeated explosive push-off on hard grounds
- Badminton, football and squash players – repeated lunging and jumping
- Gym-goers starting box jumps, skipping or treadmill running suddenly
- Adults over 35, people with higher body weight, diabetes or high cholesterol
- People taking fluoroquinolone antibiotics or after steroid injections near the tendon
Symptoms and Diagnosis
Typical symptoms
- Pain and stiffness in the Achilles, worst first thing in the morning or after sitting
- Pain at the start of a run that may ease as you warm up, then returns later or the next day
- Tenderness when the tendon is squeezed
- A thickened or lumpy tendon
Is it tendinopathy or a tear?
A tendon rupture happens suddenly – a feeling of being kicked in the calf, with immediate loss of push-off. It needs same-day assessment. See our guide to Achilles tendon rupture.
How it's diagnosed
The diagnosis is usually made by examination – where the pain is, how the tendon feels, and whether loading the tendon (such as hopping) reproduces it. An ultrasound can confirm thickening and rule out a tear; MRI is reserved for unclear cases. Scan appearances don't always match symptoms, so treatment is guided by how the tendon feels and functions.
The Best Exercises for Achilles Tendinopathy
The 2024 clinical practice guideline gives its strongest recommendation to tendon-loading exercise – at loads as high as you can tolerate, at least three times a week – as the first-line treatment (JOSPT, 2024). “Loading” includes eccentric, heavy slow resistance, isometric and, later, plyometric exercise.
Heavy slow resistance vs eccentric training
In a randomised trial of 58 people with mid-portion tendinopathy, both a 12-week heavy slow resistance programme and the traditional eccentric (Alfredson) programme produced equally good, lasting improvements in pain and function at one year. Adherence was higher with heavy slow resistance (92% vs 78% of sessions) (Am J Sports Med, 2015).
|
Programme |
What you do |
Typical dose |
|---|---|---|
|
Eccentric heel drops (Alfredson) |
Rise on both feet, lower slowly on the painful leg; straight and bent knee |
3 × 15 each, twice daily, 12 weeks; add weight in a backpack as it eases |
|
Heavy slow resistance |
Slow seated and standing calf raises on a machine or with weights (about 3 seconds up, 3 seconds down) |
3–4 sets, 3 times a week; load increased as reps drop from 15 to 6 |
|
Isometric holds |
Hold a calf raise or press against resistance |
5 × 30–45 seconds; useful when the tendon is very irritable |
Using pain as a guide
- Some pain during exercise is acceptable – generally up to about 3–4 out of 10
- Pain should settle by the next morning, without extra morning stiffness
- If it doesn't, reduce the load for a few days rather than stopping completely
Stretching
Stretching isn't a treatment on its own, and aggressive stretching can irritate an insertional tendinopathy. It may help if your ankle is stiff.
Other Treatments: What Works and What Doesn't
|
Treatment |
What the evidence shows |
Our view |
|---|---|---|
|
Shockwave therapy |
Some trials suggest adding shockwave to exercise improves results, e.g. Rompe et al. (Am J Sports Med, 2009) |
A reasonable add-on if exercise alone isn't enough |
|
PRP injection |
A trial of 240 patients found a PRP injection no better than a sham injection at 6 months (function score 54.4 vs 53.4), with more injection-site discomfort (JAMA, 2021) |
Not recommended |
|
Steroid injection into the tendon |
Short-term relief at best; concern about weakening the tendon |
Avoid |
|
Heel lifts, taping |
May reduce symptoms short-term |
Useful aids, not cures |
|
Low-level laser, ultrasound alone |
The 2024 guideline advises against them as stand-alone treatment |
Not recommended |
|
Surgery |
Considered after 6 months or more of good-quality rehab without improvement |
For a small minority |
When is surgery considered?
If symptoms persist despite a structured programme for at least 6 months, options include procedures to clean up the tendon and surrounding tissue, release the plantaris tendon, or – for insertional problems – remove a heel bump and diseased tendon. See our guide to Achilles tendon tenotomy.
Recovery Timeline and Running
Tendons adapt slowly. Expect early gains within a few weeks and meaningful improvement by about 12 weeks, with full recovery often taking 3–6 months – longer for long-standing or insertional cases.
|
Stage |
Typical timing |
Focus |
|---|---|---|
|
Settle |
Weeks 0–2 |
Reduce aggravating load; isometric holds; walking and cycling |
|
Build strength |
Weeks 2–12 |
Progressive heavy slow or eccentric loading 3+ times a week |
|
Build speed |
Months 3–4 |
Skipping, hopping, then jumping and running drills |
|
Return to sport |
Months 3–6 |
Gradual increase in running and sport-specific training |
Can I keep running?
Often, yes – at a reduced level. A practical rule many physiotherapists use:
- Pain during running stays at about 3–4 out of 10 or less
- It settles within 24 hours
- Morning stiffness is no worse the next day
If any of these isn't met, cut back on distance, speed and hills, or switch to cycling or swimming for a while. Avoid hill sprints and speedwork until strength is restored.
Prevention
- Build up training gradually – avoid sudden jumps in distance, speed, hills or jumping
- Plan recovery days, especially during tournaments and race build-ups
- Strengthen your calves year-round with heel raises, even when pain-free
- Be careful with changes in surface, footwear or running shoes – make them gradually
- Act early on Achilles stiffness or pain – early load adjustment settles symptoms much faster than waiting
- Manage general health – body weight, diabetes and cholesterol
When to See a Specialist
Book a review if:
- Pain has lasted more than 4–6 weeks despite reducing your training
- Pain affects walking or daily life
- There is a lump or significant swelling on the tendon
- Physiotherapy hasn't helped after about 3 months
- You need guidance before an important race or season
Seek same-day care for a sudden pop or kick in the calf with loss of push-off – this may be a rupture.
How Sports Orthopedics Institute Can Help
Our team in HSR Layout, Bengaluru offers accurate diagnosis with ultrasound, structured loading programmes with our physiotherapists, shockwave therapy where appropriate, and surgery for the small number who need it.
Book at sportsorthopedics.in or call +91 6364538660 / +91 9008520831.
Frequently Asked Questions
How long does Achilles tendinopathy take to heal?
Early cases often settle in 6–12 weeks with load management. Established cases usually need 3–6 months of progressive strengthening, and some long-standing or insertional cases take longer.
What is the best exercise for Achilles tendinopathy?
Progressive calf loading. Heavy slow resistance calf raises and eccentric heel drops work equally well in trials, so pick the one you can do consistently. For insertional pain, keep heel drops on flat ground.
Can I keep running?
Usually, at reduced volume, if pain stays mild (around 3–4 out of 10) and settles by the next morning.
Should I get a PRP injection?
Although certain evidence in a 240-patient trial says PRP was no better than a sham injection, there are select patients in whom PRP Injection may be beneficial.
Should I get a steroid injection?
Steroid injections into the Achilles tendon are generally avoided because they may weaken it.
Is tendinopathy the same as a tear?
No. Tendinopathy develops gradually and the tendon is intact. A rupture happens suddenly, with loss of push-off, and needs urgent assessment.
Will I need surgery?
Most people don't. Surgery is considered only after at least 6 months of well-supervised rehabilitation without adequate improvement.
Does the tendon return to normal?
Most people regain full function, even if the tendon still looks thickened on a scan. How it feels and performs matters more than how it looks.
How much does treatment cost in India?
Costs vary with the stage and the facility. A typical conservative course – consultation, an ultrasound and several months of physiotherapy – commonly costs in the range of ₹20,000 to ₹60,000; shockwave therapy or surgery adds to this. We will give you a personalised estimate at consultation.
References
- Chimenti RL, et al. Achilles pain, stiffness, and muscle power deficits: midportion Achilles tendinopathy – revision 2024. J Orthop Sports Phys Ther, 2024;54(12):CPG1–CPG32.
- Beyer R, et al. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. Am J Sports Med, 2015;43(7):1704–1711.
- Kearney RS, et al. Effect of platelet-rich plasma injection vs sham injection on tendon dysfunction in chronic midportion Achilles tendinopathy. JAMA, 2021;326(2):137–144.
- Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion Achilles tendinopathy: a randomized controlled trial. Am J Sports Med, 2009;37:463–470.
Medical disclaimer: This article is for patient education only and does not replace advice from a qualified healthcare professional.