The first steps out of bed tell the story. The back of your heel is stiff and sore, you hobble to the bathroom, and ten minutes later it feels almost normal, until you sit at your desk for an hour and stand up again. That pattern, pain that warms up and then comes back, is the fingerprint of an Achilles tendon problem.
People still call it tendonitis, and we use that word in the title because it is the word everyone searches for. Clinicians mostly say tendinopathy now, because when researchers look at sore Achilles tendons under a microscope, they usually do not find much inflammation. What they find is a tendon that has been loaded beyond what it could handle and has started to change, thicker, less organised, less able to spring. That distinction matters, because a tendon in that state does not need anti-inflammatory thinking. It needs load, dosed properly.
Why it happens
The Achilles is the largest tendon in the body, and it works hard. It can handle forces many times your bodyweight when you run or hop. Problems usually start with a change: a new running program, a sudden jump in hill work, a return to sport after a quiet winter, or a change in footwear. Sometimes there is no obvious trigger, and it creeps in alongside weight gain or a new job that keeps you on your feet on concrete floors.
There are two common sites. Mid-portion pain sits a few centimetres above the heel bone, where the tendon often thickens into a tender lump. Insertional pain sits right where the tendon attaches to the heel, and it behaves a bit differently, deep heel raises off a step can aggravate it, so the program changes.
How physiotherapy helps
The core of treatment is a progressive loading program, and this is where most people go wrong in both directions. Complete rest makes the tendon weaker and less tolerant, so the pain returns the moment you resume activity. Pushing through hard training keeps it irritated. The middle road is heavy, slow resistance work, usually heel raises, built up gradually in weight and range, done consistently over about twelve weeks.
The JOSPT clinical practice guideline on Achilles tendinopathy recommends exactly this approach: mechanical loading as the central intervention, with load management education around it. In our visits, we sort out which activities to trim rather than cut, check your calf strength side to side, look at what your foot and hip are doing, and set the home program at a level your tendon accepts. A useful rule: some discomfort during exercises is acceptable if it settles back to baseline by the next morning. Pain that is still worse 24 hours later means the dose was too big.
What recovery usually looks like
Tendons change slowly. Most people notice the morning stiffness easing within three to four weeks of consistent loading, but full rebuilding takes around three months, sometimes longer for insertional pain. That timeline frustrates runners at first. Then they notice they are doing single-leg heel raises with a backpack on, and the tendon that screamed at a slow jog is quiet. Strength is the outcome that matters most, because a strong calf is what protects the tendon when you go back to sport.
What you can do at home
- Keep moving. Short, frequent walks usually beat one long one early on.
- Try a small heel lift in your shoes for a few weeks if the pain is at the insertion.
- Start gentle heel raises on flat ground, both legs, and progress slowly, your physiotherapist will set the dose.
- Avoid sudden spikes: add distance or hills one at a time, not together.
- Skip aggressive stretching into the tendon if your pain is at the heel bone itself.
When to get it checked promptly
If you felt a pop or a kick in the back of the leg, cannot push off, or the tendon went suddenly weak, that is a possible rupture and needs same-day assessment. Gradual pain that is not improving after six to eight weeks of sensible loading also deserves a closer look.
References
- Martin RL, Chimenti R, Cuddeford T, et al. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018: Clinical Practice Guidelines. Journal of Orthopaedic & Sports Physical Therapy. 2018;48(5):A1–A38. doi:10.2519/jospt.2018.0302
- Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine. 2009;43:409–416. doi:10.1136/bjsm.2008.051193
General information only, not medical advice. If you are dealing with Achilles pain, an assessment can sort out which type you have and set the loading dose for you.