Health condition · Clinically reviewed
Achilles tendinopathy, insertional and mid-portion — modern loaded rehab.
Overuse tendon pain, not “tendinitis”. Loaded rehabilitation (Alfredson eccentric and heavy slow resistance) is first-line. Injections and surgery reserved for select refractory cases.
Why trust this guide
- 01
Clinically reviewed
Written by our editorial team and reviewed by a registered UK clinician before publication.
- 02
Sourced from guidance
Every claim is checked against BOFAS, BJSM and peer-reviewed sources you can see at the end.
- 03
Current for 2026
Reflects current UK guidance on loaded rehab, shockwave, PRP and modern surgery.
Key facts
Achilles tendinopathy at a glance.
The essentials, in plain English — what tendinopathy is, why it is different from a torn Achilles, and what the evidence says actually helps.
-
Definition
Achilles tendinopathy is an overuse tendon disorder — degenerative and not primarily inflammatory, so the older term “tendinitis” is misleading.
-
Two patterns
Insertional tendinopathy sits at the bone-tendon junction; mid-portion tendinopathy affects the tendon 2–6 cm above the heel.
-
Who gets it
Runners and middle-aged adults are most commonly affected — often with a step-up in training load or sedentary years followed by return-to-sport.
-
Rehab is the mainstay
Loaded rehabilitation — Alfredson eccentric loading or heavy slow resistance (HSR) — is the first-line treatment for both patterns.
-
Avoid intratendinous steroid
Intratendinous cortisone carries a real risk of tendon rupture and is avoided — peritendinous, image-guided options are used with care.
-
Shockwave and PRP
Extracorporeal shockwave therapy and platelet-rich plasma are considered for refractory disease that has not settled with 6+ months of loaded rehab.
Why this guide matters
Load the tendon, don’t inject it.
Achilles tendinopathy responds to loaded rehabilitation, not rest and cortisone — this guide sets that order out clearly so nobody skips ahead too fast.
-
Loaded rehab beats rest
Structured Alfredson or HSR loading, done for months, outperforms rest and short-term fixes over the medium term.
-
Intratendinous steroid is out
Cortisone into the tendon weakens it and risks rupture — the modern pathway avoids it in favour of loading and image-guided options.
-
Shockwave and PRP when things stall
For genuinely refractory disease, ESWT and PRP have a place — well before considering open surgery.
How the diagnosis is made
From painful tendon to a clear plan.
The steps a UK GP will normally follow, in order — so you know what to expect and why.
Phase 1 · Recognising
Symptoms and clinical examination
Phase 2 · Confirming
Imaging, tear exclusion and strength testing
Phase 3 · Managing
Physio first, specialist if refractory
- 01
Recognising
Symptom pattern
Start-up pain after rest and pain that returns after activity — a very characteristic story for tendinopathy rather than acute injury.
- 02
Recognising
Clinical examination + palpation
Local tenderness at the insertion or mid-portion, a fusiform thickening and pain on single-leg heel raise are the classic findings.
- 03
Confirming
Ultrasound / MRI if uncertain
Imaging is reserved for uncertain diagnosis, atypical pain or when a partial tear is suspected — most cases are diagnosed clinically.
- 04
Confirming
Rule out partial tear
A palpable defect, sudden change in pain or weakness on heel raise should prompt imaging to exclude a partial or full-thickness tear.
- 05
Confirming
Assess calf strength deficits
Objective single-leg heel-raise testing quantifies calf weakness and sets a baseline for the loaded rehab programme.
- 06
Managing
Physiotherapy assessment
A tendon-literate physiotherapist prescribes and progresses a loaded rehab programme — the single most useful intervention.
- 07
Managing
Foot & ankle surgery referral
For genuinely refractory cases after 6+ months of good rehab — for shockwave, PRP, tenotomy or open surgery in select patients.
Typical timeline: 2–4 weeks from first appointment to a settled plan.
Symptoms
What Achilles tendinopathy actually feels like.
The pattern is more telling than any single symptom — start-up pain, post-activity soreness and a thickened, tender tendon.
-
Morning start-up pain
Pain and stiffness on the first few steps of the morning, easing as the tendon warms up — a classic tendinopathy feature.
-
Post-activity pain
Pain that appears after — rather than during — a run or walk, sometimes hours later or the next morning.
-
Stiffness in tendon
A tight, ropey feeling in the tendon after rest or first thing in the morning that loosens with gentle movement.
-
Fusiform nodule mid-portion
A palpable, spindle-shaped thickening 2–6 cm above the heel — the hallmark of mid-portion tendinopathy.
-
Insertional pain at heel
Pain and tenderness right at the back of the heel where the tendon inserts into the calcaneus.
-
Haglund’s deformity
A bony prominence at the back of the heel that can rub in shoes and coexist with insertional tendinopathy.
-
Weight and load management
Body weight and rapid changes in training load are strong drivers — steady progression matters as much as the exercises themselves.
-
Red flag
Sudden pop with weakness — suspect Achilles rupture and go to A&E the same day rather than treating as tendinopathy.
Treatment
How Achilles tendinopathy is treated in the UK.
A staged approach — loaded rehab and simple aids first, then shockwave and image-guided options, with surgery reserved for genuinely refractory disease.
-
Alfredson eccentric loading
A well-studied protocol of 3×15 eccentric heel drops twice daily, straight and bent-knee — the classic first-line loaded rehab programme.
-
Heavy slow resistance (HSR)
Slow, heavy calf raises 3× a week — modern evidence suggests HSR matches Alfredson with better patient adherence.
-
Silicone heel raise
A small heel lift offloads the insertion and helps early symptom control in insertional tendinopathy while rehab progresses.
-
Extracorporeal shockwave therapy (ESWT)
A course of focused or radial shockwave — genuine evidence in refractory tendinopathy when 6+ months of loaded rehab has not settled things.
-
Platelet-rich plasma (PRP)
An option in specialist hands for refractory mid-portion disease — evolving evidence, considered alongside shockwave rather than as a first move.
-
High-volume image-guided injection
A peritendinous saline injection to disrupt neovascular in-growth — considered for refractory mid-portion tendinopathy under ultrasound guidance.
-
Percutaneous tenotomy
A minimally invasive needle procedure to stimulate healing in chronic tendinopathy — used selectively for refractory disease.
-
Open debridement / gastrocnemius recession
Reserved for refractory insertional disease — debridement of degenerate tendon, removal of Haglund’s prominence and, in selected cases, gastrocnemius recession.
What this guide is based on
The sources behind every claim on this page.
UK national guidance and specialist society standards, current at the time of last review.
Key references
Guidelines and standards we relied on.
A quiet reminder
This guide is for information, not medical advice.
Your GP, physiotherapist or foot and ankle team knows your history and can tell you which parts apply to you. If in doubt, get seen.
-
British Orthopaedic Foot and Ankle Society (BOFAS). Patient information and clinical standards.
-
British Journal of Sports Medicine (BJSM). Consensus statements on Achilles tendinopathy.
-
Alfredson H. Eccentric heel-drop protocol — original and follow-up trials.
-
American Academy of Orthopaedic Surgeons (AAOS). Achilles tendinopathy resources.
Red flags
When Achilles pain is not just tendinopathy.
Most Achilles pain is overuse tendinopathy and settles with loading. These are the situations where a different diagnosis needs to be considered.
-
Acute rupture
Sudden pop, calf weakness and a palpable gap — needs same-day A&E review, not a tendinopathy pathway.
-
Systemic inflammatory arthritis
Insertional pain with other joints or spinal stiffness — consider seronegative spondyloarthropathy and refer to rheumatology.
-
Diabetic tendon disease
Diabetes changes tendon biology and healing — a lower threshold for imaging and specialist input is sensible.
-
Fluoroquinolone-associated tendinopathy
Recent ciprofloxacin or similar antibiotic can trigger tendon pain and rupture — stop the drug and review urgently.
-
Post-injection rupture
Sudden pain and weakness after any peritendinous injection — needs urgent orthopaedic assessment.
-
Bilateral aggressive disease
Bilateral, severe tendinopathy in a younger patient warrants a broader search for inflammatory, metabolic or drug-related causes.
-
Failed 6-month conservative care
Persistent symptoms after a proper 6-month loaded rehab programme should be reviewed by a foot and ankle surgeon.
-
Neuropathic differential
Burning, tingling or radicular pain suggests a nerve source (sural, S1 radiculopathy) rather than tendinopathy.
-
Complex regional pain syndrome
Disproportionate pain, allodynia and skin changes after minor injury or surgery — needs a broader pain assessment, not more injections.
Living with it
A slow condition, but a very manageable one.
Four things that make the biggest difference day to day — loading, footwear, gradual return and patient review.
A quiet reminder
Consistency beats intensity, every time.
Small, steady changes — kept up for months — do more than a heroic week that does not last.
- 01 Rehab
Do the loading, daily
Alfredson or HSR done consistently over months — dull, unglamorous and the single biggest lever in tendinopathy recovery.
- 02 Footwear
Support the heel
Supportive shoes with a small heel raise for insertional disease — avoid barefoot on hard floors while symptoms are active.
- 03 Load
Progress load gradually
Return-to-run and training progressions in small, planned steps — sudden jumps in mileage or intensity reliably flare the tendon.
- 04 Reviews
Reassess in weeks, not days
Loaded rehab takes weeks to months to work — reassess at 6–12 weeks, and consider shockwave or specialist referral if things stall.
Frequently asked
Everything we get asked about Achilles tendinopathy.
Quick answers on loading, shockwave, PRP, cortisone and when to seek help.
-
What actually causes Achilles tendinopathy?
It is an overuse tendon disorder — the collagen and cellular structure of the tendon change under repeated load. Rapid increases in training, tight calves, higher body weight and certain drugs (notably fluoroquinolone antibiotics) are the main drivers, not a single injury.
-
How long does it take to get better?
Most cases settle over 3–6 months with consistent loaded rehab, with some taking up to a year. It is genuinely slow — reassuring people that this is normal is a big part of managing it well and avoiding jumping to injections too early.
-
Do I need a scan?
Not usually. The diagnosis is clinical. Ultrasound or MRI is reserved for uncertain cases, when a partial tear is suspected, or when symptoms have not responded to several months of good loaded rehab.
-
Does shockwave therapy actually work?
Yes — extracorporeal shockwave therapy (ESWT) has real evidence in refractory Achilles tendinopathy, particularly mid-portion disease. It is typically offered after 6+ months of failed loaded rehab as a course of 3–5 sessions.
-
Why is cortisone avoided?
Intratendinous cortisone can weaken the tendon and precipitate rupture, so it is avoided in Achilles tendinopathy. Peritendinous, image-guided options — such as high-volume injections — are used selectively and never as a shortcut past rehab.
-
What is the red flag I should not ignore?
A sudden pop with weakness — the inability to push off or do a single-leg heel raise — suggests an Achilles rupture and needs same-day A&E review rather than a tendinopathy pathway.
Related content
Keep reading.
-
Achilles tendon rupture
Acute tendon injury — recognition and repair.
Learn more -
MSK ultrasound
Imaging the Achilles tendon and soft tissues.
Learn more -
Running form basics
Load management for feet, calves and tendons.
Learn more -
All conditions
The full A–Z of our patient guides.
Learn more -
Musculoskeletal MRI
Related diagnostic test.
Learn more -
X Ray
Related diagnostic test.
Learn more -
Cortisone Shots
Related treatment option.
Learn more -
Chondroplasty
Related treatment option.
Learn more
Nearby in the library