Achilles Tendinopathy – Risk Factors and Management


An Article Written by Yen-Chii Wong
Podiatrist – New Step Podiatry

The Achilles tendon is what connects your main calf muscles (the gastrocnemius and soleus) to the heel bone (calcaneus). It acts as a spring for your ankle and leg when it undergoes forces approximately 6-8 times of body weight when running (Lee at el., 2019).

Achilles tendinopathy is a term for pain, swelling, and impaired function of the Achilles tendon. It can affect the midportion of the tendon or the insertional tendon (where it connects to the heel bone). Common symptoms of Achilles tendinopathy include stiffness in the morning that warms up after a few steps and pain that increases with higher impact or more load on the tendon (this includes activities like jumping, hopping, or running). In fact, according to de Vos et al. (2021) runners have a 52% chance of having an Achilles tendon injury in their lifetime.

What are the risk factors for Achilles tendinopathy?

There isn’t a lot of solid evidence that backs up the reliability of risk factors and their role in predicting and preventing Achilles tendinopathy from occurring. BUT, in saying this we can rely on clinical experience and smaller case studies to form a list of potential risk factors. These include:

– A previous history of injury to the Achilles or calf

– Sudden increase in activity that requires the use of Achilles (e.g. increase or change in training, starting a new job with a lot of time spent standing or walking, change in footwear)

– Change to shoes with a different heel pitch

– Direct trauma to the area

– Older age

– Reduced calf strength

– Reduced ankle dorsiflexion (ability to move the foot up towards the leg)

– Having a chronic condition that affects tendon quality, for example diabetes or rheumatoid arthritis

What are other causes of pain in the back of the heel?

If your pain or function isn’t improving with treatment for Achilles tendinopathy, it might be misdiagnosis. Other causes of heel pain in this area include:

Retrocalcaneal or superficial calcaneal bursitis

Bursitis is inflammation of a bursa, which is a fluid-filled sac that helps to reduce friction between bone and tendons or muscles. In the heel, there is a bursa that sits between the Achilles tendon and the calcaneus, and another that sits on top of the tendon, closer to the skin. Irritation to these bursas can occur with repetitive friction. Retrocalcaneal bursitis is commonly seen with insertional Achilles tendinopathy and a Haglund’s deformity (a bone spur).

Achilles paratenonitis

The paratenon is a thin sheath that surrounds the Achilles tendon. Paratenonitis is inflammation of this structure and occurs mainly due to friction from repetitive loading. The area can become red, swollen, and hot to touch. The symptoms normally get worse with more exercise, which is different from tendinopathy which typically decreases as it warms up.

Sural nerve entrapment

The sural nerve sits along the calf and travels just outside of the Achilles tendon. Impingement of the nerve can feel like pins and needles, burning, or numbness on the side of the Achilles tendon.

Plantaris tendinopathy

The plantaris is a smaller and often overlooked calf muscle (we love an underdog!). It travels just next to the Achilles tendon. Plantaris tendinopathy is normally in a location that is a bit higher than a midportion Achilles tendinopathy.

Posterior ankle impingement

Pain can be vague in location and always replicated with plantarflexion (pointing down) of the ankle. Pain caused by impingement generally doesn’t increase when load is increased. This is a common diagnosis in ballet dancers and soccer players as their sport requires a lot of time with the ankle in a flexed position. It can sometimes be exacerbated by an accessory bone, known as the os trigonum.

Does my Achilles or calf need imaging?

Most of the time, imaging is not needed to diagnose Achilles tendinopathy. A thorough clinical examination and understanding of the history of your injury is normally sufficient for us to make a diagnosis. We know that structural changes seen in imaging aren’t always linked with pain levels – someone with large pathologies in tendon scans may experience no pain and vice versa – so we don’t solely rely on imaging for your diagnosis. In some cases, your podiatrist may decide that an ultrasound or MRI is necessary to rule out other potential causes of heel pain.

What to expect in an Achilles injury assessment by a Podiatrist

Your podiatrist will do a thorough biomechanical and musculoskeletal assessment, where we will gather information about you. This can include:

– Medical history (including any issues affecting your hips, knees, legs, ankles, and feet)

– Your activity levels

– Desired outcomes you wish to reach from seeing us

– Joint movement and muscle strength, both overall and specific to your injury

– Achilles tendon specific testing

– Foot and ankle posture and movement

– Shoe assessment

– Walking and/or gait analysis (in the hallway, using a treadmill or with PodoSmart insoles)



How can a Podiatrist treat Achilles tendinopathy?

1. Keep moving!

Tendons LOVE load. Most of the time, a painful tendon is due to too much or sudden increases in load. Your podiatrist will help you modify your current activities to reduce this load on the tendon while it’s sore.

2. Calm the Achilles tendon down and keep it happy

This can be done through reducing activity that puts more load on the Achilles tendon, adding in-shoe padding, applying strapping, manual therapies, changing footwear, or wearing foot orthoses.

3. Strengthening and progressive loading

Your exercise program will depend on your level of activity, goals that you wish to achieve from your rehabilitation, time constraints you may have, and equipment you own.

4. Be patient!

As much as we’d like for your Achilles pain to disappear in a flash, there is a chance that symptoms can persist for a while. Your podiatrist can guide you through this process.


de Vos, R., van der Vlist, A. C., Zwerver, J., et al (2021). Dutch multidisciplinary guideline on Achilles tendinopathy. British Journal of Sports Medicine. 55(1125-1134).

Lee, K. K. W., Ling, S. K. K., & Yung, P. S. H. (2019). Controlled trial to compare the Achilles tendon load during running in flatfeet participants using a customized arch support orthoses vs an orthotic heel lift. BMC Musculoskeletal Disorders, 20(535).

van der Vlist, A. C. , Breda, S. J., Oei, E. H. G., et al (2019). Clinical risk factors for Achilles tendinopathy: a systematic review. British Journal of Sports Medicine, 20(1352-1361).

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