Understanding Achilles Tendon Pain: Causes, Diagnosis, and Treatment

Pain in the Achilles tendon can range from a mild inconvenience to a debilitating injury. To

effectively treat it, the first step is to determine which structure is actually causing the pain —

because the treatment for each condition can be very different.

There are four main causes of Achilles tendon pain:

• Mid-tendon tendinopathy

• Insertional tendinopathy

• Tendon sheath irritation

• Achilles tendinitis

Tendinopathy vs Tendinitis

The term tendinopathy has largely replaced tendinitis in recent research. Tendinopathy refers

to structural changes in the tendon rather than just inflammation. Achilles tendinopathy is

common in elite athletes, recreationally active individuals, and so-called 'weekend warriors.'

1. Mid-tendon Tendinopathy

The most common form occurs about 3 cm (1") above the heel bone.

- Pain may be accompanied by swelling or thickening but can also look normal.

- The tendon often feels better once 'warmed up' but worsens after activity and the next

morning.

2. Insertional Tendinopathy

This type affects the tendon where it attaches to the heel bone.

- Pain is localized directly at the insertion.

- It can feel pinpoint and sharp, or more diffuse across the attachment area.

3. Tendon Sheath Irritation

The tendon sheath (covering of the tendon) can also become irritated.

- Pain is diffuse, with possible swelling.

- The tendon may feel crunchy during ankle movement, and sometimes a physiotherapist can

hear a sandpaper-like sound with a stethoscope.

- Pain often worsens with ongoing activity.

4. Achilles Tendinitis

A true tendinitis is an acute inflammatory response to overload.

- The tendon becomes painful and swollen after sudden excessive use.

- With rest and support, symptoms usually settle within 10–14 days.

Treatment Goals in Manual Physical Therapy

1. Correct Diagnosis

The first goal is identifying the exact source of pain — because treatment differs significantly between mid-tendon, insertional, sheath irritation, and acute tendinitis.

2. Unloading the Tendon

Reducing stress on the Achilles is critical. This involves:

- Biomechanical assessment of the foot, ankle, knee, hip, pelvis, and spine.

- Addressingl dysfunctional areas with manual therapy, stretching, mobilization, exercise, and taping.

- Supportive strategies like proper footwear, heel lifts, night splints, K-tape, and sometimes orthotics.

-Shockwave therapy using the Swiss Dolorclast can be effective for tendon pain.

- Education on what activities can safely continue — including guidance on frequency,

distance, and intensity.

3. Progressive Exercise

A structured exercise program is key for rehabilitation and prevention

- Acute phase: isometric holds (10–30 seconds) can reduce pain and protect the tendon.

- Less acute or mid-tendon pain: both eccentric (lengthening under load) and concentric

(shortening under load) exercises are recommended.

- The program must carefully balance progressive loading with adequate recovery to promote healing, improve strength, and restore flexibility.

- Later stages of rehabiliation may include sport-specific or plyometric drills to help get back to activity / sport.

Final Word

Every Achilles injury is unique. Exercise dosage, progression, and manual therapy techniques should be tailored to your specific diagnosis, guided by the best available research and your physiotherapist’s clinical expertise.