Achilles tendon pain? Which type do you have?

Massage on runners calf and Achilles tendonIf you have suffered from Achilles pain in the back of the heel or calf you know how long it can last and how bad it can be. Understanding why you’re getting Achilles pain plays a big role on the road to recovery and prevention.  The pain is often due to Achilles tendinopathy and used to be called Achilles tendinitis; “itis” means inflammation and we now no longer believe that it involves inflammation so we don’t use that term anymore.  Either way, Achilles tendinopathy is one of the most common runners’ injuries that I see at Sundial Clinics here in Brighton. In this series of articles you will learn some of the ways in which you can avoid, treat and manage this common and troubling tendon pain. 

Types of Achilles tendinopathy?

First off, it is important to establish exactly what is causing the problem and exactly what type of Achilles pain you have.  There can be several other reasons why you may be getting Achilles symptoms, but for the purpose of this article, we will concentrate on the most common.

Recent studies have shown that injury rates are as much as 29-58% in new runners. It’s also estimated that 60-70% of running injuries are due to overuse or training error.

In other words, don’t just concentrate on the painful point!  Rehabilitation from an injury can be complicated and unless you’re addressing the root cause of the problem, it’s likely to come back!  This is why seeing a physio can be useful: we can help you to understand the reasons for your symptoms and help you address the imbalance and weakness which may lead to injury.  


Diagram of Achilles tendinopathy, tendinitis

Mid Portion Achilles Tendinopathy

The most common cause of Achilles pain is mid-portion Achilles tendinopathy. This commonly affects the Achilles 2-7cm above the bony point at the back of the heel.  Typically, this is likely to appear swollen, be tender to touch and will often cause pain and stiffness first thing in the morning and when weight-bearing.

Insertional Achilles Tendinopathy

This condition is less common but still a prevalent problem that I see in the clinic.  The key difference between the two is that mid-portion tendinopathies are commonly caused by tensile loading and insertional tendinopathies are caused by compression.  

The main presentation for the insertional kind is a pain at the heel bone where the Achilles attaches and pain with the ankle flexed to stretch the tendon i.e. the position of the foot when walking up a steep hill.  This position of the foot is what causes the compression and aggravates the symptoms – and why exercises that exacerbate this should be avoided!

Below I will outline the best way to manage these conditions, along with links to some self-help videos for exercise and pain management.  However, it’s probably worth mentioning at this stage that these are only to be used as a rough guide and if you are unsure about your condition please book yourself in for a physio consultation.  The first appointment is free! And it may help you avoid getting it wrong and potentially delaying your healing time.

Tendinopathy Phases

Now that you have a rough idea of why you have tendinopathy, you now need to figure out what stage of tendinopathy you are dealing with.  To avoid going full physio geek on you, we’ll keep this simple and concentrate on two phases of tendinopathy, the first being the reactive type and the second being the degenerative tendinopathy. 

Phase One – Reactive Tendinopathy

Commonly caused by an increase in loading exercise, for example trying to run faster or further than you’ve ever done before…we’ve all done it!  This will typically cause pain during or after the activity and may be exacerbated first thing in the morning or during weight-bearing activity.  

The key to your management at this stage is to reduce the load that you’re putting through your Achilles and try and calm the symptoms down.  It’s pretty simple: if you carry on doing the same thing at the same pace and effort then you are likely to make it worse!

Phase Two – Degenerative Tendinopathy

At the tender age of 41 and having played sports for most of my life, sadly I would fit into this category.  In fact, I would say it is almost normal to have a degenerative tendon somewhere in your body if you’ve been active for most of your life, especially with high impact sports such as running, football, netball and basketball. So do not fear – this is common!  

Basically, if you’re older and have a previous history of Achilles pain and a grumbly tendon that is prone to flare-ups, it’s likely that you will also fit into this category.  The typical presentation is a thickened tendon, which is painful to touch and is often sore first thing in the morning and during weight-bearing activity. Again, load management is important. If you keep aggravating it, there is potential to make the situation chronic and potentially lead to a partial or full Achilles rupture.

It is also possible to have a reactive, degenerative tendon.  An example of this would be a 60-year-old man who has a history of Achilles pain with symptoms which have been under control for several years, but a recent increase in tennis has caused his degenerative tendon to become reactive.  If this is the case with you, then start your management at the reactive phase i.e. reduce the load, pain management, rehab exercises then graded return to activity.  Tendons are complicated and there is no one recipe for treatment. Finding the right treatment is an important part of your recovery.

Now that we have the geeky part out of the way, let’s look at treatment. Part Two is a step by step guide to recovery for both the mid-portion and insertional Achilles tendinopathy. Click to read it

James Masterson


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