Achilles Tendon Injury

Achilles Tendon Injury


‘Even Achilles was only as strong as his heel’


What is it?

The Achilles tendon attaches the calf muscles to the heel and is the thickest and strongest tendon

Achilles Tendon

in the body.  When the calf muscle contracts, this pulls on the Achilles tendon, pushing the foot downwards (during running, walking and jumping). Each Achilles tendon is subject to your entire body weight with each step and that can be further increased by 3-12 times during a sprint or push off (dependent on speed, stride, terrain and additional weight).


All Achilles tendon injuries are different, starting as something minor (and relatively quickly reversible) but can easily progress to a more severe injury. Ultimately the tendon can rupture, requiring urgent medical attention and long rehabilitation, so it’s important to look for early signs and symptoms.


Signs and Symptoms:achilles tendonitis

Usually pain comes on gradually, either at the site of the tendon or around the heel. The tendon may be tender to touch (especially 2-5cm above the heel) or around the insertion site with sharp localized pain.

Pain may be felt at the start of a game or training session, which may go after a ‘warm-up period’. As the injury progresses, pain will start to last longer into the game or training session. The pain may present again when the session is finished.

There may be stiffness in the area (particularly after prolonged rest i.e. in the morning) that gets better after walking around.


Potential Causes:

The main cause of injury is excessive stress/loading of the tendon without enough time to adapt to the load. Interestingly, physical activity does not always cause injury to the Achilles tendon – hint to all you ladies’ wearing Louboutins. It is important to acknowledge all intrinsic and extrinsic factors.

Intrinsic Factors include:

  • Avascularity of tendon.
  • Calf muscle weakness/imbalance.
  • Decreased flexibility and/or control of the lower limbs.
  • Genetic predisposition.
  • Biomechanical abnormality.


Extrinsic Factors include:

  • Changes in training pattern – an increase in training sessions.
  • Poor training technique.
  • Inadequate footwear.
  • Training surfaces (hard, slippery, slanting surface).
  • Increased lower limb weight training.



When you first notice early symptoms, management can often be very simple: change the amount of stress on the tendon by temporarily reducing the frequency, load and duration of exercise. Training sessions may involve changing training so you are not on your feet as much i.e. cycling, rowing and swimming. In the early stages, it is also advisable to avoid lots of jumping.

A study conducted comparing physiotherapy treatment and a control group (no treatment) illustrated significant improvements in activity-related pain for the physiotherapy treatment group incorporating transverse friction massage, therapeutic ultrasound, ice and an exercise programme consisting of eccentric, concentric, balance and proprioception activities (1).

A Physiotherapy led exercise programme initiating a period of controlled loading to the tendon is person lowering heels off steprecommended in order to avoid further damage. The best way of doing this is through slow lowering of the heel from the toe position on a step otherwise widely used as an eccentric exercise protocol known as the Alfredson protocol (2). Ideally this should be done on one leg, but if this is too painful, you can make it easier by using both feet.

Exercises should be followed in a controlled systematic manner to ensure safe progression.

It is important to ensure sufficient load on the tendon (as most people do not use enough weight progression), only progress to harder exercises when you can safely complete the lower levels.

Usually as the weight progresses, so too does the speed of the exercise. But do not sacrifice quality for speed!

Your return to sport/running should be graded and not cause any increase in your symptoms.


If you are experiencing any of the signs or symptoms or have a question about any of the issues discussed above, please do not hesitate to contact JT Physiotherapy.




  • Mayer, F., Hirschmuller, A., Muller, S., Schuberth, M. and Baur, H. (2007). Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy. British Journal of Sports Medicine, 41(7), pp.e6-e6.


  • Habets, B. and van Cingel, R. (2014). Eccentric exercise training in chronic mid-portion Achilles tendinopathy: A systematic review on different protocols. Scand J Med Sci Sports, 25(1), pp.3-15.



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cathal-ellis-jt-physio                            Cathal Ellis MISCP

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