Achilles Tendon Pain: What Helps and Why Is It Not Getting Better?
Achilles tendon pain can be incredibly frustrating and a common cause of foot and ankle pain.
You may have rested it, stretched it, completed weeks of calf raises and stopped running, only for the pain to return as soon as you try to increase your activity again.
This is one of the reasons Achilles tendinopathy can feel as though it simply will not heal.
In reality, recovery from Achilles tendon pain is rarely about finding one exercise or waiting for the tendon to completely rest. It usually requires understanding why the tendon has become painful, identifying what it currently has the capacity to tolerate and progressively rebuilding that capacity over time.
For many people, that process takes longer than they expect.
The good news is that most Achilles tendinopathy can be managed without surgery. The challenge is making sure rehabilitation is appropriately structured and progressed for the individual.
Table of Contents
What is Achilles tendinopathy?
The Achilles tendon connects the calf muscles to the heel bone and plays an important role in walking, running, jumping and pushing through the foot.
Achilles tendinopathy describes a painful condition affecting the tendon.
It is commonly divided into two presentations.
Midportion Achilles tendinopathy affects the tendon several centimetres above the heel.
Insertional Achilles tendinopathy affects the lower part of the tendon where it attaches to the heel bone.
This distinction can be important because the two presentations may require slightly different approaches to rehabilitation.
People commonly experience pain and stiffness when first getting out of bed, discomfort when beginning to walk or run and pain following periods of increased activity.
The tendon may also feel better once it has warmed up, only for symptoms to increase again afterwards or the following morning.
What causes Achilles tendon pain?
There is rarely one single cause.
Often there has been a change in the amount or type of load being placed through the tendon.
For a runner, this might involve increasing mileage, introducing hills, running faster, changing footwear or returning to running after a period of reduced activity.
But Achilles tendinopathy is not exclusively a running problem.
It can develop in people who walk, play racket sports, attend the gym or simply experience a change in their usual activity.
Age, general health and other individual factors can also influence tendon health and capacity.
Importantly, the activity that appears to trigger the symptoms is not necessarily the whole explanation.
Someone may feel their Achilles during a run, but the relevant question is often what the tendon has been asked to tolerate over the preceding days and weeks.
That is why understanding training and activity history can be just as important as examining the painful area itself.
Why does Achilles tendinopathy take so long to recover?
Tendons adapt relatively slowly.
That matters because rehabilitation is ultimately trying to increase the amount of load the Achilles can tolerate.
Reducing activity can often settle symptoms reasonably quickly. But feeling better after a period of rest does not necessarily mean that the tendon has regained the capacity required for running, sport or whatever activity originally provoked it.
This can create a familiar cycle.
The Achilles becomes painful.
Activity is stopped.
Symptoms improve.
The person returns to their previous level of activity.
The pain returns.
It can then feel as though the tendon has been repeatedly injured when, in reality, its capacity may never have been sufficiently rebuilt before the activity was reintroduced.
This is one reason recovery often needs to be measured in months rather than days or a couple of weeks.
Should you rest Achilles tendon pain?
Usually not completely.
Reducing particularly provocative activity can be sensible when symptoms are highly irritable.
That is different from avoiding load altogether.
Current clinical guidance recommends continuing activity within an individual's pain tolerance rather than prescribing complete rest for Achilles tendinopathy. Tendon loading exercise remains a central part of treatment.
The challenge is finding the appropriate amount.
Too much load can repeatedly aggravate symptoms.
Too little load may fail to provide the stimulus required to improve tendon and muscle capacity.
Rehabilitation therefore involves finding a starting point the Achilles can tolerate and progressively increasing demand from there.
Is it safe to exercise with Achilles tendon pain?
Often, yes.
One of the difficulties with tendinopathy is that waiting for absolutely no discomfort before exercising can sometimes result in unnecessary reductions in activity.
Some pain during rehabilitation does not automatically mean that the tendon is being damaged.
However, that does not mean pain should simply be ignored.
The response to exercise matters.
How does the Achilles feel during the activity?
What happens afterwards?
How does it feel later that day?
What happens the following morning?
Is function gradually improving?
These responses can help determine whether the current level of loading is appropriate.
Someone experiencing mild, predictable symptoms that settle quickly may be in a very different position from somebody whose pain escalates substantially and remains worse for several days after each session.
The exercise programme should reflect that difference.
What exercises help Achilles tendinopathy?
Calf strengthening is usually central to rehabilitation.
Historically, eccentric heel drops became almost synonymous with Achilles tendinopathy treatment.
They can be useful.
But they are not the only way to rehabilitate an Achilles tendon.
Contemporary rehabilitation can involve different forms of progressive tendon loading depending on the individual's presentation and goals.
This might include:
Isometric calf loading
Heel raises through an appropriate range
Seated calf raises
Standing calf raises
Progressing from two legs to one
Adding external resistance
Increasing speed where appropriate
Eventually introducing jumping, hopping or running specific loading
The programme should become progressively more demanding as capacity improves.
A person hoping to return to running or tennis eventually needs their Achilles to tolerate considerably more than a few bodyweight calf raises.
That progression is important.
Why do calf raises sometimes not work?
This is a common frustration.
Someone may say:
“I've already done the exercises for my Achilles and they didn't help.”
Sometimes the diagnosis needs reconsidering.
But often the issue is not that exercise itself has failed.
The rehabilitation programme may simply not have progressed far enough.
For example, three sets of ten bodyweight calf raises might initially be challenging.
After several weeks, the same exercise may become easy.
If the eventual goal is running, where the Achilles is repeatedly exposed to much higher forces, continuing indefinitely with exactly the same exercise is unlikely to prepare the tendon adequately.
Load matters.
Dosage matters.
Frequency matters.
Progression matters.
The response between sessions matters.
And the demands of the activity someone wants to return to matter.
This is why a generic exercise sheet may provide a reasonable starting point but cannot automatically provide a complete rehabilitation programme.
Can you run with Achilles tendinopathy?
Sometimes.
Running does not necessarily need to be completely avoided simply because an Achilles is painful.
The decision depends on the severity of symptoms, current tendon capacity, how symptoms respond to running and whether the overall trajectory is improving.
For someone with highly irritable symptoms, temporarily reducing or stopping running may be appropriate.
For somebody further through rehabilitation, continuing a reduced amount of running while building strength may be entirely reasonable.
Eventually, rehabilitation needs to bridge the gap between strengthening exercises and the demands of running.
That might involve gradually increasing walking tolerance before introducing a walk and jog programme, then progressively changing running duration, frequency, speed or terrain.
Trying to progress all of those variables simultaneously can make it difficult to understand what the Achilles is actually tolerating.
A graded return is generally more useful.
Do you need a scan for Achilles tendon pain?
Not routinely.
Achilles tendinopathy can often be diagnosed through the history and clinical examination.
Ultrasound and MRI can identify structural changes within the tendon, but those findings need to be interpreted in context.
Structural abnormalities can exist without symptoms, and the appearance of a tendon does not necessarily tell us how painful it will be or what somebody is capable of doing.
Imaging becomes more useful when the diagnosis is uncertain, symptoms are behaving unexpectedly, there has been a significant injury, or the result is likely to change management.
Again, the question is not simply:
Can we see something abnormal on a scan?
It is:
Would imaging provide information that changes what we do next?
Do injections help Achilles tendinopathy?
Injections are sometimes discussed when Achilles tendon pain persists, but they should not usually be the starting point.
It is also important not to treat all injections as though they are the same intervention.
Corticosteroid injections have historically been used for tendon problems, but their use around the Achilles is approached cautiously. They are not routinely recommended as a treatment for Achilles tendinopathy, particularly given concerns around the tendon and uncertainty about longer term benefit.
Other injectable treatments have therefore attracted considerable interest.
PRP injections
Platelet rich plasma, usually referred to as PRP, involves injecting a concentration of the patient's own platelets around or into the affected area.
It sounds biologically appealing and is now offered by many private providers.
However, popularity should not be confused with evidence of effectiveness.
Research examining PRP for Achilles tendinopathy has not demonstrated convincing improvements in pain or function compared with placebo.
That does not mean nobody ever reports improvement following PRP.
It means that, when comparing groups scientifically, current evidence does not support presenting PRP as a reliably effective treatment for Achilles tendinopathy.
High volume injections
High volume injections are another intervention sometimes considered for persistent midportion Achilles tendinopathy.
There is some promising evidence, particularly around shorter term outcomes, but uncertainty remains regarding longer term effectiveness and which patients are most likely to benefit.
As a result, they should not simply be viewed as the automatic next step when rehabilitation has not worked.
For most people, appropriately progressed tendon loading remains central to management.
If symptoms persist despite well structured rehabilitation, the first question should not automatically be:
Which injection should I have?
It should be:
Why has this not improved as expected?
That may lead us towards modifying rehabilitation, reconsidering the diagnosis, obtaining imaging or, in selected circumstances, considering another intervention.
When should persistent Achilles pain be reassessed?
If symptoms are not improving despite appropriate rehabilitation, it is worth reconsidering the clinical picture.
Not every pain around the Achilles is straightforward Achilles tendinopathy.
Other conditions can affect the back of the ankle and heel, and insertional Achilles problems can behave differently from midportion tendinopathy.
A partial tendon tear may occasionally need to be considered, particularly where there has been an appropriate mechanism or unexpected loss of function.
The rehabilitation programme itself should also be reviewed.
Has loading actually been progressed?
Has the calf become stronger?
Has overall activity been appropriately managed?
Are repeated spikes in running or walking load continuing to aggravate symptoms?
Is the programme preparing the person for what they actually want to return to?
Are there health factors that might influence tendon recovery?
But nor should somebody continue doing the same programme indefinitely simply because they have been told that tendons take a long time to recover.
Reassessment should determine what needs to change.
How long does Achilles tendinopathy take to recover?
There is no single recovery time.
Milder presentations identified early may improve relatively quickly.
Longstanding Achilles tendinopathy, particularly where symptoms have been present for many months and physical capacity has significantly reduced, commonly requires a much longer rehabilitation period.
For many people, meaningful rehabilitation takes several months.
Returning to higher demand activities such as running and racket sports can take longer because becoming relatively comfortable during everyday walking is very different from restoring the capacity required for repeated high force loading.
This is why I am cautious about promising somebody that Achilles tendinopathy will resolve in six weeks or after a particular number of treatment sessions.
The more useful markers are whether symptoms are becoming more manageable, strength and capacity are improving and the person is progressively returning to the activities that matter to them.
What if your Achilles tendon pain is not getting better?
Persistent Achilles pain does not necessarily mean you need a scan, injection or surgery.
It does mean that the situation deserves proper reassessment.
This is where the reasoning involved in an Advanced Physiotherapy assessment can be particularly useful.
The aim is to establish whether the diagnosis still makes sense, understand what the tendon currently has the capacity to tolerate and determine whether rehabilitation has genuinely been optimised.
Sometimes the answer is to adjust the loading programme.
Sometimes overall activity needs to change.
Sometimes the diagnosis needs reconsidering.
Sometimes imaging would provide useful information.
And occasionally, another intervention or specialist opinion may be appropriate.
At Genuine Physio in Tadworth, near Kingswood, the aim is not simply to provide another set of Achilles exercises.
It is to understand why the problem has persisted and determine what needs to happen next.
Frequently Asked Questions
How long does Achilles tendinopathy take to heal?
Recovery varies considerably, but Achilles tendinopathy commonly requires rehabilitation over several months rather than a few weeks. The timeframe depends on symptom duration, severity, current capacity and the activity someone wants to return to.
Should I rest if my Achilles tendon hurts?
Complete rest is not routinely recommended. Temporarily reducing particularly provocative activities may be useful, but appropriately progressed tendon loading is generally an important part of rehabilitation.
Is it OK to do calf raises if my Achilles hurts?
Often, yes. Some discomfort during tendon loading does not necessarily indicate damage. The appropriate amount depends on symptom severity and how the tendon responds during and after exercise.
Can I run with Achilles tendinopathy?
Sometimes. Running may need to be reduced or temporarily stopped when symptoms are highly irritable, but many people can gradually reintroduce running as tendon capacity improves.
Why does my Achilles feel better after warming up?
People with Achilles tendinopathy commonly report stiffness and pain when first moving that temporarily improves with activity. This does not necessarily mean the underlying problem has resolved, which is why symptoms can return later or the following morning.
Do I need an MRI for Achilles tendon pain?
Usually not initially. Achilles tendinopathy can often be diagnosed clinically. Imaging becomes more useful when the diagnosis is uncertain, symptoms are behaving unexpectedly or the findings would influence management.
Does PRP work for Achilles tendinopathy?
Current research has not demonstrated convincing improvements in pain or function compared with placebo. PRP should therefore not be assumed to be more effective simply because it is a newer or more expensive intervention.
Can a steroid injection help Achilles tendinopathy?
Corticosteroid injections around the Achilles are generally approached cautiously and are not routinely recommended for Achilles tendinopathy. If an injection is being considered, the type of injection, evidence, potential risks and alternatives should be discussed carefully.
Does Achilles tendinopathy need surgery?
Most people with Achilles tendinopathy do not require surgery. Surgical assessment may occasionally be considered for persistent symptoms where the diagnosis is clear and appropriately optimised conservative management has been unsuccessful.
Struggling with persistent Achilles tendon pain?
If your Achilles tendon pain keeps returning or you have completed rehabilitation without making the progress you expected, get in touch with Genuine Physio.
A detailed assessment can help establish whether the diagnosis is correct, identify what may be limiting recovery and determine how rehabilitation should be progressed.
If imaging or another opinion is genuinely required, that can be considered too.
The goal is not simply to settle the Achilles temporarily.
It is to rebuild enough capacity for you to return confidently to the activities that matter to you.
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