Achilles Tendinopathy – How to manage it

Tendinopathy, simply put is an overuse tendon injury that results in pain, decrease in exercise tolerance and function.  Most tendon injuries are a result of gradual wear and tear to the tendon from occupational overuse syndrome or general ageing. Tendons are designed to endure high, repetitive loading, however when the load applied to the tendon becomes too great for the tendon to withstand, the tendon then begins to become stressed. When tendons become stressed, they sustain micro tears which promote inflammatory chemicals and swelling. This condition is called tendonitis, which means inflammation of the tendon. However, inflammation is normal and is part of the tendon healing response which can cause some pain.  If the tendon is continuously overloaded, these micro tears in the tendon can exceed the rate of repair. This will progressively become worse causing pain and dysfunction. The result is tendinopathy.  Tendinopathy can deteriorate into the degenerative (cell death) phase, which is characterised by collagen degeneration in the tendon due to repetitive overloading. These tendinopathies do not respond well to anti-inflammatory treatments and are best treated with exercise rehabilitation.

Exercise is the most evidence-based treatment for tendinopathy. Tendons need to be loaded progressively so that they can develop greater tolerance to the loads that is required in the individual’s sports, activity of daily living and work function.  Typically, there are three phases to the exercise rehabilitation programme:

Phase 1 – Isometric

It is very common for tendinopathy to cause high levels of pain. Isometric exercises are implemented to decrease pain as it has an analgesic effect on the injured area. Perform 4 sets of 30 second isometric holds. For example, for Achilles tendon: you can perform static step hold – toes on the edge the step with heels hanging over the edge.

Phase 2 – Isotonic

Once pain levels decrease, the next stage is to gradually load the tendon. Pain levels is the best way to determine how much loading is appropriate.  Loading of the tendon will cause a slight increase in pain in the tendon, as this will cause a healing response without exacerbating it too much. The increase in pain while performing isotonic exercises should reduce in the next 2-4 hours. If too much load is applied, an increase in pain will stay elevated for a few days. Isotonic exercises are performed through as much range of motion as possible, with an emphasis of controlled eccentric and concentric phase of movement. For example, performing calf raises (with knees straight or bent) for the Achilles tendon.

Phase 3 – Dynamic Loading

After decreasing pain levels and gradually increasing load through the tendon, the final stage is to add dynamic loading, which includes light and low intensity plyometric exercises. For example, for Achilles tendon: running on toes, box jumps, single leg hops.

The exercise prescription needs to be individualised, this is based on the individual’s pain levels, ADL and/or work function. There should be a gradual increase in load to enable restoration of goal function whilst monitoring pain levels. Tendinopathy responds very slowly to exercise, so patience is vital. To ensure the correct and appropriate exercises are prescribed for you, contact the team of Accredited Exercise Physiologist at Absolute Balance for an expert advice and an individualised exercise programme.


Daniel Nguyen (B.Sc. Exercise Physiology)

Accredited Exercise Physiologist (AES, AEP)(ESSAM)



Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med 2009;43:409–16.


Brett M. Andres and George A.C. Murrell. (2008). Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon. Clinical Orthopaedics and Related Research, 1539–1554.

Jacobs, S. (2017). LIFTER’S GUIDE TO TREATING TENDINOPATHY. The Barbell Physio.