Achilles Tendinopathy
Lower LimbOverview
Achilles tendinopathy is a chronic condition characterized by pain, stiffness, and functional limitation of the Achilles tendon, typically occurring at the midsubstance or insertional region. It results from repetitive microtrauma, degenerative changes, and failed healing responses rather than acute inflammation. The condition is prevalent in athletes and individuals with biomechanical dysfunction, often causing significant functional impairment and reduced quality of life.
Pathophysiology
Achilles tendinopathy develops through cumulative microtrauma from excessive tensile loading, particularly in activities requiring rapid eccentric loading (running, jumping). This leads to disruption of the collagen matrix, failed neovascularization, and intratendinous degeneration. Degenerative changes include mucoid degeneration, collagen disorganization, and neovascularity with abnormal nerve ingrowth (neurogenic inflammation). The condition progresses through stages: reactive tendinopathy, tendon disrepair, and degenerative tendinopathy.
Typical Presentation
Site
Achilles tendon, typically at the midsubstance (2-6cm proximal to insertion) or at the insertional region; may present bilaterally; pain often radiates into the calf
Quality
Dull, aching pain with morning stiffness; sharp pain with activity onset; burning sensation; occasional clicking or creaking sensation with movement
Intensity
Mild to moderate pain (3-7/10) at rest, increasing significantly with activity; morning stiffness often worse than baseline pain; variable day-to-day symptoms
Aggravating
Sudden increase in activity intensity or volume; hill running or stairs; prolonged sitting followed by activity; tight footwear; prolonged standing; eccentric loading (descending stairs); cold exposure; returning to activity after rest
Relieving
Rest and activity modification; ice application; gentle stretching; gradual warm-up; heel lifts; anti-inflammatory medications; physiotherapy-based loading programs
Associated
Calf muscle tightness; ankle stiffness and reduced dorsiflexion range; foot pronation; altered gait pattern; limping; reduced plantarflex strength; morning stiffness worse than end-of-day pain; pain with passive dorsiflexion stretch
Orthopaedic Tests
Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.
Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).
Midportion Achilles Tendon Palpation
Procedure
Patient prone with the feet over the end of the plinth. Pinch the tendon gently between thumb and finger from the calf muscle down to the heel, comparing with the other side.
Positive Finding
Tenderness, and often a thickened area, about 2–6 cm above the heel bone.
Sensitivity / Specificity
Interpretation
Pain on palpation in this area, with the typical history (morning stiffness, pain at the start of activity that may ease, then worsen after), supports midportion Achilles tendinopathy. Tenderness at the heel bone itself points to insertional tendinopathy or a bursitis. From one small study (Hutchison 2013) of 21 people with and without Achilles tendinopathy, with ultrasound as the reference. The abstract does not say whether the comparison participants had symptoms, so the specificity is not shown. Pain on palpation 2–6 cm above the heel, together with the history, is the main basis for the diagnosis.
Sources
- Reference bookMedina Pabón MA, Bergman R, Naqvi U. Achilles Tendinopathy. StatPearls [Internet]. StatPearls Publishing; updated 8 Jun 2026.
- RelatedHutchison AM, Evans R, Bodger O, Pallister I, Topliss C, Williams P, et al. What is the best clinical test for Achilles tendinopathy?. Foot Ankle Surg. 2013;19(2):112-7.
Single-Leg Calf Raise (Heel Rise Test)
Procedure
Ask the patient to stand on one leg, with a fingertip on the wall for balance, and rise onto the toes repeatedly at a steady pace until they cannot continue. Compare the number and height of raises with the other leg.
Positive Finding
Pain in the tendon during the raises, or fewer or lower raises than on the other side.
Interpretation
Measures calf capacity and pain with load, which guides loading exercise and return to activity. It does not diagnose tendinopathy on its own. A literature search (Europe PMC, September 2026) found no study reporting the diagnostic accuracy of this test, so no figure is shown. Heel-raise capacity is used to measure function and guide loading rather than to diagnose.
Matles Test (Knee Flexion Test)
Procedure
Patient prone with both knees bent to 90°. Watch the resting position of both feet.
Positive Finding
The foot on the affected side falls into neutral or dorsiflexion instead of the normal slight plantarflexion.
Interpretation
A test for Achilles tendon rupture, not tendinopathy. It is normal in tendinopathy. Sudden pain at the back of the heel with a feeling of being kicked, and a positive Matles or Thompson test, needs same-day referral. (The dorsiflexion–eversion test is a separate tarsal tunnel test.) The figure stored here belongs to Achilles tendon rupture (the Matles test is a rupture test), not to this condition, so no figure is shown.
Achilles Tendon Squeeze Test (Thompson Test)
Procedure
Patient prone with the feet over the end of the plinth, or kneeling on a chair. Squeeze the calf muscle firmly and watch the foot.
Positive Finding
No plantarflexion of the foot when the calf is squeezed (positive = rupture).
Interpretation
A test for Achilles tendon rupture, used here to exclude one. In tendinopathy the foot plantarflexes normally when the calf is squeezed. The figure stored here belongs to Achilles tendon rupture (see that page), not to this condition, so no figure is shown.
Resisted Plantarflexion (Isometric)
Procedure
Patient prone or seated, knee straight. Ask the patient to push the foot down against your resistance and hold, then compare with the other side.
Positive Finding
Pain in the tendon during resisted plantarflexion, or weakness compared with the other side.
Interpretation
Loads the tendon and helps gauge irritability. Not a diagnostic test on its own. A literature search (Europe PMC, September 2026) found no study reporting the diagnostic accuracy of this test, so no figure is shown.
Ankle Plantarflexion Strength Testing (Manual Muscle Test)
Procedure
Test plantarflexion strength against manual resistance, or better, count single-leg heel raises, which reflect calf strength more realistically than manual testing.
Positive Finding
Weakness or pain compared with the other side.
Interpretation
Calf weakness is common in Achilles tendinopathy and is a target for rehabilitation. Manual testing often misses deficits because the calf is so strong; heel-raise counts are more informative. A literature search (Europe PMC, September 2026) found no study reporting the diagnostic accuracy of this test, so no figure is shown.
⚠ Red Flags
- •Sudden, severe pain with audible/palpable 'pop' or 'snap' suggesting acute rupture
- •Complete loss of plantarflexion strength or positive Thompson's test indicating tendon rupture
- •Severe swelling, warmth, and erythema suggesting infection or cellulitis
- •Constitutional symptoms (fever, malaise, weight loss) suggesting systemic infection
- •History of heel trauma with severe pain disproportionate to clinical findings
- •Progressive neurological deficit in lower limb
- •Night pain at rest unrelated to activity suggesting malignancy
- •Bilateral Achilles pain with systemic symptoms suggesting spondyloarthropathy or inflammatory condition
⚡ Yellow Flags
- •High pain catastrophization and fear-avoidance behaviors limiting functional recovery
- •Poor psychosocial coping mechanisms and perceived lack of control over condition
- •Significant occupational or sports-related stress and pressure to return quickly
- •History of previous failed treatment attempts and treatment disappointment
- •Social isolation and lack of support network for rehabilitation compliance
- •Perfectionist traits associated with overtraining and failure to modify activity appropriately
- •Depression or anxiety comorbidity affecting pain perception and recovery trajectory
- •Unresolved trauma or significant life stress exacerbating pain experience
Osteopathic Techniques
Conservative care comes first: activity modification, a progressive tendon-loading or eccentric exercise programme, and orthoses or a heel lift where needed. Eccentric exercise has the strongest evidence; whether manual therapy adds to it is still a research gap.
- Reference bookMedina et al. · StatPearls 2026
- Journal articleRowe et al. · Sports Med 2012
Region
Gastrocnemius-soleus, with tibialis anterior and the peroneals
Technique
Rationale
Calf and lower-leg soft tissue is usually given alongside a loading or stretching programme.
How it's done & evidence
How it's done
Hands-on kneading, stroking and sustained pressure to the calf (gastrocnemius and soleus), the Achilles tendon and the peroneal and tibial muscles of the lower leg. In trials it was given alongside exercise, such as eccentric calf loading.
Evidence in Achilles Tendinopathy
Ko 2023 (network meta-analysis, 9 trials, n=464, insertional Achilles tendinopathy): eccentric exercise plus soft tissue therapy ranked as the most effective treatment for short-term pain (SUCRA 84.8). Rowe 2012 (midportion): strong evidence for eccentric loading and shockwave; the effectiveness of manual therapy was named a research gap.
Sources
- Journal articleFurlan et al. · Cochrane 2015
- Journal articleKo et al. · BMC Musculoskelet Disord 2023
- Journal articleRowe et al. · Sports Med 2012
Region
Ankle joint (talocrural and subtalar)
Technique
Rationale
Ankle, subtalar and midfoot glides, mainly to restore dorsiflexion and foot mobility.
How it's done, cautions & evidence
How it's done
Passive, rhythmic, low-velocity glides of the ankle (talocrural), subtalar, midfoot and toe joints, within or up to the end of the available range, often aimed at restoring ankle dorsiflexion.
Cautions
Before mobilising an acute ankle injury, check for fracture with the Ottawa ankle rules (tenderness over either malleolus), and palpate the base of the 5th metatarsal, the navicular and the midfoot for a Lisfranc injury.
Evidence in Achilles Tendinopathy
Searched 25 Oct 2026: no trials. Jayaseelan 2017 (case series, 3 runners with chronic Achilles tendinopathy): joint mobilisation and manipulation added to eccentric loading and calf stretching, with better VISA-A, pain and heel raises at discharge and 9 months. The authors note joint mobilisation had not been studied in Achilles tendinopathy.
Sources
- Journal articleCoulter et al. · Spine J 2018
- Reference bookBergman et al. · StatPearls 2025
- Journal articleJayaseelan et al. · J Man Manip Ther 2017
Region
Gastrocnemius-soleus (calf)
Technique
Rationale
Calf muscle energy technique to ease gastrocnemius-soleus tightness that limits ankle dorsiflexion.
How it's done, cautions & evidence
How it's done
The calf is taken to its barrier by dorsiflexing the ankle. The patient pushes the foot gently down, at about 10–20% effort, against resistance for 5–10 seconds, relaxes for 3–5 seconds, and the new barrier is taken up.
Cautions
Not used with an acute fracture, a joint infection or a bone malignancy; take care with severe osteoporosis or after surgery that limits muscle contraction. Use the least force needed: too much can tear a muscle or pull off a tendon, especially in older patients.
Evidence in Achilles Tendinopathy
Searched 25 Oct 2026: no trials of calf muscle energy technique in Achilles tendinopathy.
Sources
- Reference bookWaxenbaum & Sina · StatPearls 2026
Region
Plantar fascia and plantar foot
Technique
Rationale
Soft tissue to the plantar fascia, foot muscles and the tissues around the heel and ankle ligaments.
How it's done & evidence
How it's done
Hands-on kneading, stroking and sustained pressure to the plantar fascia, the small muscles of the foot and the tissues around the heel and the ankle ligaments.
Evidence in Achilles Tendinopathy
Searched 25 Oct 2026: no trials of plantar foot soft tissue in Achilles tendinopathy.
Sources
- Journal articleFurlan et al. · Cochrane 2015
Rehabilitation Exercises
Gastrocnemius-Soleus Standing Stretch
Plantarfascia and Calf Wall Stretch (Lower Leg Against Wall)
Ankle Alphabet Exercise (Writing Letters with Foot)
Eccentric Heel Drops (Alfredson Protocol - Double Leg Beginner Variation)
Seated Plantarflexion with Resistance Band
Single-Leg Stance (Supported)
Single-Leg Eccentric Heel Drops (Intermediate Progression)
Calf Raise with Isometric Hold (Double Leg to Single Leg Progression)
Single-Leg Balance on Unstable Surface (Wobble Board or Foam Pad)
Hip Strengthening (Glute Med Activation - Clamshells and Side-Lying Hip Abduction)
Swimming or Pool Walking (Low-Impact Cardiovascular Conditioning)
Plyometric Training (Box Step-Downs and Lateral Bounds - Advanced Eccentric Loading)
Referral Criteria
- •Suspected Achilles tendon rupture (inability to plantarflex, positive Thompson's test, audible/palpable 'pop')
- •Signs of infection including warmth, erythema, swelling, and constitutional symptoms
- •Severe pain unresponsive to conservative management after 3-6 months of structured rehabilitation
- •Refractory tendinopathy requiring imaging to exclude partial tear (ultrasound or MRI)
- •Insertional tendinopathy potentially requiring surgical assessment and Haglund's deformity management
- •Concurrent systemic inflammatory arthropathy (spondyloarthropathy) diagnosed or suspected
- •Significant functional limitation affecting activities of daily living or occupational capacity
- •Failure to progress in rehabilitation suggesting need for advanced imaging or specialist orthopedic assessment
- •Suspected associated nerve compression or complex regional pain syndrome development
- •Requirement for advanced intervention such as platelet-rich plasma injection, shockwave therapy, or surgical intervention