Exercises for Achilles tendonitis – Sometimes less is more

When your Achilles tendonitis is not healing even when you’re dutifully doing your Achilles rehab exercises, it may be time to take a step back and use the “less is more” approach. We explain how this works depending on which stage your injury is in. Remember, if you need more help with an Achilles injury, you're welcome to consult one of our team via video call.

The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in our articles.

In this article:

1. Two stages of overuse Achilles injuries

2. Less is more in the reactive stage

3. Less is more in the dysrepair stage

4. How we can help

We've also made a video about this:

Two stages of overuse Achilles injuries

An overuse Achilles tendon injury happens when you’ve worked it too hard. This can be either during a single monster training session or race or match, or it can develop over a longer period if you don’t give it enough time to recover between sessions.

The first stage, when you become aware of the injury, is the reactive stage. The tendon is typically thick or swollen and very sensitive and painful. This can last up to three weeks.

If your tendon does not manage to fully recover, this is followed by the dysrepair stage. The pain usually comes and goes depending on what activity you subject your Achilles tendon to, but in some cases it may be sore most of the time.

Less is more in the reactive stage

The idea with “less is more” in this stage is to get your super sensitive tendon to calm down to the extent that you can start strengthening it without increasing your pain in a vicious circle.

So, don’t even think about doing those Achilles rehab exercises you got off the Internet – they are likely to feed that vicious circle. It’s much better to nurse and rest your tendon in this stage.

When we see a patient for the first time and it’s clear that they are still in their reactive stage, we usually simply prescribe things that will reduce the strain on their Achilles tendon by limiting the extent to which it is stretched, e.g. “put a heel raising insert into your shoe” or “wear shoes with a bit of a heel”.

As for their daily non-exercise activities, we recommend that they try to restrict them to those that don’t cause an increase in their pain while they’re doing them or in the 24 hours afterwards.

Less is more in the dysrepair stage

Once your tendon’s sensitivity has subsided somewhat, it is indeed time to strengthen it with rehab exercises. Just resting it until all the pain goes away won’t cut it. Your tendon is weaker than before and will not be able to cope with your daily life (and maybe exercise/sport) and will just get painful again.

Now, while it is true that strength training with a high load/weight has been shown by research to be the best rehab for Achilles tendinopathy, you shouldn’t necessarily dive right in and start doing those. You have to start at the right level for your tendon’s current strength and sensitivity.

Many of our patients only come to us when they have already entered their dysrepair stage; some have even had their tendon pain for more than 10 years. We then listen to their history and make them do some physical tests in front of the camera to gauge the capacity of their tendon. Based on this, we decide what is a sensible level of exercise difficulty to start with, and it may be as “easy” as doing calf raises on both legs without any extra weight.

And in this instance, the “less is more” approach means that we err on the side of caution and really make sure that the tendon reacts in a favourable way before we start adding too much weight. Better to have a slow start to rehab than risking re-injuring the tendon with too much weight or too many repetitions and going all the way back to square one.

The high-load exercises that everyone talks about when they talk about Achilles rehab will usually only come after a gradual progression in the difficulty of the exercises. How high the load eventually gets will depend on each patient’s activity goals. However, there are some patients whose tendons are pretty strong and not very sensitive from the outset. In these cases we do start them off with more intense exercises, but only if our assessment tells us that it is the right thing to do.

So, to summarise: If you have an Achilles tendon that's really sore and just doesn't want to settle down no matter how much you try to rehab it, it may be sensible to take a step back and give it some time off. Just pamper it for a week or two – not too long, just to get that reactive pain to calm down – and then start a really conservative rehab programme. This is often the key to getting your rehab back on track.

And then, once it has settled down, you can usually ramp things up. But again, according to how quickly it builds its strength, not just randomly. It's about hitting those targets and ticking the boxes of “Okay, I can do this now without flaring my tendon up” before moving on to something more challenging.

How we can help

Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master's Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.