Achilles tendonitis treatment – What works, what doesn’t work, and what makes it worse?

There’s no one-size-fits-all treatment for Achilles tendonitis or tendinopathy. However, there is a general approach supported by research that works well for our patients with Achilles tendonitis. In this article, we explain that approach and other useful treatments, and we point out which treatments are a waste of money or may even make your injury worse. 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. What treatment works best for Achilles tendonitis?

2. Treatments that can reduce pain but will not heal your injury

3. Treatments that might promote tendon healing

4. Treatments that should only be used in specific cases of Achilles tendonitis

5. Treatments that don’t work for Achilles tendonitis

6. Treatments that may make your Achilles tendonitis worse

7. How we can help

We've also made a video about this:

What treatment works best for Achilles tendonitis?

A personalised rehabilitation plan consisting of the right combination of rest and exercise is usually the most effective intervention for Achilles tendonitis. This has to be tailored to the individual, because every case varies in terms of how sensitive the tendon is, how strong it is, and the activity or exercise goals the patient may have.

This approach is supported by the latest research, and it has worked well for the more than thousand patients all over the world we have treated via video call at Treat My Achilles.

We often see patients in our clinic who have tried Achilles exercises they found on the Internet or even ones provided by other clinicians, only to find that these either had no effect or actually made their symptoms worse.

Relative rest vs. complete rest

To allow your tendon pain to settle down and recovery to take place, you have to temporarily reduce your activities to a level that does not irritate your tendon.

We are big proponents of relative rest. This means that we only get you to cut out the really aggravating activities in your daily life or to adjust your training programme so that you can continue to train without making the injury worse.

Being injured and not able to exercise can make you feel rather low. Relative rest is great, as it not only allows you to maintain your cardiovascular fitness through cross-training but also helps to lift your mood.

We’ve become experts over the years in helping our patients analyse their training programmes and creating plans that allow them to resume all sorts of activities, including walking, running, and racket sports, as quickly as possible but without reinjuring themselves.

Rest alone or prolonged periods of rest is not useful for getting tendons to recover. It may make the pain feel better for a while, but it doesn’t restore the strength of the tendon, so it remains prone to further injury.

Exercises for Achilles tendonitis

The exercises for treating Achilles tendonitis can be divided into three groups:

1. Exercises to reduce pain and help you move with less discomfort

2. Exercises that restore and strengthen the Achilles tendon so it can once again tolerate the loads produced by your activities and sport

3. Exercises that strengthen the rest of the body, thereby reducing the load placed on the Achilles tendon when you walk, run, and jump.

The most commonly used exercise for treating Achilles tendonitis is the calf raise, i.e. going up and down on your toes. But there are lots of different ways in which the calf raise exercise can and should be adapted to suit the strength, pain levels, and goals of the individual patient – we discuss them in detail in this article.

Your rehab exercises must match your tendon's current strength and sensitivity.

Where patients (and sometimes clinicians) often go wrong is that they either start out with exercises that are too hard for their Achilles, causing the injury to flare up, or they stick to the same set of “safe” exercises without gradually making them more difficult; this has little or no effect.

If your Achilles tendonitis is caused by diabetes, an inflammatory condition, or antibiotics, it will require a slightly different treatment approach.

Avoid focusing too much on Achilles or calf stretches

During the 1990s and early 2000s, stretches for the calf muscles and Achilles tendon were seen as the main treatment for Achilles tendonitis. Since then, lots of research has shown that this offers very little long-term benefit, because it doesn’t strengthen the tendon, and that it even prolongs or delays recovery in the case of insertional Achilles tendonitis.

Calf and Achilles stretches often increase Achilles pain if done too soon.

However, we are all different, and some of our patients with ongoing mid-portion Achilles tendonitis do find that stretching their tendons produce pain relief. But, in cases where the tendon is very sensitive or the injury is located close to the heel bone (insertional), stretching often increases pain several hours after doing them, despite feeling good and satisfying in the moment.

Our advice is:

• Avoid stretching if you have insertional Achilles tendonitis or heel bursitis.

• Avoid stretching if your tendon injury is less than three weeks old or has flared up in the past couple of weeks.

• Only introduce stretching later in your rehab, monitor how your pain responds in the 24 hours after stretching, and compare that to when you don’t stretch. If you find that your tendon tends to be more sensitive several hours later or the next day, stretching may not be a good idea.

Reducing stress and anxiety

Recent research has highlighted how Achilles pain can be amplified or reduced by increasing or decreasing our stress and anxiety levels.

We’ve explained it in detail here, but in a nutshell, stress and anxiety cause our bodies to produce more stress hormones (like cortisol) which, if produced over a prolonged period, can cause increased inflammation and tissue hypersensitivity. This may cause our bodies to overreact to movement and activity and cause excessive pain flare-ups even when the activity is not enough to injure our Achilles tendons.

If you’re currently experiencing high levels of stress or anxiety, taking steps to address this may help your recovery.

Stress and anxiety can make your pain feel worse.

Treatments that can reduce pain but will not heal your injury

Getting your Achilles pain to settle down to a manageable level is important. Pain can wear you down, prevent you from getting on with your life, and prevent you from starting or progressing with your rehab.

The following treatments can help to reduce your Achilles tendonitis pain, but they usually don’t have a direct effect on healing and should not be used in isolation. They should always be used in combination with a progressive rehab plan that restores your tendon’s strength (see above).

• Heel lift shoe inserts can reduce the strain on the Achilles tendon.

• Wearing shoes with a slight heel as opposed to flat shoes can likewise reduce the strain on the tendon.

• Gentle massage, but not cross friction, may help the calf muscles to relax and provide temporary pain relief.

• Dry needling

• Taping the Achilles tendon and calf

• Low-level laser therapy

• Shockwave may help to reduce pain, but it doesn’t work for everyone. It often doesn’t produce good results if used too early (a newly flared up injury) but can be useful in cases that have been ongoing for more than a few weeks, especially insertional Achilles tendonitis.

• Ice usually works better than heat to provide pain relief, but it should be used in moderation.

• TENS (transcutaneous electrical nerve stimulation)

• Losing weight – Being overweight can lead to chronic low-level inflammation in the body and also increases the load on the Achilles tendon.

• High-volume injections

• Tenex may help reduce pain by removing the injured part of the tendon and is less invasive than open surgery, but there is no research into its long-term effects.

Heel lift inserts reduce the strain on the Achilles tendon and may reduce your pain.

Treatments that might promote tendon healing

• PRP injections are thought to stimulate tendon healing, but there is no research to support its use specifically for Achilles tendonitis. In practice we find that it works for some people and not for others.

• Supplements – There is some evidence that a combination of Vitamin C and collagen, when combined with strength training exercises, may enhance your tendon’s ability to restore and strengthen itself.

• Nitroglycerin patches – The research jury is still out on whether these promote tendon healing, but the side effects are low risk, so you could speak to your doctor about adding them to a personalised rehab plan (see above) if the latter doesn't have the desired effect.

Treatments that should only be used in specific cases of Achilles tendonitis

• Hormone replacement therapy (HRT) may improve healing if you’re in the menopause. Oestrogen is one of the main hormones in charge of getting your tendons to produce new and stronger collagen fibres (the main building block of a tendon). The drop in oestrogen levels due to the menopause has been shown to both cause tendonitis and delay healing.

• Arch support insoles are only useful in cases where a person is found to over-pronate.

• Immobilisation in a boot may be useful in some cases that are super painful and do not calm down with using heel lift inserts and load management, but it should never be used for more than a few days.

• Anti-inflammatory medication may be useful if you have heel bursitis, inflammatory enthesopathy, or if your tendonitis was caused by antibiotics or an inflammatory condition like gout. It is not effective for ongoing Achilles tendonitis or tendinopathy caused by overload and may interfere with your recovery if used for a long time.

• Surgery may be an option in cases of Achilles tendonitis where no other treatments bring relief. It is currently advised to consider surgery only if you’ve tried a progressive rehab plan (as described above) for at least 12 months.

Complete immobilisation in a boot is rarely needed for Achilles tendonitis and should only be used for a few days when necessary.

Treatments that don’t work for Achilles tendonitis

• Ankle braces

• Night splints

• Ultrasound

Ankle braces are not an effective treatment for Achilles tendonitis or tendinopathy.

Treatments that may make your Achilles tendonitis worse

• Corticosteroid injections into the tendon may increase your risk of Achilles tendon rupture and lead to poorer long-term outcomes.

• Corticosteroid tablets may also increase your risk of tearing a tendon.

• Prolonged immobilisation in a boot or cast – This weakens your tendon even further and the pain usually returns after you've removed the boot or cast.

• Cross-friction massage

• Prolonged periods of rest – Resting your tendon for short periods when needed is important. But long periods of rest with very little activity can actually make it feel more uncomfortable (due to reduced circulation) and cause your tendon to lose more strength. Applying the concept of relative rest is much more effective in the long run.

Corticosteroid tablets and injections should not be used as treatment for Achilles tendonitis.

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.

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