Achilles Tendinopathy: How to Treat It Properly

A Physio's Conservative Management Plan

Jessica McDonald, senior physio - MOVE Sports Physiotherapy & Pilates

The short version: The vast majority of Achilles tendinopathy gets better without injections or surgery — if it's loaded properly. Tendons get stronger by being loaded, not rested, so the fix isn't time off; it's the right load at the right time. A well planned staged guide will: settle the pain and rebuild tendon strength so you can earn your way back to running and sport.

Here's exactly how we manage it conservatively at MOVE — including the criteria you need to hit before progressing to the next stage.

What is Achilles tendinopathy?

First, the reassuring part: tendinopathy is not a tear, and it's not permanent damage. It's an overloaded tendon, that's been asked to do more than it's had a chance to recover from. The tendon becomes irritable, and is sending you a message.

It helps to think of a tendon on a continuum. At the reactive end, it's grumpy but very responsive to a sensible change in load. Left overloaded for long enough, it can shift toward a more stubborn, structurally changed state. The good news: even well down that continuum, tendons respond remarkably well to the right loading program.

You may have been told "degeneration, nothing you can do". This is outdated and unhelpful.

Where it hurts changes the plan. This is the bit generic advice gets wrong

• Mid-portion Achilles tendinopathy — pain located a few centimetres above the heel — loves load. We rebuild it with strength, and we can stretch and load it through full range.

• Insertional Achilles tendinopathy — pain right where the tendon meets the heel bone — dislikes compression. Deep calf stretches and dropping the heel below a step squash the sore spot, causing a flare. So early on, we keep the heel from going below flat and skip the deep stretches.

Why "just rest it" makes Achilles worse

Rest feels logical. It's also a trap. When you fully rest a tendon, it de-conditions — making it weaker and less able to tolerate load. So when you go back to your sport, you're returning a weaker tendon to the same demand that overloaded it in the first place. Pain comes straight back, often worse, and now you also believe the tendon is fragile.

Conservative management done well does the opposite. We load the tendon in a controlled, progressive way that drives adaptation — so the tendon you return to sport is genuinely more capable than the one that got sore.

The MOVE approach: Earn the right to progress

What makes our rehab different is that we use criteria-led rehab. You progress to the next stage when your tendon shows it's ready, not because a set number of weeks has passed. Every stage has clear green lights. You don't start running because it's been six weeks; you start because you've earned the right to run.

It's the same three-stage spine we use for every tendon and running injury at MOVE:

1. Dial Down — settle the pain and calm the tendon

2. Build Confidence & Capacity — rebuild the tendon with real strength

3. Performance & Prevention — return to running and sport, and keep it gone

One tool runs through all three stages: the 24-hour rule. Your tendon talks to you the next morning. A little stiffness that settles within about 10 minutes is fine. Pain that's clearly worse the next day means we went overboard. That's information (not failure) to help direct your next session.

Stage 1 — Dial Down

Goal: We work on settling pain, while keeping the tendon loaded enough to stop it de-conditioning.

What we do

• Confirm it's tendinopathy and work out whether it's mid-portion or insertional

• Rule out the other causes of heel and calf pain

• Set your load budget — what to keep, what to dial back

• Get you started on isometric loading and education

What you do

• Keep moving within comfort — relative rest, not the couch

• Pull back the big aggravators: hills, speed work, and sudden jumps in mileage

• Start the isometric holds below

• Track your morning stiffness as your daily guide

Movements we'll get you doing in Stage 1

• Isometric calf-raise — rise onto your toes and hold. 5 holds of up to 45 seconds, at a firm but comfortable effort, once or twice a day. Loaded holds like this can genuinely settle tendon pain for up to 45 minutes and start building strength.

• Comfortable walking and pain-free range work

• Insertional modification: skip deep calf stretches and heel-drops off a step for now; a small heel raise in your shoe can take pressure off while it settles

✅ Earn the right to load — your green lights to Stage 2

You're ready to step it up when you can tick all of these:

• Morning stiffness settles within about 10 minutes

• Pain during your isometric holds sits at 3/10 or less

• Walking and everyday activity feel comfortable

• No flare-up the morning after your current activity

Stage 2 — Build Confidence & Capacity

Goal: rebuild the tendon. First we build your confidence to load it, then we build capacity — and capacity means strength. This is the stage that does the heavy lifting, and skipping it is the single most common reason Achilles pain drags on for months.

Build confidence

• Reintroduce loading gradually, double-leg before single-leg

• Move through controlled, full range of motion

• Keep using the 24-hour rule to pace each step

• Build trust in the heel before we add any speed or spring

Build capacity (strength)

• Heavy slow resistance (HSR) calf raises — your main driver. 3 seconds up, 3 seconds down, through full range. 3–4 sets of 6–15 reps, 2–3 times a week. Start around a 15-rep-max load and build toward a 6-rep-max over roughly 12 weeks. Train both a straight knee (gastrocnemius) and a bent knee / seated (soleus).

• Eccentric heel drops — slow, controlled lowers, straight-leg and bent-leg, building toward 3 sets of 15 (mid-portion only takes these below the step; insertional stays at or above flat)

• Single-leg progressions as your capacity builds

✅ Earn the right to run — your green lights to Stage 3

Running goes back in once the tendon can absorb it. You're ready when:

• You're tolerating your strength work with no next-morning flare

• Your single-leg heel-raise strength is clearly building toward your other side

• Pain is stable and sitting at 3/10 or less day to day

• You can hop on the spot on one leg without sharp pain

What the evidence says: heavy slow resistance training produces outcomes as good as the older eccentric-only programs, with high client satisfaction (Beyer et al., 2015), and isometric holds can reduce tendon pain in the short term (Rio et al., 2015). The throughline of the research is consistent: progressive loading, guided by how you respond, is what rebuilds a tendon. There's no shortcut around it — and no need for one, because it works.

Stage 3 — Performance & Prevention

Goal: return to running and sport, rebuild your spring, and lock in the habits that stop it returning.

Return to your thing

• Graded return to running — walk-run intervals first, then steady runs, building gradually

• Reintroduce hills and speed work last, one variable at a time

• Plyometrics — pogos, skipping and hopping, low intensity first then building — to rebuild the elastic, energy-storage capacity running and sport demand

• Keep your strength work going as you build mileage; don't drop it the moment you're running again

Stay there

• Keep calf and Achilles strength twice a week

• Respect load spikes — build mileage gradually and reintroduce intensity carefully

• Build in easier weeks so the tendon can adapt

• Remember tendons reward consistency over heroics

✅ Earn the right to return to sport

The final tick-list before full training and competition:

• Pain-free hopping and pogos on the affected side

• Single-leg heel-raise capacity matching your other leg

• You can handle your planned running and training load with no next-day flare

How long does Achilles tendinopathy take to heal?

Tendons don't read calendars, but they do follow rules. A reactive, recently irritated tendon caught early can settle and rebuild over a couple of months. A stubborn, long-standing one needs a full loading program — around 12 weeks of progressive strength training (sometimes longer). Criteria-led rehab keeps you honest here: because you progress on capability, you're never returning to running on a tendon that can't take it.

What about injections, scans and surgery?

For the large majority of people, conservative management — loading done properly, is the answer, and it's the first-line approach for good reason. Scans often aren't needed to start treatment, and they don't always match how much pain you're in. Injections and surgery sit well down the list and are considered only when a genuine, well-executed loading program hasn't worked. Start with the loading. Most people never need anything else.

When to get it checked promptly

Get assessed quickly if:

• You felt a sudden, sharp pain or "snap" and lost your push-off power — this can signal an Achilles rupture and needs urgent assessment

• Your pain is getting worse despite easing your load

• It's not improving after a few weeks of sensible loading

• You're not sure which stage you're in — that's exactly what we're here for

Why people around Geelong trust MOVE with their Achilles

At Move Sports Physio we confirm which type of Achilles tendinopathy you have, set your load budget, and progress you through a proper strength program using our gym space and Clinical Pilates. Our criteria-led approach means you always know what you're working toward and exactly when you've earned the next step. Two clinics across Geelong, longer appointments, and physios who load tendons the way the evidence actually supports.

Ready to fix your Achilles tendiopathy properly?

Book an assessment with one of our Geelong physios. We'll diagnose which type of Achilles tendinopathy you have, build your staged loading plan, and get you back moving stronger than before.

BOOK NOW

Achilles tendinopathy FAQ

Should I rest my Achilles tendinopathy? Not completely. Full rest weakens the tendon, so the pain returns when you go back to sport. The fix is relative rest — easing the big aggravators while keeping the tendon loaded through a progressive strength program.

What are the best exercises for Achilles tendinopathy? Loaded calf work is the backbone: isometric holds early to settle pain, then heavy slow resistance calf raises (slow, heavy, both straight and bent knee) and eccentric heel drops to rebuild the tendon, before progressing to plyometrics and a graded return to running.

Can I run with Achilles tendinopathy? Only once you've earned the right to — meaning your strength work causes no next-morning flare, your single-leg heel-raise capacity is building, and you can hop pain-free. Running before that point typically keeps the tendon irritable.

What's the difference between insertional and mid-portion Achilles tendinopathy? Mid-portion pain sits a few centimetres above the heel and tolerates full-range loading and stretch. Insertional pain sits right at the heel bone and dislikes compression, so early on we avoid deep stretches and dropping the heel below flat.

How long until my Achilles tendinopathy goes away? A recently irritable tendon may settle in a couple of months; a long-standing one often needs around 12 weeks of progressive strength work or more. Because we progress on criteria, you return to sport on a tendon that can genuinely handle it.