Achilles Tendinopathy Treatment
Specialist diagnosis and rehabilitation for Achilles tendon pain — using diagnostic ultrasound to see exactly what's happening inside your tendon and build a treatment plan around the findings.
What is Achilles Tendinopathy?
Achilles tendinopathy is a painful, degenerative condition of the Achilles tendon — the largest and strongest tendon in the body, connecting your calf muscles (gastrocnemius and soleus) to your heel bone (calcaneus). It is one of the most common overuse injuries we treat at Lower Limb Clinic, affecting runners, recreational athletes, and non-athletic individuals alike.
The term "tendinopathy" has largely replaced "tendinitis" in modern clinical practice, and the distinction matters. Research over the past two decades has shown that Achilles tendon pain is rarely caused by acute inflammation. Instead, it represents a failed healing response within the tendon — a process of disorganised collagen repair, increased ground substance, and in many cases, the ingrowth of new blood vessels (neovascularisation) into areas of the tendon that are normally avascular.
Achilles tendinopathy is classified into two distinct types based on where the pathology occurs, and the distinction is clinically important because they behave differently and require different treatment approaches.
Mid-portion tendinopathy affects the body of the tendon, typically 2–6cm above its insertion into the heel bone. This is the most common type, particularly in runners and active individuals. The tendon becomes thickened, painful, and structurally disorganised at the point of maximum mechanical load.
Insertional tendinopathy affects the lower portion of the tendon where it attaches to the calcaneus. It is often associated with Haglund's deformity (a bony prominence on the back of the heel), retrocalcaneal bursitis, and calcification within the tendon insertion. Insertional tendinopathy is more common in less active individuals and can be more challenging to treat.
Both types can affect the same patient, and both require accurate imaging to determine the extent of pathology and guide treatment.
Classic Symptoms
- Pain and stiffness in the Achilles tendon, worst first thing in the morning or after periods of rest
- A 'warm-up' effect — pain that eases after a few minutes of walking but returns after prolonged activity
- Pain during or after exercise, particularly running, hill walking, or stair climbing
- Visible or palpable thickening of the tendon compared to the other side
- Tenderness when squeezing the tendon between thumb and finger
- Stiffness or reduced ankle dorsiflexion (ability to pull the foot upward)
Signs You Need Specialist Assessment
- Pain that has persisted for more than 2–3 weeks despite rest or reduced activity
- Pain that is worsening or affecting your ability to walk normally
- Morning stiffness that takes more than 10–15 minutes to ease
- A sudden increase in pain, a popping sensation, or difficulty pushing off — these may indicate a partial tear
- Previous treatment (stretching, ice, rest, anti-inflammatories) hasn't resolved the problem
- You've been told to 'rest it' but the pain returns every time you increase activity
Why Accurate Diagnosis Matters
Achilles tendinopathy is not a single condition — it exists on a continuum of pathology, from early reactive changes through to advanced degeneration. Where your tendon sits on this continuum fundamentally changes how it should be treated.
A reactive tendon (early stage) that has become irritated by a sudden increase in load requires load modification and careful management. A degenerative tendon (late stage) with structural breakdown, neovascularisation, and loss of normal collagen architecture requires a progressive loading programme designed to stimulate tendon remodelling. Treating a degenerative tendon like a reactive one — with rest and anti-inflammatories — is ineffective. Treating a reactive tendon like a degenerative one — with aggressive loading — risks making it worse.
Clinical examination alone cannot reliably distinguish between these stages. This is why we use diagnostic ultrasound in every Achilles tendinopathy assessment.
Conditions that can mimic Achilles tendinopathy:
- Retrocalcaneal bursitis — Inflammation of the bursa between the Achilles tendon and the heel bone. Causes pain very similar to insertional tendinopathy. On ultrasound, the distended bursa is clearly visible.
- Paratenon pathology — The Achilles paratenon can become inflamed or thickened, causing pain that mimics tendinopathy. Ultrasound differentiates paratenon involvement from intratendinous pathology.
- Partial Achilles tendon tear — A partial tear within a degenerative tendon requires different management. Without imaging, partial tears can be missed and inappropriate loading may risk progression to a complete rupture.
- Haglund's deformity — A bony enlargement on the back of the calcaneus that causes mechanical irritation of the tendon and bursa. Identifying this on imaging changes the treatment approach.
- Plantaris tendon involvement — The small plantaris tendon runs alongside the Achilles and can become entrapped or irritated, contributing to medial-sided Achilles pain. Frequently overlooked without ultrasound.
How We Diagnose Achilles Tendinopathy
Diagnostic Ultrasound Scanning
Ultrasound is recognised as the first-line imaging modality for Achilles tendon assessment. The Dutch Multidisciplinary Guideline on Achilles Tendinopathy recommends ultrasound as the primary imaging tool. At Lower Limb Clinic, every Achilles pain assessment includes diagnostic musculoskeletal ultrasound.
- Tendon thickness — A normal Achilles measures approximately 5–6mm. In tendinopathy, this increases — a cutoff of 10mm or greater confirms significant pathology. We measure precisely and compare to the unaffected side.
- Tendon structure (echogenicity) — A healthy tendon has tightly organised parallel collagen bundles. In tendinopathy, we see hypoechoic areas representing disorganised collagen and structural breakdown.
- Neovascularisation (Power Doppler) — New blood vessels growing into damaged areas bring small nerve fibres strongly associated with pain. Research shows the site of maximum neovascularisation correlates with maximum pain.
- Staging the pathology — Using the Cook and Purdam continuum model, ultrasound findings allow us to stage as reactive/early dysrepair or late dysrepair/degenerative — with direct treatment implications.
- Identifying partial tears — Areas of fibre disruption, interstitial tears, and partial-thickness tears change rehabilitation timeline and loading parameters.
- Associated structures — We evaluate the retrocalcaneal bursa, paratenon, calcaneal insertion, and plantaris tendon to ensure nothing is missed.
- Dynamic assessment — Unlike MRI, ultrasound allows us to assess the tendon during movement in real time, identifying areas of restriction or adhesion.
- Treatment monitoring — Repeat ultrasound objectively tracks response. If tendon thickness, echogenicity, and neovascularisation aren't improving, we adjust the programme.
Pressure Plate Gait Analysis
Achilles tendon loading is directly influenced by how your foot functions during walking and running. Pressure plate analysis provides objective data on the mechanical factors contributing to your tendinopathy.
- Rearfoot loading patterns — Excessive heel loading during contact phase increases eccentric demands on the Achilles tendon.
- Propulsion mechanics — The push-off phase is where the Achilles is loaded most heavily. We assess efficiency and symmetry.
- Pronation timing and magnitude — Excessive or late-phase pronation causes a "wringing" effect concentrating load on the medial tendon — a common finding in mid-portion tendinopathy.
- Asymmetry — Comparing both feet identifies loading differences that explain why one side is affected.
Clinical Biomechanical Assessment
Comprehensive hands-on examination including assessment of ankle dorsiflexion range (one of the strongest risk factors for Achilles tendinopathy), calf muscle strength testing using single-leg heel raise endurance and maximum height, assessment of gastrocnemius and soleus individually, lower limb kinetic chain assessment including hip and knee control, and running gait analysis where relevant.
Treatment Options
Every treatment plan is built on the ultrasound findings and the biomechanical assessment. The stage of your tendinopathy determines which treatments are appropriate and in what order.
Progressive Loading Rehabilitation
The cornerstone of treatment. Structured, stage-appropriate loading progressing through isometric, eccentric, heavy slow resistance, and sport-specific plyometric protocols — determined by your ultrasound findings.
Shockwave Therapy (ESWT)
Primary adjunctive treatment for chronic tendinopathy with established neovascularisation. Delivers controlled acoustic energy to disrupt neovascular ingrowth and stimulate collagen remodelling. Typically 3–6 weekly sessions.
Custom 3D-Printed Orthotics
Manufactured in-house at Réalta Labs using selective laser sintering, designed from pressure plate data and 3D foot scans. Specifically optimised to control rearfoot motion and reduce rotational forces on the tendon.
Ultrasound-Guided Injection
High-volume injection of saline with local anaesthetic into the space between tendon and paratenon, mechanically stripping neovascular tissue. Performed under real-time ultrasound guidance throughout.
Footwear & Load Management
Evidence-based guidance on training modification, footwear selection (heel-toe drop, cushioning), and activity management. Complete rest is almost never the answer — the goal is finding the right load.
Common Causes & Risk Factors
Training Errors
Sudden increases in running mileage, intensity, or hill work are the most common trigger. The tendon can adapt to progressive loading, but cannot cope with abrupt spikes. The 'too much, too soon' pattern is responsible for the majority of cases.
Calf Weakness & Reduced Dorsiflexion
Weakness in the gastrocnemius and soleus muscles means the tendon absorbs a disproportionate share of loading forces. Reduced ankle dorsiflexion increases eccentric demand on the tendon during every step.
Biomechanical Factors
Excessive or late-phase pronation, poor hip and knee control, leg length differences, and altered running mechanics all influence how the tendon is loaded. Pressure plate analysis and gait assessment identify these objectively.
Age, Footwear & Systemic Factors
Tendon collagen undergoes structural changes from the mid-30s onwards. Low-drop or minimalist running shoes increase eccentric demand. Certain medications (fluoroquinolone antibiotics), diabetes, and high cholesterol can predispose to tendinopathy.
What to Expect at Your First Appointment
Your story
5 minWe need to understand when it started, what triggers the pain, how it affects your activity, and what you've already tried. For runners, we'll discuss training history, mileage changes, and footwear.
Clinical examination
5–10 minHands-on assessment including palpation, range of motion testing, calf strength assessment, and functional tests to determine irritability level.
Diagnostic ultrasound
10 minWe scan both Achilles tendons, measuring thickness, assessing structure and fibre integrity, evaluating neovascularisation with Power Doppler, checking the insertion and retrocalcaneal bursa, and staging your tendinopathy. You see the screen throughout.
Pressure plate analysis
5 minWalking assessment to capture your loading patterns and identify biomechanical contributors.
Diagnosis & treatment plan
5 minWe tell you exactly what stage your tendinopathy is at, what's driving it, and what the treatment programme looks like. In most cases, you'll start your loading programme the same day.
Total appointment time: approximately 45–60 minutes. No GP referral needed.
Recovery & Prognosis
Achilles tendinopathy responds well to appropriate treatment, but it requires patience and consistency. Mild to moderate cases typically show meaningful improvement within 6–12 weeks of a structured loading programme. More chronic or severe cases — particularly those with significant structural degeneration on ultrasound — may take 3–6 months to achieve full recovery.
Approximately 70–80% of patients with Achilles tendinopathy recover fully with conservative treatment. The key to successful recovery is accurate staging through ultrasound, a loading programme matched to your tendon's capacity, and consistent adherence to the rehabilitation protocol. We monitor your progress with regular clinical review and repeat ultrasound, ensuring the programme is adjusted based on how your tendon is actually responding — not just how it feels.
Your Clinicians
Paul McMullan BSc(Hons) MSc FRCPSGlasg MRCPod leads the specialist tendon service. Paul holds a Master's degree in Podiatric Sports Medicine from Queen Mary University of London and is a Fellow of the Royal College of Physicians and Surgeons of Glasgow. With over 15 years of clinical experience managing tendinopathy in runners and athletes, Paul combines diagnostic ultrasound expertise with evidence-based loading rehabilitation and advanced injection techniques.
Darren Costello BSc(Hons) MSc HCPC MRCPod specialises in sports podiatry, biomechanics, and ultrasound imaging. Darren holds an MSc in Sports and Exercise Medicine from Ulster University and is currently completing a Postgraduate Certificate in Lower Limb MSK Ultrasonography at Brunel University London. His Master's research investigated the impact of taping interventions on gait and plantar fascia structure, reflecting his evidence-based approach to lower limb rehabilitation. Darren provides Achilles tendinopathy assessment, ultrasound-guided staging, and structured loading programmes at our Lisburn Road and Ormeau Road clinics.
Having two MSc-qualified clinicians with diagnostic ultrasound training means shorter waiting times for specialist assessment, collaborative case discussion for complex presentations, and continuity of care throughout your rehabilitation programme.
Why Patients Choose Lower Limb Clinic
Diagnostic ultrasound in every Achilles assessment
We stage your tendinopathy using ultrasound, measuring thickness, assessing structure, and evaluating neovascularisation. This directly determines your treatment programme.
Evidence-based loading programmes
Structured, stage-appropriate rehabilitation based on the latest research. We build a progressive programme matched to your ultrasound findings and functional goals.
Shockwave therapy
NICE-approved ESWT using the EMS Swiss DolorClast for chronic tendinopathy that hasn't responded to loading alone.
Ultrasound-guided injection therapy
High-volume injection performed under real-time ultrasound guidance for cases with significant neovascularisation.
In-house orthotic manufacturing
Custom 3D-printed orthotics from Réalta Labs, designed from your pressure plate data to address the biomechanical factors driving your tendinopathy.
600+ five-star Google reviews
The highest-rated podiatry clinic in Northern Ireland.
Frequently Asked Questions
Common questions about Achilles Tendinopathy at Lower Limb Clinic.
Find Your Nearest Clinic
Get Achilles Tendinopathy at our clinic, conveniently located in East Belfast
Lisburn Road Clinic
385 Lisburn Road, BT9 7EP
Ormeau Road Clinic
373 Ormeau Road, BT7 3GP
Newcastle Clinic
1 Shimna Road, BT33 0AS
We serve patients from across Belfast and Northern Ireland including East Belfast, South Belfast, Lisburn, Bangor, Holywood, Newtownards, Dundonald, Carryduff, Hillsborough, and Comber.
Get Expert Treatment
- Same-week appointments available
- No GP referral needed
- MSc-qualified specialists
Related Conditions
Find Your Nearest Clinic
Get Achilles Tendinopathy at our clinic, conveniently located in East Belfast
Lisburn Road Clinic
385 Lisburn Road, BT9 7EP
Ormeau Road Clinic
373 Ormeau Road, BT7 3GP
Newcastle Clinic
1 Shimna Road, BT33 0AS
We serve patients from across Belfast and Northern Ireland including East Belfast, South Belfast, Lisburn, Bangor, Holywood, Newtownards, Dundonald, Carryduff, Hillsborough, and Comber.