Morning Achilles Pain? Let’s Break Down What’s Really Going On
Do you ever wake up with a stiff Achilles, struggling to take those first few steps in the morning? Or maybe after a long run or game, your Achilles feels tight, sore, and tender? These are common signs of Achilles tendinopathy—a condition that can sneak up on anyone, from athletes to those just going about their daily routine.
To keep things simple, we’ll focus on Achilles tendinopathy—an umbrella term for different types of tendon issues. This includes tendinosis, where the tendon fibers start to break down over time, and paratendinitis, where the sheath surrounding the tendon becomes inflamed. Both can cause discomfort and limit your ability to move freely, especially if left untreated.
What Causes Achilles Tendinopthy?
One of the most common culprits is poor foot mechanics. If you have flat feet (overpronation) or high arches, the way your foot strikes the ground can place abnormal stress on the Achilles tendon. With each step, your tendon is forced to compensate, leading to overuse and eventual wear and tear. Footwear that lacks proper support can also worsen these issues by not providing the stability your feet need during movement.
Another major factor is calf muscle tightness. The calf muscles are directly connected to the Achilles tendon, and if they’re too tight, they pull on the tendon constantly. This excessive tension can cause microtears over time, leading to the chronic degeneration seen in tendinosis. It’s no surprise that people who don’t regularly stretch or warm up their calves before exercise are at greater risk of developing Achilles problems.
Overuse and sudden increases in activity are also key contributors. If you’ve recently ramped up your running mileage, started playing a new sport, or even just added more walking into your routine, your Achilles tendon might be struggling to keep up. The tendon needs time to adapt to new stresses, and overloading it too quickly can lead to injury. This is particularly true for athletes, but even non-athletes can be affected by sudden changes in their activity level.
Lastly, age plays a role. As we get older, the tendon naturally becomes less flexible and less able to tolerate stress. This makes people over the age of 30, especially those who are active, more susceptible to Achilles tendinopathy.
Symptoms of an Achilles Tendinopathy
- Achilles tendinopathy symptoms often start subtly—a little stiffness in the morning, some mild discomfort after a workout—but these early signs can quickly progress if ignored. What begins as a slight annoyance can turn into persistent pain, affecting your ability to walk, run, or even stand for long periods.
- The most common early symptom is pain and stiffness at the back of the ankle, just above the heel. This stiffness is usually worse when you first get out of bed, as the Achilles tendon tightens overnight. Those first few steps might feel like your heel is stuck, but as you move around, the pain often eases—only to return later in the day or after activity. If you’ve noticed a nagging ache that just won’t go away, this could be the start of Achilles tendinopathy.
- As the condition progresses, swelling and tenderness may develop around the tendon, often accompanied by noticeable thickening. You might find it painful to touch the area, or you may see swelling that makes it hard to wear certain shoes. Climbing stairs, walking uphill, or pushing off your toes can become more difficult as the pain worsens with movement.
- Some people also experience a crackling or grating sensation, known as crepitus, when they move their ankle. This is a sign that the tendon is becoming more irritated or damaged. Over time, the discomfort can increase, especially after high-impact activities like running or jumping. What might have been manageable at first can become a more significant problem, interfering with your ability to stay active.
- In more severe cases, if you feel a sudden sharp pain in the back of your ankle or struggle to push off your foot, you could be dealing with a partial or full Achilles tendon tear—a much more serious injury that requires immediate medical attention.
Diagnosis
Diagnosing Achilles tendinopathy typically starts with a thorough clinical examination by your physio. They’ll ask about your symptoms, activity level, and any recent changes in your routine, such as an increase in exercise or new footwear. Your physio will then perform a physical exam, checking for pain, swelling, and tenderness along the Achilles tendon, as well as evaluating your ankle’s range of motion and strength.
One of the key tests used to diagnose Achilles tendinopathy is the palpation test, where the physio will press along the tendon to pinpoint areas of pain or thickening. They may also ask you to perform certain movements, like standing on your toes or walking, to assess how your tendon responds under stress.
Imaging Tests
In most cases, a clinical diagnosis is straightforward, and additional tests aren’t needed. However, if your symptoms are more severe, long-lasting, or if there’s a concern about other issues (like a tendon tear), imaging tests may be used to further assess the injury.
Ultrasound is commonly used to evaluate the condition of the tendon, providing real-time images to assess thickening or tears. MRI may be ordered if there’s a need for a more detailed view of the tendon and surrounding tissues, particularly in complex or persistent cases.
Despite the availability of imaging tests, it’s important to note that most cases of Achilles tendinopathy can be diagnosed easily through clinical examination alone, and most will respond well to treatment without the need for diagnostic investigation.
Types of Achilles Tendinopathy
Achilles tendinopathy can be categorized into two main types: Insertional Achilles Tendinopathy and Non-Insertional Achilles Tendinopathy. Each type involves different areas of the tendon and presents unique challenges, so understanding the distinction is crucial for effective management.
Insertional Achilles Tendinopathy
Insertional Achilles tendinopathy affects the lower portion of the Achilles tendon, where it attaches to the heel bone (calcaneus). This form of tendinopathy is often more complicated to treat due to its proximity to the bone. The key challenge is that the area where the tendon inserts has less blood supply, which can slow down healing. Poor circulation to this part of the tendon can lead to longer recovery times and a greater chance of recurrence if not properly managed.
In some cases, an underlying structural issue, such as a Haglund’s deformity (a bony bump on the back of the heel), can complicate matters further. This bony prominence causes additional friction on the tendon, exacerbating the pain and potentially hindering recovery. The increased pressure from the bone irritation can lead to further tendon damage, making healing more challenging.
Non-Insertional Achilles Tendinopathy
Non-insertional Achilles tendinopathy is the more common type and typically occurs in the middle part of the Achilles tendon, rather than at its attachment point. This form of tendinopathy involves the degeneration of tendon fibers, leading to pain, thickening, and reduced function. Fortunately, non-insertional Achilles tendinopathy generally responds very well to physiotherapy and rehabilitation. Because it occurs away from the bone, it doesn’t face the same challenges with blood supply or bone-related complications, which typically allows for a smoother recovery process.
The treatment for Achilles tendinopathy usually involves a combination of strategies aimed at reducing pain, improving tendon health, and preventing future injury. Here’s a breakdown of the typical approach
- Rest and Activity Modification: The first step is to reduce or modify activities that aggravate the tendon. This may involve taking a break from high-impact exercises like running or jumping, and opting for low-impact alternatives, such as swimming or cycling.
- Manual Therapy: Physiotherapists often use manual techniques to address tightness in the tendon and surrounding calf musculature. This helps to improve flexibility, reduce muscle tension, and increase circulation to the affected area.
- Shockwave Therapy: For some cases, shockwave therapy can be used to stimulate healing in the tendon. This treatment uses high-energy sound waves to promote blood flow, reduce pain, and encourage tissue regeneration.
- Orthotics: If there are clear biomechanical issues contributing to the tendinopathy, such as overpronation or poor foot alignment, custom orthotics may be recommended to help support the arch and reduce strain on the Achilles tendon.
Achilles Loading Program: A structured Achilles loading program, focused on eccentric strengthening exercises, is a key part of the treatment. These exercises help to gradually load and strengthen the tendon, promoting healing and preventing future injuries
Most people respond well to this comprehensive approach, with significant improvements in pain, strength, and function. With consistency and proper management, the majority of individuals recover successfully and return to their usual activities.
Achilles tendinopathy, whether insertional or non-insertional, can be a frustrating condition, but with the right treatment plan, most people experience significant improvement. By combining rest, manual therapy, shockwave therapy, orthotics (if needed), and a tailored Achilles loading program, the tendon can heal and strengthen effectively.
With patience and consistency, recovery is not only possible but highly likely, allowing you to get back to the activities you love. If you’re struggling with Achilles pain, consult a physio to develop a plan that works for you.
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