Here’s the truth: Achilles tendinopathy is a load problem, not a flexibility problem. Stretching and foam rolling don’t rebuild the tendon’s capacity to handle load. That’s the only thing that actually fixes it. But before we go further, let’s clear up another common misunderstanding. Tendinopathy vs Tendonitis vs Tendonosis: whats the difference?
Tendonitis is the “old school” term most people know. It occurs when a tendon is suddenly overloaded, causing micro-tears and a classic inflammatory response (swelling and heat). This was the preferred term when I was in PT school (15 years ago).
Tendinopathy is the preferred medical term because most persistent tendon pain isn’t actually driven by inflammation. Instead, the tendon’s collagen fibers become disorganized and “break down” because they haven’t had enough time to heal between repeated stresses.
Tendinosis is a specific type of tendinopathy that refers to the actual non-inflammatory degeneration of the tissue. Ok, now that we’ve got sorted out, let’s get back to the fun stuff.
Think of your Achilles like a thermometer
Your tendon has a load capacity in the same way a muscle has a strength capacity. When the load you place on the tendon exceeds that capacity, the tendon reacts with pain and stiffness. Rest brings the temperature down. But it doesn’t raise the set point (load capacity). The only way to raise the ceiling is to progressively load the tendon in a way it can handle and adapt to.
Stage 1: Isometrics
A calf raise held at the top for 30 to 45 seconds. Isometrics provide an analgesic effect, reducing pain for up to 45 minutes after the exercise. One thing most programs miss: the Achilles is formed by two muscles. The gastroc works with the knee straight. The soleus works with the knee bent. Both have to be trained and we need to train both with the appropriate amount of resistance.
A body weight isometric calf raise is appropriate for a very painful tendon with a very weak load capacity. We need to stress the tendon to about 70% of it’s max capacity for there to be noticeable changes. Keep this in mind if you are trying to program these exercises yourself. If it’s too aggressive, it’ll be painful and feel worse. If it’s not aggressive enough, you won’t notice any difference and think this isn’t the right approach for you.
Stage 2: Heavy slow resistance
Slow, controlled movement under load. 3 seconds up, pause, 3 seconds down. The tendon responds to time under tension. Start with two legs, add weight gradually, progress to single leg as strength builds. You may need to add weight to push yourself to the necessary level to effect change at the level of the tissue (as describe above).
Stage 3: Plyometrics and return to running
Simple pogo hops progressing toward the demands of your actual activity. For runners, we typically use a benchmark of three sets of 50 pain-free pogo hops before returning to running. These are three examples, one at each stage. There are certainly many more exercises that can, and often need to, be done at each stage. The key thing is understanding that there are 3 stages and that if you progress through them at the right intensity and pace, you can absolutely get rid of your tendon pain and get back to living your active life.
When StemWave helps
For Achilles tendinopathy present for more than 3 to 6 months, StemWave shockwave therapy restarts the healing process, triggering angiogenesis and stem cell recruitment that make the subsequent loading program more effective.
At Land and Sea PT in Oceanside, we work through this progression 1-on-1 with a Doctor of PT every session. If Achilles pain has been limiting your running, come in and let us build a proper plan.
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Dr. Jonny Blue is a Doctor of Physical Therapy and founder of Land and Sea Physical Therapy in Oceanside, CA. He specializes in orthopedic PT, root cause methodology, and helping active adults in North County San Diego get back to the activities they love without surgery or pain medication.