Achilles tendon pain: why it lingers, what works and what to avoid

Achilles tendinopathy is pain and stiffness in the thick tendon at the back of your ankle, usually with thickening and pain when you load it [1]. You may also hear it called Achilles tendinitis. There are two main types, and the difference matters for your rehab [1]:

• Midportion: the pain is more than 2 cm (about 3/4 inch) above where the tendon attaches to the heel
• Insertional: the pain is within 2 cm of that attachment

It is usually diagnosed with a physical exam. When the signs fit, imaging is not needed [1].

Who gets it

In a large study of recreational runners, 100 of 1,929 (5.2%) developed it while training for a running event [2]. But it is not only a runner’s problem: in a Dutch primary care study, only 35% of midportion cases had a recorded link to sports [3].

The best-supported risk factor is a previous episode [4]. That is one more reason to finish your rehab rather than stopping when the pain eases.

One risk many people do not know about: fluoroquinolone antibiotics, such as ciprofloxacin and levofloxacin, carry an FDA boxed warning for tendinitis and tendon rupture, most often in the Achilles [5]. This appears to be rare, but the risk goes up with oral steroids [6] and is higher in people over 60 and in those with kidney, heart or lung transplants [5]. Problems can start within hours or days, or as long as several months after finishing the medicine [5]. If you are taking ciprofloxacin and get tendon pain, the NIH advises you to stop taking it, rest and call your doctor right away [7].

How long does it take?

Think in months, not weeks. The Dutch guideline recommends calf strengthening for at least 12 weeks, and says getting back to full, pain-free loading usually takes at least a few months of active treatment [1]. Most people improve, but how much and how fast varies [8]. Pain can last longer than 3 months even with early treatment [9].

Doing nothing is the weak option. The guideline expects little or no short-term improvement with wait and see [1], and a review of 29 trials does not recommend it [10].

Long term, the picture is good but not perfect:

• No symptoms at 5 years (34 patients)65%
• No physical limitations at 10 years (77 patients)63%
• Completely pain free at 5 years (58 tendons)40%

Sources: Silbernagel et al., 2011 [11]; Johannsen et al., 2018 [12]; van der Plas et al., 2012 [13]. These are small studies with different definitions and treatments, so they cannot be compared directly. In the 10-year study, some patients also had steroid injections.

The guideline says 23% to 37% of people may still have symptoms for up to 10 years, while 85% of athletes return to sport [1]. Having some symptoms does not always mean you cannot be active: in the 5-year study with the lowest pain-free rate, tendon scores were still much better than at the start [13].

What works: loading the tendon

Exercise is the first-line treatment. The 2024 physical therapy guideline gives its strongest grade to tendon loading exercise, with loads as high as tolerated [8]. In a review of 29 trials, exercise scored about 20 points better than wait and see on a 0 to 100 scale at 3 months, although the certainty of the evidence was low [10].

There is no single magic exercise. The guideline says eccentric exercise is not required, because different types of loading work [8]. In a trial of 58 people with midportion pain, heavy slow resistance and eccentric training both worked and the results lasted for a year; people attended more of their heavy slow sessions (92% vs. 78%) [14].

Complete rest is not the answer. The guideline says to keep up activities within your pain tolerance [8]. In a trial of 38 people, those who kept running and jumping with pain monitoring did about as well as those who rested from those activities for 6 weeks [15]. This was a small study, and it does not mean you should push through anything. The Dutch guideline advises temporarily stopping or replacing what provokes the pain, then building back gradually [1]. A therapist can help you find the right balance.

Insertional pain needs a different plan. Heel drops off a step should only be done for the noninsertional type [9], and the Dutch guideline suggests starting exercises on a flat surface [1]. In a 2025 trial of 42 active people with insertional pain, a program that limited how far the ankle bent during exercise, removed calf stretching and added heel lifts beat a standard program, with a 24.4 vs. 12.2 point gain at 12 weeks [16]. It was a small trial, and the authors could not say which part of the program made the difference.

Heel lifts may be used temporarily [8]. In a trial of 100 people with midportion pain, they did slightly better than eccentric exercise at 12 weeks, but the difference fell just short of what the authors considered meaningful [17].

Injections, shockwave and surgery

When exercise is not enough after about 3 months, the Dutch guideline says add-on treatments can be discussed, along with how uncertain they are [1]. Here is what the better studies found:

Treatment	What the evidence shows
Platelet-rich plasma (PRP) injection	No benefit over a sham or saline injection in two trials, one with 240 people [18] and one with 54 [19]
High-volume injection	No improvement over a sham at 12 months in a trial of 192 adults, with or without a steroid [20]
Steroid injection	Evidence conflicts. One trial of 100 people found better results at 6 months when added to exercise [21], but the high-volume trial found worse results at 26 weeks when a steroid was added [20]. Orthopedic surgeons advise against injecting into the tendon because of the risk of a tear [9] [22]
Shockwave therapy	A 2026 review of 9 trials found no clinically meaningful benefit and advised against routine use [23]. The Dutch guideline lists it as a possible add-on after 3 months [1]
Night splints, low-level laser	The physical therapy guideline says not to use them [8]
Manual therapy, dry needling, taping	Supported only at the lowest levels of the guideline, such as expert opinion [8]

Surgery is reserved for people who have not improved after at least 6 months of active treatment [1] [9]. Recovery can take up to 12 months of rehab, and up to 20% to 30% of patients have continued pain afterward [9].

What you can do now

• Reduce what aggravates the tendon and switch to low-impact activity for a while, such as biking, an elliptical or swimming [9]
• Put an ice pack in a towel on the sore spot for up to 20 minutes every 2 to 3 hours [24]
• Wear comfortable shoes with a low heel and soft sole, and try soft insoles or heel pads [24]
• Do not use anti-inflammatory pills for more than a month without talking to your doctor [9]
• Do not rush back: returning to full activity within days is linked to more recurrences [1]

See a clinician if your heel pain has not improved after 2 weeks of home care, or sooner if it is intense or getting worse [24]. Let them know if you also have back pain that started before age 45 or psoriasis, since the guideline says insertional pain in those cases may call for a check for inflammatory disease [1].

Get urgent care for a possible rupture. Warning signs include a sudden pop in the back of your calf or heel [9], severe pain and swelling near the heel, and not being able to walk on the leg or stand on your toes [22].

The takeaway

• Achilles pain usually takes months to settle, so plan on at least 12 weeks of exercise.
• Progressive loading is the first-line treatment, and complete rest is not.
• Pain near the heel bone needs a different program than pain higher up the tendon.
• PRP and shockwave have not clearly beaten sham treatment, and the evidence on steroid injections conflicts.
• Tell your doctor about tendon pain if you are taking a fluoroquinolone antibiotic, and take a sudden pop seriously.

You can start physical therapy in Utah without a referral. If your Achilles has been bothering you for weeks, an evaluation can confirm which type you have and build a loading plan that keeps you moving.