Achilles Tendinopathy: When Ankle Stiffness, Calf Tightness or Heel Pain May Be Coming from the Achilles

Creator: Mark Reyneker, BTech (Podiatry), MSc (Palaeontology), Registered Podiatrist, Foot & Gait Specialist | Founder & Clinical Director, Family Podiatry Centre
Published: 2026-10-10T11:30:00+08:00

10 October 2026

By Mark Reyneker, BTech (Podiatry), MSc (Palaeontology), Registered Podiatrist, Foot & Gait Specialist | Founder & Clinical Director, Family Podiatry Centre

Published: 10 October 2026 | Last reviewed: 6 October 2026

Summary answer

Achilles tendinopathy is a disorder of the Achilles tendon that commonly causes stiffness, reduced function and pain during loading. However, patients do not always arrive complaining specifically of “Achilles tendon pain.” They may describe a stiff or tight ankle, calf tightness or cramping, discomfort around the back of the ankle, reduced push-off, foot stiffness or associated heel pain. Some people notice reduced running or walking performance before significant pain develops.

From a biomechanical perspective, Achilles tendinopathy cannot simply be blamed on either pronation or supination. Running studies have repeatedly identified increased rearfoot eversion and prolonged pronation in some people with Achilles tendinopathy, making pronation the more commonly reported dynamic foot-motion association. Reduced ankle dorsiflexion — sometimes described clinically as ankle equinus when sufficiently restricted — is also frequently identified, although evidence that it directly causes Achilles tendinopathy remains mixed. Supination is not considered the dominant movement pattern, although some research has identified more lateral foot roll-over in affected individuals.

The important point is that Achilles tendinopathy is usually multifactorial. The tendon, calf muscles, ankle movement, foot mechanics, training load and general tendon health all need to be considered rather than attributing the condition to one foot type or movement.

Achilles tendinopathy does not always begin with obvious Achilles pain

The textbook description of Achilles tendinopathy is pain in the Achilles tendon. That description is correct, but it does not always reflect the language patients use when they first seek help. At Family Podiatry Centre, patients with Achilles-related problems frequently describe symptoms such as:

a stiff ankle;
tightness around the back of the ankle;
calf tightness;
recurrent calf cramping;
stiffness when first standing after sitting;
a feeling that the foot does not move properly;
discomfort around the ankle rather than a clearly identified tendon;
plantar heel pain;
reduced power when walking uphill or climbing stairs;
difficulty running normally;
a feeling that one leg is “tighter” than the other.

Some patients are surprised when examination focuses on the Achilles tendon because they did not consider the Achilles to be the source of their problem. This distinction matters for online searches as well.

Someone experiencing “tight ankle when walking”, “calf tightness when running”, “ankle stiff in the morning” or “heel and ankle pain” may never search for Achilles tendinopathy. Yet those symptoms may justify assessing the Achilles–calf–ankle complex.

Pain is important, but it is not the only symptom

Achilles tendinopathy is clinically characterised by a combination of pain, stiffness and impaired function. Stiffness after rest is particularly characteristic. A person may get out of bed and notice that the ankle and lower calf initially feel stiff. The first few steps can feel awkward. After moving for a while, the area may loosen.

The same phenomenon may occur after sitting at a desk, driving or remaining inactive for a prolonged period. In athletes, an interesting pattern can develop in which symptoms are present during the beginning of exercise and then temporarily improve as the person warms up. Reduced performance can also precede significant pain.

Research describing Achilles tendinopathy in athletes notes that some people notice slower running, reduced jumping ability or declining plantar-flexor performance before pain becomes the dominant complaint. This is one reason that Achilles problems should not be considered purely a pain disorder.

A patient may not identify the Achilles tendon as the painful structure

The Achilles lies at the posterior ankle, so patients do not always describe the anatomical location accurately. They may point broadly to the ankle. Others point to the heel. Some describe a pulling sensation extending into the calf. The terminology used by the patient and the anatomical structure producing the symptom are therefore not necessarily the same. There is, however, an important clinical distinction.

For a diagnosis of symptomatic Achilles tendinopathy, contemporary diagnostic literature still places considerable importance on:

pain associated with tendon loading;
the location of that pain;
tenderness during examination;
stiffness;
functional impairment.

A recent international consensus similarly identified pain location, pain during activity, provocation testing and palpation as essential diagnostic domains.

Therefore, someone who has calf cramps or ankle stiffness but absolutely no symptoms involving the tendon during examination should not automatically be diagnosed with Achilles tendinopathy. Other conditions need to be considered.

Achilles tendon abnormalities can exist without Achilles pain

This introduces another fascinating aspect of tendon pathology. A tendon can look abnormal on ultrasound or MRI while producing no symptoms whatsoever. A large systematic review examining more than 10,000 Achilles tendons found substantial numbers of imaging abnormalities in people without Achilles symptoms, although prevalence varied widely depending on age, activity level, body mass index and how an “abnormal” tendon was defined.

This tells us something important: the appearance of a tendon and the symptoms experienced by the patient are not the same thing. Structural changes may exist before symptoms develop. They may remain asymptomatic.

Conversely, a painful tendon does not necessarily have dramatic abnormalities on imaging. An ultrasound report therefore cannot diagnose the patient by itself. The clinical picture still matters.

The Achilles tendon is much more than a cord connecting the calf to the heel

The Achilles tendon is the largest tendon in the human body. It connects the calf muscle complex to the calcaneus, or heel bone.

The major contributors are the: gastrocnemius, which crosses both the knee and ankle; and the soleus, which lies deeper and crosses the ankle. Their tendon fibres combine to form the Achilles tendon before inserting into the posterior calcaneus. This arrangement means that the Achilles forms the mechanical connection between powerful calf muscles and the foot.

Every time the heel lifts from the ground, this system participates. Walking requires it.

Running places substantially greater demands upon it.

Jumping, sprinting, hill running and rapid changes of direction increase those demands further.

The tendon therefore behaves not simply as a rope but as an elastic biological structure capable of storing and releasing energy.

The Achilles tendon stores energy when we walk and run

During running, the Achilles stretches under load and stores elastic energy.

Some of that energy is returned during propulsion.

This makes human locomotion considerably more efficient.

Rather than the calf muscles having to generate every unit of force from scratch during every step, the muscle–tendon system behaves partly like a spring.

But a spring has to tolerate repeated loading.

Training therefore creates a balance between:

the amount of load entering the tendon

and

the tendon’s capacity to tolerate and adapt to that load.

When loading increases faster than tendon capacity, symptoms can develop.

That increase may come from greater mileage, faster running, hills, jumping, a change in sport, reduced recovery or simply accumulating more activity than the tendon is currently prepared to tolerate.

The problem is therefore often better considered as a load-capacity mismatch than as an isolated inflammatory injury.

Tendinopathy is not quite the same thing as tendonitis

The older term Achilles tendonitis remains commonly used online.

“Tendonitis” implies that inflammation is the primary pathological process.

Modern understanding is more complicated.

Chronic tendinopathy involves changes in tendon structure, collagen organisation, cellular activity and tendon matrix rather than simply persistent conventional inflammation.

For this reason, Achilles tendinopathy is generally the preferred clinical term.

This does not mean inflammatory processes never occur.

It means that chronic tendon disease cannot adequately be explained as inflammation alone.

There are two important locations of Achilles tendinopathy

Achilles tendinopathy is commonly separated into two groups.

Midportion Achilles tendinopathy

This typically affects the tendon approximately 2–6 cm above the heel bone.

Patients may notice local thickening, tenderness, stiffness or pain in this region.

This is the most common form.

Insertional Achilles tendinopathy

This occurs where the Achilles attaches directly to the calcaneus.

Symptoms are therefore located much closer to the heel itself.

Compression between the tendon and heel bone becomes particularly important in this region.

Associated structures such as the retrocalcaneal bursa may also contribute to symptoms.

Approximately three-quarters of Achilles tendinopathy presentations have historically been described as midportion disease, with insertional problems accounting for a smaller proportion.

The distinction matters because these two regions do not behave identically.

Ankle stiffness can be one of the most noticeable complaints

One of the common complaints we hear clinically is:

“My ankle feels tight.”

The patient may not feel pain directly in the tendon.

Instead, the ankle feels restricted.

Walking downstairs may feel different.

Squatting may feel limited.

Running may feel less fluid.

The person may notice that the knee cannot move forwards over the foot as easily on one side.

An important movement here is ankle dorsiflexion.

Dorsiflexion is the movement that occurs when the shin advances forwards over the foot.

It is essential during normal walking.

The Achilles–gastrocnemius–soleus complex directly influences how much dorsiflexion is available.

Recent systematic-review evidence found that people with Achilles tendinopathy demonstrated, on average, reduced ankle dorsiflexion when compared with asymptomatic individuals. They also demonstrated reduced plantar-flexor endurance.

The direction of cause and effect, however, is not completely settled.

Limited dorsiflexion might contribute to abnormal Achilles loading.

Alternatively, people with a painful Achilles may begin moving differently and subsequently demonstrate reduced movement.

Both mechanisms may occur.

Ankle equinus is not actually a type of foot movement

This is important when discussing whether Achilles tendinopathy is associated with pronation, supination or equinus.

These three terms do not describe equivalent things.

Pronation and supination are movements.

Equinus describes restriction of ankle dorsiflexion.

A person with ankle equinus cannot move the shin sufficiently forwards over the foot without compensating somewhere else.

One common reason is gastrocnemius tightness.

Because the gastrocnemius crosses both the knee and ankle, its effect on ankle dorsiflexion changes according to knee position.

This relationship forms the basis of the Silfverskiöld test, which helps clinicians determine whether limited dorsiflexion is substantially influenced by the gastrocnemius.

Equinus therefore deserves separate consideration from pronation and supination.

Pronation is the foot movement most commonly associated with Achilles tendinopathy

When researchers have investigated running biomechanics in people with Achilles tendinopathy, one of the recurring findings has been greater rearfoot eversion.

Rearfoot eversion forms part of pronation.

Some studies have also reported a longer period of pronation during stance.

An earlier systematic review found increased rearfoot eversion range of motion in runners with Achilles tendinopathy.

A later systematic review again identified increased ankle eversion and differences in the timing of maximum pronation.

More recent research has described an overall tendency towards what investigators called a pattern of medial collapse, although the authors emphasised that study quality remains limited and biomechanical findings are not completely consistent.

Therefore, if the choice is specifically:

pronation or supination?

the literature more commonly implicates pronation/rearfoot eversion.

But that does not mean everyone with Achilles tendinopathy overpronates.

Overpronation should not become the universal explanation

It is tempting to see a pronated foot and conclude that it caused the Achilles problem.

The evidence does not support such a simple conclusion.

Some studies have found increased rearfoot eversion.

Others have not.

Static foot posture is also different from what the foot does dynamically while walking or running.

A foot that appears pronated while standing may function quite differently once it begins moving.

A systematic review examining prospective risk factors concluded that static foot posture had not been convincingly demonstrated to predict Achilles tendinopathy.

More recent case-control work has found associations between abnormal foot posture and Achilles tendinopathy, particularly hyperpronation, but hypopronated feet were also represented.

The safest conclusion is therefore:

pronation can be relevant, but it is not a universal cause of Achilles tendinopathy.

Supination can also alter Achilles loading

Supination is essentially the opposite movement pattern.

A more supinated foot may remain relatively rigid and load the lateral side of the foot for longer.

This can also alter how force travels through the lower limb.

Interestingly, a systematic review of prospective clinical risk factors found limited evidence linking Achilles tendinopathy with a more lateral foot roll-over pattern during gait.

That finding is important because it prevents the discussion becoming overly simplistic.

Achilles tendinopathy is not exclusively a pronation disorder.

Both excessive mobility and excessive rigidity can potentially alter how forces are transmitted through the Achilles–foot system.

What matters is the movement occurring in that individual patient.

Reduced ankle dorsiflexion may be as clinically important as foot posture

In everyday practice, limited ankle movement deserves particular attention.

If the ankle cannot dorsiflex normally, the body still has to move forwards.

Something has to compensate.

The foot may pronate more.

The heel may lift earlier.

The leg may rotate differently.

The stride may change.

The person may shorten the step.

The knee or hip may compensate.

Different patients solve the same ankle restriction in different ways.

This is why equinus cannot automatically be equated with pronation.

One patient with limited dorsiflexion may compensate by pronating heavily.

Another may remain relatively supinated and lift the heel early.

Another may simply reduce stride length.

The resulting loading pattern through the Achilles can therefore be very different.

The evidence for equinus as a cause is still mixed

Clinical experience often identifies restricted ankle dorsiflexion in people with Achilles problems.

Research supports an association, but causality is less certain.

A systematic review of prospective risk factors found conflicting evidence regarding limited ankle dorsiflexion and subsequent Achilles tendinopathy.

A newer systematic review and meta-analysis found that patients who already had Achilles tendinopathy demonstrated approximately 5 degrees less non-weight-bearing ankle dorsiflexion with the knee bent than controls.

These two findings are not contradictory.

One addresses whether limited dorsiflexion predicts the development of the condition.

The other demonstrates that reduced dorsiflexion is commonly found once the condition exists.

We therefore should not claim:

“Equinus causes Achilles tendinopathy.”

A more accurate statement is:

reduced ankle dorsiflexion is commonly relevant in Achilles tendinopathy and should be assessed, but it is only one component of a multifactorial condition.

Calf tightness and calf cramping deserve attention

The gastrocnemius and soleus ultimately become the Achilles tendon.

It is therefore unsurprising that patients with Achilles problems frequently describe symptoms higher in the calf.

Some experience a persistent sensation of calf tightness.

Others describe fatigue.

Some notice that one calf cramps more easily during running or at night.

Calf cramping is not a specific diagnostic sign of Achilles tendinopathy. Many neurological, metabolic, circulatory and muscular factors can produce cramps.

However, Achilles tendinopathy is associated with measurable deficits in the plantar-flexor system.

Systematic-review evidence shows that affected individuals commonly demonstrate reduced heel-raise endurance and reduced plantar-flexor strength.

This means the calf–Achilles unit may not simply feel different.

Its functional capacity may genuinely be reduced.

Foot stiffness can be part of the same mechanical picture

Another patient may not complain about the ankle at all.

Instead, the description is:

“My foot feels stiff.”

The Achilles influences how the heel leaves the ground and how the body progresses over the foot.

If ankle dorsiflexion, calf function or Achilles loading changes, the timing of movement elsewhere in the foot can also change.

People may alter:

how long the heel remains on the floor;
where pressure travels under the foot;
how quickly they move over the forefoot;
how much the rearfoot everts;
how strongly the calf generates propulsion.

Systematic reviews have identified altered plantar-pressure patterns and changes in the centre of pressure in people with Achilles tendinopathy.

The patient experiences the result simply as a foot that feels different.

Plantar heel pain may coexist with Achilles and calf problems

Plantar heel pain deserves particular attention because patients sometimes develop symptoms underneath the heel while also demonstrating significant calf–Achilles restriction.

The plantar fascia and Achilles tendon are anatomically separate structures, but mechanically they are closely related through the calcaneus and through the way the leg moves over the foot.

Gastrocnemius tightness and restricted ankle dorsiflexion have long been associated with plantar heel pain.

A systematic review examining plantar fasciopathy described the close anatomical and mechanical relationship between the gastrocnemius–Achilles complex and the plantar fascia. Increased Achilles tension and reduced dorsiflexion may increase loading through the plantar fascia during weightbearing.

This does not mean plantar heel pain is a symptom that proves Achilles tendinopathy.

Plantar fasciopathy, heel-pad disorders, nerve entrapments, stress injury and other conditions remain important causes of plantar heel pain.

But when plantar heel pain occurs alongside:

calf tightness + limited ankle dorsiflexion + Achilles stiffness

the entire calf–ankle–foot system deserves examination rather than treating the painful heel in isolation.

The Achilles can be abnormal before it hurts

Tendon disease does not necessarily begin on the day pain begins.

Ultrasound studies have repeatedly identified tendon abnormalities in asymptomatic individuals.

Prospective research has also shown that athletes with abnormal tendon structure on ultrasound are more likely to develop Achilles symptoms in the future, although most abnormal tendons do not inevitably become painful.

This supports an important concept:

pain is one stage of the clinical presentation, not necessarily the beginning of the biological process.

A runner may first notice reduced spring.

Another notices persistent calf fatigue.

Another feels stiff every morning.

Another experiences obvious Achilles pain.

These presentations should not automatically be assumed to represent the same stage or even the same condition, but they demonstrate why clinical assessment is more informative than symptom labels alone.

Morning stiffness is particularly characteristic

Tendon stiffness after inactivity is one of the more recognisable features of Achilles tendinopathy.

The patient may feel relatively comfortable while sitting.

Then they stand and the ankle feels stiff.

The first several steps are awkward.

After walking, movement becomes easier.

A similar pattern can occur at the beginning of a run.

The tendon initially feels uncomfortable or stiff.

It warms up.

Symptoms diminish.

They then return later in the session or afterwards.

This “warm-up phenomenon” is commonly described in Achilles tendinopathy literature.

As the condition becomes more established, the comfortable period may become shorter and symptoms can begin interfering with normal daily activity.

Some patients first notice loss of performance

An active person may notice that something is wrong before identifying pain.

Running pace drops.

Hill running becomes harder.

The affected leg does not push as strongly.

Jumping feels less powerful.

Repeated heel raises become difficult.

The calf fatigues earlier.

This makes sense mechanically.

The Achilles tendon and plantar-flexor muscles are fundamental to propulsion.

Recent systematic-review evidence found people with Achilles tendinopathy performed approximately 10 fewer heel raises than asymptomatic controls in pooled testing.

Reduced performance therefore deserves attention even when pain is relatively mild.

Achilles tendinopathy is not just a running injury

Runners are strongly associated with Achilles tendinopathy because running places repeated high loads through the tendon.

But Achilles tendinopathy also occurs in people who do not run.

One review estimated that around one-third of affected patients may have relatively sedentary lifestyles.

Tendon health is influenced by numerous factors beyond exercise.

Age, metabolic health, cholesterol, diabetes, medications, previous injury, tendon capacity and sudden changes in activity can all influence tendon behaviour.

Fluoroquinolone antibiotics are a particularly recognised medication-related risk because of their association with Achilles tendon disorders and rupture.

The clinical assessment therefore needs to extend beyond simply asking how somebody runs.

The entire lower limb participates in Achilles loading

Foot mechanics are only one part of the picture.

Research comparing athletes with and without Achilles tendinopathy has identified differences involving:

the foot;
ankle;
calf;
knee;
hip;
muscle activation;
plantar-flexor strength;
hip strength;
running mechanics.

A 2023 systematic review found evidence of altered calf and hip muscle function alongside changes in lower-limb kinematics, although the authors stressed that the available studies were generally of low quality.

This supports a broader clinical approach.

The Achilles tendon sits at the ankle.

The forces reaching it are generated by the whole moving body.

Pronation versus supination versus equinus: the practical conclusion

For patients trying to understand the biomechanics, the distinction can be summarised simply.

Pronation

Some of the strongest repeated dynamic observations involve increased rearfoot eversion and altered pronation timing.

Pronation is therefore the foot movement most commonly associated with Achilles tendinopathy in running-biomechanics research.

It is not present in every patient and should not automatically be considered the cause.

Supination

Supination is less commonly presented as the classic Achilles tendinopathy pattern.

However, lateral foot roll-over and relatively rigid mechanics may also alter tendon loading.

A supinated foot should therefore not be dismissed.

Ankle equinus

Equinus is not a movement pattern.

It describes restricted ankle dorsiflexion.

Reduced dorsiflexion is commonly found clinically in Achilles tendinopathy and may influence loading and compensatory foot movement.

However, research has not conclusively established equinus as a universal cause.

The overall answer

There is no single Achilles tendinopathy foot type.

Pronation has the clearest repeated association among dynamic foot movements.

Limited ankle dorsiflexion is an important accompanying impairment.

Supinated mechanics can also matter.

The individual pattern needs to be measured rather than assumed.

The location of symptoms still matters

Although this article deliberately highlights less obvious presentations, localisation remains important.

Pain directly within the midportion Achilles suggests one group of conditions.

Pain directly at the insertion suggests another.

Pain anterior to the Achilles may suggest posterior ankle impingement.

Pain around the side of the tendon may involve neighbouring tendons or nerves.

Plantar heel pain requires a different differential diagnosis.

Deep calf pain and swelling may occasionally indicate something requiring urgent medical assessment rather than a tendon disorder.

An international Delphi consensus published in 2025 identified several important alternative diagnoses around the Achilles region, including partial tendon tear, posterior ankle impingement, plantaris pathology, other flexor-tendon disorders, paratendinopathy, nerve pathology, bursitis, calcaneal stress injury and ankle or subtalar pathology.

This is precisely why symptoms around the ankle should not automatically be labelled Achilles tendinopathy.

Imaging is useful when it answers a clinical question

Achilles tendinopathy can often be diagnosed clinically.

Ultrasound can assess tendon thickness, structure and vascularity.

MRI provides detailed assessment of the tendon and surrounding tissues.

Imaging becomes particularly useful when the presentation is unusual, when another diagnosis needs to be excluded or when symptoms are not behaving as expected.

But imaging must be interpreted carefully.

A tendon can look abnormal and not hurt.

A painful tendon can occasionally show relatively modest structural changes.

The scan should therefore support the diagnosis rather than replace the examination.

Treatment should follow the diagnosis and the mechanical findings

Because Achilles tendinopathy is multifactorial, treatment should not consist of applying the same protocol to every patient.

The broad goals are usually to:

reduce inappropriate tendon overload, restore appropriate tendon capacity, identify relevant calf and ankle restrictions, assess foot and lower-limb mechanics and progressively return the tendon to the demands required of it.

Exactly how that is achieved depends on whether the problem is insertional or midportion, how irritable the tendon is, the patient's strength, ankle mobility, foot mechanics, activity level and the presence of associated pathology.

For that reason, detailed treatment is beyond the purpose of this article.

The important first step is establishing what structure is actually producing the symptoms and why the Achilles–calf–foot system is behaving differently.

Persistent ankle stiffness and calf symptoms deserve investigation

A patient does not need to arrive saying:

“I think I have Achilles tendinopathy.”

The presentation may be much less obvious.

Persistent symptoms such as:

ankle stiffness, calf tightness, recurring calf cramping, difficulty moving the knee forwards over the foot, reduced push-off, morning stiffness, posterior ankle discomfort, progressive running difficulty or heel pain

can all provide clues that the calf–Achilles–ankle complex deserves examination.

They are not diagnostic by themselves.

They are reasons to look more carefully.

At Family Podiatry Centre, Achilles assessment therefore extends beyond simply pressing on the tendon.

The objective is to determine:

whether the Achilles tendon is actually involved;
whether the condition is insertional or midportion;
whether another structure is producing the symptoms;
how much ankle dorsiflexion is available;
whether gastrocnemius or soleus restriction is present;
how the rearfoot moves;
whether the patient predominantly pronates or supinates during gait;
how pressure moves through the foot;
how effectively the calf produces propulsion;
and what activity or loading factors may have contributed to the problem.

The painful area is important.

The movement system producing the load is equally important.

Key takeaway

Achilles tendinopathy does not always arrive as an obvious complaint of Achilles tendon pain. Patients may initially describe ankle stiffness, calf tightness or cramping, reduced mobility, foot stiffness, heel discomfort or declining walking and running performance. True clinical Achilles tendinopathy still usually demonstrates local tendon symptoms when the tendon is specifically examined or loaded, while structural abnormalities can exist in completely painless tendons.

Biomechanically, pronation — particularly increased rearfoot eversion — is the foot movement most repeatedly associated with Achilles tendinopathy, but it is not a universal cause. Reduced ankle dorsiflexion or ankle equinus is also commonly relevant, while supinated or lateral loading patterns can occur in some patients. Achilles tendinopathy is therefore best understood as a multifactorial problem involving tendon capacity, calf function, ankle mobility, foot mechanics and load rather than a condition caused by one particular foot type.

References

Docking, S.I., Hart, H.F., Rio, E., Hannington, M.C., Cook, J.L. and Culvenor, A.G. (2021). Explaining variability in the prevalence of Achilles tendon abnormalities: a systematic review with meta-analysis of imaging studies in asymptomatic individuals. Journal of Orthopaedic & Sports Physical Therapy, 51(5), pp.232–252. DOI: 10.2519/jospt.2021.9970. PubMed
Johannsen, F.E., Rydahl, J.P., Jacobsen, A.S., Brahe, C.C.H. and Magnusson, P.S. (2024). Foot Posture and Ankle Dorsiflexion as Risk Factors for Developing Achilles Tendinopathy and Plantar Fasciitis: A Case-Control Study. Foot & Ankle International, 45(12), pp.1380–1389. DOI: 10.1177/10711007241281289. PubMed
Martin, R.L. et al. (2024). Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2024. Journal of Orthopaedic & Sports Physical Therapy. DOI: 10.2519/jospt.2024.0302. PubMed
McAuliffe, S. et al. (2025). Achilles tendinopathy physical impairments evaluated through clinician-friendly measures: a systematic review with meta-analysis and GRADE recommendations. PubMed
Munteanu, S.E. and Barton, C.J. (2011). Lower limb biomechanics during running in individuals with Achilles tendinopathy: a systematic review. Journal of Foot and Ankle Research, 4, 15. DOI: 10.1186/1757-1146-4-15. PubMed
Ogbonmwan, I., Kumar, B.D. and Paton, B. (2018). New lower-limb gait biomechanical characteristics in individuals with Achilles tendinopathy: a systematic review update. Gait & Posture, 62. DOI: 10.1016/j.gaitpost.2018.03.010. PubMed
Quarmby, A., Mönnig, J., Mugele, H., Henschke, J., Kim, M., Cassel, M. and Engel, T. (2023). Biomechanics and lower limb function are altered in athletes and runners with Achilles tendinopathy compared with healthy controls: a systematic review. Frontiers in Sports and Active Living, 4, 1012471. DOI: 10.3389/fspor.2022.1012471.

Frequently Asked Questions

Early symptoms can include morning ankle stiffness, tightness around the back of the ankle, calf tightness, reduced push-off, discomfort after exercise and a gradual decline in running or walking performance. Some patients do not initially describe obvious Achilles tendon pain.

Yes. Stiffness, particularly after rest or first thing in the morning, is a common feature of Achilles tendinopathy. Some people notice tightness or restricted ankle movement before pain becomes their main complaint.

Achilles disorders can be associated with altered calf function, fatigue and reduced plantar-flexor endurance. Some patients describe calf tightness or cramping, although cramps are not specific to Achilles tendinopathy and can have many other causes.

Increased rearfoot eversion and altered pronation timing have been reported in some people with Achilles tendinopathy, particularly runners. However, overpronation is not a universal cause, and many people with Achilles tendinopathy do not have an excessively pronated foot.

Pronation, particularly increased rearfoot eversion, is more consistently reported in Achilles tendinopathy research than supination. However, supinated or lateral loading patterns can also alter Achilles loading, so foot mechanics need to be assessed individually.

Reduced ankle dorsiflexion, sometimes described clinically as ankle equinus when sufficiently restricted, is commonly found in people with Achilles tendinopathy. It may alter how the foot and lower limb compensate during walking and running, although it should not be considered a universal cause.

Achilles tendinopathy and plantar heel pain are separate conditions, but they can coexist. Restricted ankle dorsiflexion and calf tightness may influence both the Achilles tendon and plantar fascia, so patients with heel pain and ankle stiffness may benefit from assessment of the entire calf–ankle–foot system.

Yes. Ultrasound and MRI studies frequently identify structural Achilles tendon abnormalities in people who have no symptoms. An abnormal scan does not automatically mean a person has symptomatic Achilles tendinopathy.

Midportion Achilles tendinopathy usually affects the tendon several centimetres above the heel. Insertional Achilles tendinopathy occurs where the tendon attaches directly to the heel bone. The two conditions involve different mechanical environments and may require different management strategies.

Assessment is advisable when stiffness, calf tightness, reduced push-off or posterior ankle discomfort becomes persistent, repeatedly returns, affects activity or is accompanied by local Achilles tenderness. Similar symptoms can also arise from other ankle, tendon, nerve or muscular conditions.