How to Treat Achilles Tendonitis: What Actually Works

Progressive loading exercise, particularly eccentric training and heavy slow resistance work, is the treatment with the strongest and most consistent evidence for Achilles tendon pain. Most other interventions people try, from platelet-rich plasma injections to shockwave therapy, have far weaker support than you might expect given how often they are offered. The picture gets more interesting, though, when you look at why the condition develops in the first place and how the location of your pain changes which treatments are worth pursuing.

Why Doctors Stopped Calling It Tendinitis

The word “tendinitis” implies inflammation, and for decades that shaped how clinicians treated Achilles tendon problems: rest, ice, anti-inflammatory drugs. But tissue samples from chronically painful Achilles tendons tell a different story. Rather than the inflammatory cells you would see in a true tendinitis, most chronic cases show disorganized collagen fibers, increased ground substance, and new blood vessel growth without meaningful inflammation.¹ This is why clinicians increasingly use the term “tendinopathy” instead. It is not just a naming preference. When the underlying problem is failed tissue repair rather than active inflammation, treatments aimed at suppressing inflammation miss the point. The tendon needs controlled mechanical loading to reorganize its collagen, not rest and NSAIDs alone.

Where Your Pain Is Changes the Approach

Achilles tendinopathy comes in two main flavors depending on where the pain sits. Midportion tendinopathy causes pain in the body of the tendon, roughly two to six centimeters above the heel bone. Insertional tendinopathy hurts right where the tendon attaches to the calcaneus, and often involves thickening at that attachment point.² This distinction matters because treatments do not perform equally across the two. Eccentric heel drops performed off a step, for instance, compress the insertion point and can aggravate insertional cases while helping midportion ones. Insertional tendinopathy tends to be more stubborn and may require modifications like limiting the range of motion during exercises so the heel does not dip below neutral.

Exercise Is the Strongest Treatment

If there is one thing the research converges on, it is that structured loading programs produce lasting improvements in pain and function. Two approaches dominate the literature: eccentric exercises and heavy slow resistance training. Every reviewed study examining eccentric exercise reported significant improvements in pain, and every study that measured function found significant gains as well.³ The classic protocol, developed by Alfredson, involves performing heel drops from a step edge with a straight knee and then with a bent knee, using body weight and adding load over time. A five-year follow-up of patients on this program showed that pain and function scores improved substantially from baseline and continued to improve between the one-year and five-year marks, with about 40% of patients completely pain-free at the end.⁴

Heavy slow resistance training uses gym equipment like a leg press or Smith machine to load the calf through its full range at a slower tempo, typically with heavier weights and fewer repetitions than the eccentric protocol. A head-to-head trial found that both approaches produced equally good clinical outcomes at one year, though patients doing heavy slow resistance reported higher satisfaction after the initial 12-week block.⁵ The structural changes in the tendon may differ slightly between approaches: a scoping review found heavy slow resistance was better at reducing pathological tendon thickness and abnormal blood vessel formation, while eccentric training produced greater improvements in tendon stiffness.⁶

One important nuance: when eccentric exercise was compared to doing nothing, it consistently won. But when compared to other active treatments or multimodal programs, the advantage was less clear.³ The message is less “this exact protocol is magic” and more “loading the tendon progressively is what works.” A trial comparing the traditional Alfredson protocol against a lower-volume “do as tolerated” approach found no difference in outcomes at six weeks, suggesting you do not necessarily need to follow the original prescription of 180 repetitions a day to get results.⁷ What matters is consistent, progressive loading over weeks and months.

Isometric Holds for Managing Flare-Ups

Isometric calf holds, where you push up onto your toes and hold the position for a sustained period, have gained popularity as a pain-management tool during flare-ups or as a warm-up before more demanding loading. A trial comparing isometric and eccentric programs over 12 weeks found that both produced equivalent improvements in function scores.⁸ Isometric holds can be a useful option if eccentric exercises are too painful initially or if you need a gentler entry point into loading. They are not a replacement for a full progressive program, but they can bridge the gap during periods when the tendon is irritable.

Heel Lifts and Load Modification

A simple heel lift placed inside the shoe can reduce Achilles tendon strain by decreasing how much the ankle bends upward during walking and running. An 18-millimeter heel lift reduced peak tendon strain during running compared to no lift.⁹ For people with insertional tendinopathy specifically, fitting a heel lift led to immediate pain reduction during walking and meaningful improvement in symptoms at two weeks.¹⁰ The mechanism likely involves shifting peak loading to a slightly later point in the gait cycle, which may reduce the rate at which force builds in the tendon.¹¹

Heel lifts are not a cure, but they are cheap, easy to try, and can make day-to-day activity more tolerable while you work through a loading program. A caveat: individual responses vary, and some runners in biomechanical studies actually showed increased tendon force with heel lifts, so if your pain worsens with them, stop.

Shockwave Therapy Has Underwhelming Evidence

Extracorporeal shockwave therapy, where a device sends acoustic pulses into the tendon, is widely offered for tendinopathy. The evidence is messy. An older review concluded that conclusive evidence recommending shockwave therapy was lacking.¹² A more recent systematic review found it safe and possibly effective for midportion tendinopathy, particularly when combined with eccentric exercises.¹³ But the largest and most recent meta-analysis, published in 2025, found no clinically meaningful benefit of shockwave therapy over sham for insertional tendinopathy and no significant differences in disability or pain for midportion tendinopathy at any time point.¹⁴

The only glimmer was very low-certainty evidence that radial shockwave (a specific type that disperses energy over a broader area) might help with disability and pain compared to sham or doing nothing.¹⁴ “Very low certainty” means the finding could easily flip with better studies. If your clinician recommends shockwave as an add-on to a loading program, the risk is minimal, but spending significant money on it as a standalone treatment is hard to justify given current evidence.

Injections Are Mostly Disappointing

Three types of injection get discussed most often for Achilles tendinopathy: platelet-rich plasma, corticosteroids, and high-volume image-guided injections. The evidence for all three is weaker than many patients expect.

Platelet-Rich Plasma

PRP involves drawing your blood, concentrating the platelets, and injecting them into the tendon. The idea is that growth factors in the platelets might stimulate repair. Two well-designed randomized trials found no benefit. One compared PRP to a simple dry-needle insertion and found no difference in tendon function scores at six months.¹⁵ Another compared PRP to a saline injection and found no difference in any outcome at three months.¹⁶ PRP for Achilles tendinopathy is one of the clearest cases where clinical popularity has outpaced the evidence.

Corticosteroid Injections

Corticosteroid injections carry a specific risk at the Achilles that they do not carry at most other sites. While the overall side-effect rate of local corticosteroid injections is low, corticosteroids can trigger a degenerative process in tendon tissue, inhibiting collagen production and potentially weakening the tendon.¹⁷ Rigorous studies found no benefit of corticosteroids over placebo for Achilles tendon problems, and animal studies showed decreased tendon strength with intratendinous injections.¹⁸ Given the theoretical rupture risk and the absence of proven benefit, most sports medicine specialists avoid corticosteroid injections into or near the Achilles tendon.

High-Volume Injections

High-volume image-guided injections use a large volume of saline, sometimes with a small amount of local anesthetic, injected around the tendon under ultrasound guidance. The aim is to strip away abnormal new blood vessels and associated nerve fibers that may be contributing to pain. Early uncontrolled studies showed promise.¹⁹ A prospective cohort study found significant improvements in pain and function at three months following the procedure.²⁰ However, when a randomized controlled trial tested it properly against an exercise program alone, the high-volume injection without corticosteroids did not add any benefit.²¹ This is a common pattern in tendinopathy research: uncontrolled early results look exciting, but rigorous trials show the exercise program was doing the work all along.

GTN Patches as an Adjunct

One treatment that does not get enough attention is topical glyceryl trinitrate, the same compound used in patches for chest pain. Nitric oxide plays a role in tendon healing, and delivering it locally through a patch applied over the tendon has shown real benefits in randomized trials. In one double-blind, placebo-controlled study, patients using a GTN patch had significantly less pain with activity at 12 and 24 weeks compared to those using a placebo patch, with roughly 78% of treated tendons becoming asymptomatic during daily activities at six months versus about 49% in the placebo group.²² A second trial confirmed these findings, showing less pain with activity and better performance on functional tests in the GTN group by the 12-week mark.²³ The main side effect is headaches, which are common with nitric oxide donors and sometimes bad enough to make people quit. But as an add-on to a loading program, GTN patches are one of the few passive treatments with decent evidence behind them.

Collagen Peptide Supplementation

Oral collagen peptide supplements have attracted interest as a way to support tendon repair from the inside. A crossover trial in patients with Achilles tendinopathy found that adding specific collagen peptides to a calf-strengthening and return-to-running program roughly doubled the improvement in function scores over three months compared to the exercise program alone.²⁴ This is a single study with a modest sample size, so it would be premature to treat collagen supplementation as an established treatment. But the effect was large enough to be clinically meaningful, and collagen peptides are widely available and safe, so adding them to an exercise program is a low-risk option while larger trials catch up.

When Surgery Makes Sense

Surgery is reserved for cases that have failed a thorough course of conservative treatment, generally meaning at least three to six months of structured loading with good compliance. A review spanning 50 years of surgical outcomes for chronic Achilles tendinopathy, covering nearly 3,000 surgically treated tendons, found an average reported success rate of about 84%.²⁵ That number has declined over time, likely because newer studies use stricter criteria for what counts as a success rather than because surgeons have gotten worse. Surgical options range from debridement of damaged tissue to tendon transfer procedures for severe insertional cases. Recovery involves weeks of immobilization followed by a gradual return to loading, so the overall rehabilitation timeline extends well beyond the surgery itself.

Biomechanical Factors Worth Addressing

Loading programs treat the symptomatic tendon, but they do not always address why it became overloaded in the first place. Research points to several biomechanical contributors: reduced plantar flexion strength (the ability to push off forcefully), decreased gluteal muscle activity, altered knee bend during running, and changes in how your center of force moves forward during gait.²⁶ If you address only the tendon without improving hip and calf strength, you may set yourself up for recurrence. This is one reason why working with a physiotherapist who assesses your whole kinetic chain, not just your ankle, tends to produce better long-term results than following a heel-drop protocol from a YouTube video.

Interestingly, ankle mobility alone does not seem to correlate with Achilles tendon stiffness or elasticity, at least in athletes.²⁷ Stretching the calf may feel good and improve ankle range of motion, but it is not a proven mechanism for protecting the tendon. Strength work appears to matter more than flexibility work for both treatment and prevention.

What Imaging Does and Does Not Tell You

If you get an ultrasound or MRI for your Achilles, keep the results in context. A prospective study found that ultrasound identified abnormal tendon structure in only about two-thirds of symptomatic tendons and, more importantly, that baseline ultrasound findings did not predict who would recover by 12 months.²⁸ Tendons that looked terrible on imaging sometimes improved clinically, and tendons that looked relatively normal sometimes stayed painful. This means a frightening-sounding imaging report should not talk you out of trying conservative treatment, and a clean scan does not mean the tendon is fine if it hurts under load.

Medications and Risk Factors That Affect Tendons

Certain medications can cause or worsen Achilles tendon problems. Fluoroquinolone antibiotics, a class commonly prescribed for urinary tract infections, are associated with Achilles tendon disorders, particularly within the first month of use.²⁹ If you are dealing with Achilles pain and have recently been prescribed ciprofloxacin or a similar antibiotic, mention it to your prescribing doctor. In some cases, switching to a different antibiotic class is the most important thing you can do for the tendon. The risk is higher in older adults, people on corticosteroids, and those with kidney impairment.

Pain catastrophizing and psychological factors play a role in many chronic pain conditions, but at least one aspect of this story is more nuanced for Achilles tendinopathy. A study examining whether people who had been dealing with symptoms for longer showed more signs of central sensitization (the nervous system amplifying pain signals) found no such correlation.³⁰ Having symptoms for years does not seem to rewire your pain processing in the way it can with some other chronic pain conditions. That is actually reassuring: it suggests that even longstanding Achilles tendinopathy can respond to the right mechanical treatment without needing to address pain sensitization as a separate problem.