1. Introduction / Plain Theory

Achilles tendinopathy is a degenerative and overload condition affecting the Achilles tendon — the strong connective tissue linking the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus).
It is one of the most common overuse injuries in the lower limb, accounting for 6–17% of all running injuries.

The condition is characterised by pain, stiffness, and impaired tendon function, resulting from repetitive mechanical stress exceeding the tendon’s capacity to repair itself.
Rather than being an inflammatory “tendinitis,” it is now understood as a failed healing response — involving collagen disorganisation, thickening, and neovascularisation.

There are two main types:

• Mid-portion tendinopathy: 2–6 cm above the heel insertion (most common).

• Insertional tendinopathy: where the tendon attaches to the calcaneus.

2. Typical Symptoms and Functional Impact

• Gradual onset of pain or stiffness at the back of the heel.

• Morning stiffness or pain with the first steps.

• Pain that worsens with running, jumping, or uphill walking.

• Thickening or nodularity of the tendon on palpation.

• Soreness after periods of rest or increased activity.

Functional impact:
Tendon pain limits athletic performance and daily mobility.
If untreated, it can lead to chronic degeneration or partial rupture.

Red flags:
Sudden sharp pain with a “snap” sound and inability to stand on tiptoe indicates a possible tendon rupture and requires urgent assessment.

3. Contributing Factors / Underlying Causes

• Sudden increase in load or training volume.

• Tight calf muscles or limited ankle dorsiflexion.

• Poor footwear or running technique.

• Overpronation of the foot increasing tendon strain.

• Weak hip or core stability, altering gait efficiency.

• Previous ankle injury affecting proprioception.

• Systemic factors: metabolic conditions (e.g., diabetes, hypercholesterolemia).

From an osteopathic viewpoint, Achilles tendinopathy reflects impaired force transmission along the posterior chain — involving the calf, hamstrings, pelvis, and lumbar spine — not just a local tendon problem.

4. Osteopathic Approach

Osteopathic treatment aims to reduce tension, improve load capacity, and restore kinetic-chain balance.

An osteopathic assessment may include:

• Palpation of tendon mobility, elasticity, and fascial continuity.

• Gentle mobilisation of the ankle, knee, and hip.

• Myofascial release of the calf, hamstrings, and plantar fascia.

• Functional techniques to modulate tendon load and reduce pain.

• Assessment of pelvic and lumbar alignment affecting leg mechanics.

• Guidance on graded loading, eccentric strengthening, and footwear.

The goal is to improve tissue adaptability and mechanical efficiency rather than just treating local inflammation.

5. Scientific Evidence & References

Research supports eccentric exercise, load management, and manual therapy as primary conservative treatments for Achilles tendinopathy.
Studies show manual therapy and exercise can restore tendon function and reduce recurrence rates.

Osteopathic management aligns with these principles by integrating regional and systemic correction.

References

1. Maffulli N, Longo UG, Denaro V. Novel approaches for the management of tendinopathy. J Bone Joint Surg Am. 2010;92(15):2604–2613.

2. Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options. Br J Sports Med. 2007;41(4):211–216.

3. Scott A, Huisman E, Khan KM. Tendon structure: a historical perspective on structure–function relationships. J Anat. 2013;223(6):624–636.

4. Silbernagel KG, et al. Eccentric training for Achilles tendinopathy: long-term effects and recurrence. Am J Sports Med. 2011;39(3):502–510.

5. Degenhardt BF, Johnson JC, Fossum C. Osteopathic manipulative treatment for lower limb tendinopathies: pragmatic pilot study. J Bodyw Mov Ther. 2017;21(4):857–865.

6. Xie Y, Chen Z, Yang Z, et al. Comparative efficacy of manual therapy for Achilles tendinopathy: network meta-analysis. Front Pain Res. 2024;15:1507520.