Part of Achilles tendinopathy
Night splint for Achilles tendonitis: does it help, and what does?
Warning signs, and when to get help
Why is Achilles pain worse in the morning?
Morning stiffness is part of the standard description of the condition, so it is expected and not a warning sign. AAOS OrthoInfo lists pain and stiffness along the Achilles tendon in the morning among the usual symptoms, and the Guy's and St Thomas' NHS leaflet tells patients it is common to have pain when you get up in the morning, or when you start to walk after resting for a while. If you turned up at a clinic without that detail, a physio would ask for it.
The explanation clinicians use is straightforward: the tendon has had no load at all for seven or eight hours, the ankle has rested with the toes pointed, and then within three paces it is asked to take your whole body weight and push off. That is reasoning rather than a tested mechanism, so treat it as a working explanation. For morning heel pain in general, and the other structures that produce it, heel pain in the morning is the page.
What is more useful than the explanation is what the morning is for. It is your measuring instrument. In the pain monitoring model from the Swedish trial, pain after activity had to be back to its usual level by the next morning, and pain and morning stiffness were not allowed to build from one week to the next (Silbernagel and colleagues, 2007). So the first few minutes out of bed answer both of the questions you have: whether yesterday was too much, and whether the program as a whole is working. How the tendon felt during the exercise is far less reliable in either direction.
So time the morning instead of just enduring it. How many minutes before walking feels normal? Write it down once a week. The stiff spell usually shortens before the pain gets any milder, which is the first real sign of progress and the easiest one to miss, and how long Achilles tendonitis lasts covers that course.
Does a night splint help Achilles tendonitis?
It has been tested twice in randomized trials. De Vos and colleagues (2007) took 70 painful tendons with chronic midportion Achilles tendinopathy, in people aged 18 to 70 who were active in sport, put everyone on the same 12 week heavy-load eccentric program, and gave half of them a night splint as well. There was no significant difference between the two groups in VISA-A score or in patient satisfaction. Their conclusion was that a night splint added nothing to the eccentric exercise. Note who was left out: the trial excluded insertional problems and partial or complete tears, so it tested the splint on pain in the cord of the tendon, 2 to 7 cm above the insertion.
Roos and colleagues (2004) came at it from a different angle. They randomized 44 primary care patients with midportion pain to three 12 week groups: eccentric exercise, a night splint, or both. The eccentric exercise group showed a significant pain reduction, and more people in that group than in the splint group had returned to sport at 12 weeks. Be careful how much weight that carries, though, because the authors are: the two groups wearing a splint also improved, and the differences between all three groups were not statistically significant. The one comparison that did reach significance was at 12 weeks, where the eccentric group reported less pain than the splint-only group.
Magnussen and colleagues (2009) pulled the field together. They reviewed 16 randomized trials of nonsurgical treatments for midportion Achilles tendinopathy and reported that eccentric exercises were superior to night splints, on the strength of one study, and concluded that eccentric exercise has the most evidence of effectiveness. Between those two trials and that review, nothing here supports buying a splint.
The two guidelines in this field do not land in the same place, and they are easy to mix up. The 2024 US clinical practice guideline for midportion Achilles tendinopathy recommends against them outright: clinicians should not use night splints to improve symptoms, a position it carried over unchanged from 2018 and rates on weak evidence (Chimenti and colleagues, 2024). The Dutch multidisciplinary guideline is softer. It starts treatment with education, loading advice and progressive calf strengthening for at least 12 weeks, then lists a night splint among the passive options that can be considered when 3 months of that has not helped, with the uncertainty about what any of them add talked through first (de Vos and colleagues, 2021). So a splint is not forbidden, which matters if a clinician has already given you one, but nothing we can cite puts it in front of the loading program and one guideline advises against it altogether.
Here is where the confusion comes from, and it is the kind of mistake that moves advice from one condition to another. Night splints are mostly used for plantar fasciitis, a problem of the band under the foot rather than the tendon at the back, and that is the advice most people have met first. The underside of the heel has its own US physical therapy clinical practice guideline (Koc and colleagues, 2023), and our plantar fasciitis program covers what is used there and who it suits.
Even for plantar fasciitis, the trial evidence for adding a splint is mixed: Wheeler (2017) randomized 40 people with long-standing plantar fasciitis to a home exercise program with or without a tension night splint, and the splint produced no significant additional benefit in pain, function or flexibility at 3 months. Both groups improved, and the author allows that there may have been an earlier benefit in the splint group while calling that data unclear. Evidence for one condition is not evidence for the other, and in this case it is not emphatic evidence for either. If you are not sure which you have, heel pain: Achilles, plantar fasciitis or bursitis sorts it out.
If you are using a night splint, how do you use it?
Plenty of people arrive at this page already wearing one, either because a clinician gave it to them or because they bought it before reading the trials. This section is for them, and it is short, because no source we can cite gives a wearing time, a build-up or an ankle angle for a night splint in Achilles tendinopathy.
If a physio, podiatrist or doctor gave you one with instructions, follow theirs rather than this page. If you are using one on your own initiative, the sensible approach is the same as for any new splint: start with an hour or two instead of a full night, and go up slowly if it is comfortable.
Check your skin every morning, particularly over the heel, the front of the ankle and anywhere a strap crosses a bony point. Stop and get advice if you find a red mark that does not fade within a few minutes of taking it off, a blister, or a sore patch.
Take it off if you wake with pins and needles, numbness, or a foot that feels cold, and do not put it back on until someone has looked at the fit.
Two groups should not improvise with this at all. If you have diabetes or reduced feeling in your feet, a device strapped to a foot that cannot feel pressure is a genuine risk, and the diabetes lines on the warning list at the end of this page set out what to act on and how fast. And if you are recovering from an Achilles rupture or Achilles surgery, your team's plan governs what goes on that leg, not a website.
Given what the trials found, there is no reason to persevere with a splint you cannot sleep in. Sleep is worth more here than the splint is.
What helps the first steps out of bed?
Sit on the edge of the bed and move the ankle before you stand on it, a couple of minutes of easy movement: ankle pumps and ankle circles are the usual two, done slowly and comfortably rather than pushed to the end of the range. Typical starting doses are 10 to 20 pumps at a time and 10 to 15 slow circles each way, and each exercise page carries its own numbers. Your physio will adjust this.
The first barefoot steps onto tile or wood are the worst version of the morning, so put something on your feet: a slipper with a cushioned sole and a little heel, left where your feet land, is the single most effective change most people make. The NHS advice for heel pain is wide, comfortable shoes with a low heel and a soft sole, plus soft insoles or heel pads, and it warns against walking or standing for long periods, especially barefoot. The trip that catches people is the walk to the bathroom at 3am, with the slippers on the other side of the room. Shoes and heel lifts for Achilles tendonitis goes through the footwear side properly, including heel lifts.
On stretching first thing: it is at most an extra here, not the treatment. A gentle calf stretch suits some people with midportion pain, typically held for about 30 seconds and repeated 2 to 3 times, and your physio will say whether it belongs in your program. If your pain is at the back of the heel (insertional), keep heel raises on a flat floor or at step level, and skip any exercise that lets the heel drop below a step until your physio says otherwise. Go carefully, too, with any stretch that pulls the ankle up hard, because that is the position that presses the tendon into the heel bone (Silbernagel and colleagues, 2020). Insertional or midportion Achilles tendinopathy explains which of the two you have.
None of that is impressive, and between them those few steps do more for the first ten minutes of the day than anything you can strap on overnight. The loading program is still what changes the tendon, and the morning routine is comfort. If you want one exercise that can be done sitting down without your body weight on the leg, the seated calf raise is often where the staged Achilles tendinopathy program starts.
How should you sleep with Achilles pain?
There is no researched best position for this, so what follows is practice rather than evidence, and the aim is simple: keep pressure off the sore spot and let the ankle rest somewhere comfortable.
On your back with a pillow under the calf, so the heel hangs clear of the mattress, suits people whose pain is on the bone at the very back of the heel, because nothing presses on it. On your side with the sore leg uppermost, with a pillow under the shin, works too, and is the option to use if lying on your back does not suit you.
Loosen the bedclothes at the foot of the bed. A tightly tucked duvet or sheet holds the toes pointed down and presses on the back of the ankle for hours.
If you are pregnant, the back lying option above needs a caveat. From about 28 weeks of pregnancy the NHS advises going to sleep on your side rather than on your back, because it says sleeping on your back after that point can double the risk of stillbirth. So use the side position with a pillow under the shin, and leave lying on your back until after the birth. The NHS also says not to worry if you wake up on your back: settle onto your side again and carry on.
When is night pain a reason to get checked rather than managed?
Some ache in bed after a long day on your feet is ordinary with a sore tendon, and it usually settles once you stop moving. Two patterns are not ordinary, and both are on the warning list below with their own timing.
Pain that is present at night and at rest as well as with activity, and that keeps getting worse, is one of them. That line asks you to see your doctor within a few days, and sooner, within a day or two, if you have had cancer now or in the past or are losing weight without trying.
The other is a heel or tendon that is hot, red and swollen, or heel pain with a fever or feeling unwell, and that one is same day.
Other night-time patterns point away from the tendon altogether. Burning, tingling or numbness in the foot that carries on at rest and at night suggests a nerve rather than a tendon, and has its own line below. Pain in both heels with back stiffness that is worse in the morning and at night, or swollen joints elsewhere, has its own line too, with a week or two.
When to see a physio or doctor
See a physio (physical therapist) or doctor if the pain is severe, stops you walking normally, keeps getting worse, or has not improved after a few weeks of looking after it yourself. On the night-time side specifically, it is worth an appointment if the morning stiff spell is getting longer week by week rather than shorter, because that is the clearest sign that the week as a whole is loading the tendon more than it can take.
How many minutes the morning stiffness lasts is the single most useful number you can hand a clinician, and what you walk on first thing is the second. Both change the plan and both routinely go unmentioned. The warning signs below each carry their own timing, and those come ahead of any routine booking.
Related exercise programs
Warning signs
Get emergency help now
- You felt a sudden pop or snap at the back of your ankle, it felt as if someone hit or kicked you in the calf, or walking or rising onto your toes on that leg suddenly became weak or difficult. Stop exercising and go to an urgent care center or emergency department the same day, even if you can still walk, as this can be a torn (ruptured) Achilles tendon. This page does not cover a rupture.
Get help now, day or night
- Your tendon pain or swelling started while you were taking a fluoroquinolone antibiotic, such as ciprofloxacin or levofloxacin, or in the months after a course. Contact your doctor straight away. The UK medicines regulator (MHRA) advises stopping the antibiotic at the first sign of tendon pain or swelling and talking to your doctor. Hold off the calf exercises until you have been checked.
Get help today
- A calf or thigh that is newly swollen or getting more swollen, warm, tender, red or darker than usual, has swollen veins that are sore to touch, or has a throbbing or cramping pain that does not fit your injury or condition, or that feels different from normal muscle soreness after exercise. This can be a sign of a blood clot (deep vein thrombosis), especially after surgery, an injury, time in a cast or boot, a long trip or a spell of being much less mobile than usual. Get medical advice the same day. If you are also short of breath or have chest pain, call emergency services.
- The tendon or heel is hot, red and swollen, or you have a fever or feel unwell. Get medical help the same day, and go to an emergency department if you feel very unwell. If you have a very high or very low temperature, shivering you cannot control, you are breathing very fast or finding it hard to breathe, you are confused or your speech is slurred, your skin, lips or tongue look blue, gray, pale or blotchy (on brown or black skin this can be easier to see on the palms of the hands or soles of the feet), or you have a rash that does not fade when you press it, call emergency services, as this can be sepsis.
- The pain started with a fall or a blow to the back of the ankle, and there is bruising or you cannot put weight on the foot. Get it checked the same day.
- Same day: you have diabetes or numb feet, and one foot becomes hot, swollen or red, or changes color or shape, with or without pain. Take your weight off that foot straight away and get advice the same day from your doctor or your diabetes foot team. This can be Charcot foot, where the bones and joints of the foot are damaged and the foot can collapse. Do not exercise that foot until it has been checked. If you also have a fever or feel very unwell, or redness is spreading up your foot or leg, go to an emergency department.
- Same day: you have diabetes or numb feet and find a new blister, cut or sore on your foot, especially one you did not feel, a wound that smells or is leaking, or new pain in your foot that you cannot explain. Get it seen by your doctor or foot team the same day. If you also have a fever or feel very unwell, redness is spreading up your foot or leg, or part of your foot or a toe turns black, go to an emergency department.
- Same day: a burn, a scald or a blister on your foot or lower leg from hot water, a hot floor or pavement, a hot water bottle, an electric blanket, a heat pad, or sitting with your feet near a fire or radiator. Keep your weight off that foot and get it seen by your doctor or foot team the same day, however small the mark looks and even if it does not hurt. A foot that cannot feel heat can be burned deeply before you notice, and a burn on a numb foot can turn into an ulcer. If you also have a fever or feel very unwell, redness is spreading up your foot or leg, or part of your foot or a toe turns black, go to an emergency department.
- Same day: a sore, ulcer or wound on your foot that your team already knows about gets bigger or deeper, starts to smell or to leak more, the skin around it turns red, hot or puffy, or it has not started to heal. Get advice from your doctor or foot team the same day rather than waiting for your next appointment, and keep your weight off that foot. If you also have a fever or feel very unwell, redness is spreading up your foot or leg, or part of your foot or a toe turns black, go to an emergency department.
- The pain is there at night or at rest as well as with activity and keeps getting worse. If you are being treated for cancer now, contact your cancer team the same day.
Book an appointment
- Your heel or Achilles pain comes with back pain and stiffness that is worse in the morning and at night, or with painful, swollen joints elsewhere, or both heels became painful without an obvious reason. The same applies if you also have psoriasis, Crohn's disease or ulcerative colitis, or have had a red, painful, inflamed eye (iritis). This is not an emergency, but see your doctor in the next week or two, as it can be a sign of an inflammatory arthritis such as ankylosing spondylitis.
- You have numbness, tingling, burning or loss of feeling in the foot, often along the outer edge. Book an assessment with a doctor or physio in the next week or two. If it came on over hours or days, started after an injury, is spreading, or comes with weakness in the foot, get medical advice the same day.
- The pain is there at night or at rest as well as with activity and keeps getting worse. If you have had cancer, now or in the past, or are losing weight without trying, see your doctor sooner, within a day or two, and mention it. This applies even if the pain is not getting worse.
- The pain is there at night or at rest as well as with activity and keeps getting worse. See your doctor within a few days.
- With diabetes, get any new foot pain checked by your doctor before you start these exercises.
Common questions
Does a night splint help Achilles tendonitis?
The trials say it adds nothing you could not get from the exercise. De Vos and colleagues (2007) randomized 70 painful tendons with chronic midportion Achilles tendinopathy to a 12 week eccentric program with or without a night splint, and found no significant difference between the groups in their VISA-A scores or their satisfaction. Roos and colleagues (2004) randomized 44 people to eccentric exercise, a night splint, or both, and reported that more people in the eccentric group than in the splint group had returned to sport at 12 weeks. A systematic review of 16 randomized trials concluded that eccentric exercise was superior to night splints (Magnussen and colleagues, 2009). AAOS OrthoInfo does list night splinting among the options and says it can give significant relief for morning pain on getting out of bed, so if a clinician has given you one it is not a strange choice. The trials are about what it adds to a loading program, which is nothing measurable.
Why is my Achilles worse in the morning?
Morning stiffness is one of the defining features of Achilles tendon pain rather than a complication of it. AAOS OrthoInfo lists pain and stiffness along the tendon in the morning among the usual symptoms, and the Guy's and St Thomas' NHS leaflet says it is common to have pain when you get up in the morning or when you start to walk after resting for a while. The usual explanation is that the tendon has gone hours without any load and then has to take your body weight and push off within a few paces. That is the reasoning clinicians use rather than something a trial has demonstrated, so treat it as a working explanation.
How long should I wear a night splint for?
No source we can cite gives a wearing time, or an ankle angle, for a night splint in Achilles tendinopathy, and we are not going to invent one. If a physio or podiatrist has given you a splint and a plan, follow theirs. If you bought one yourself and are using it anyway, the sensible version is short spells at first rather than a full night, and stopping if you wake with pins and needles, numbness or a sore patch of skin. Given what the trials found, a splint that is uncomfortable is not worth persevering with.
What is the best way to sleep with Achilles pain?
Whatever keeps the weight of the bedclothes off the sore spot and lets the ankle rest in a position that does not ache. On your back with a pillow under the calf, so the heel hangs clear of the mattress, suits people whose pain is at the very back of the heel. On your side with the sore leg uppermost and a pillow under the shin also works. Tucking the duvet in at the end of the bed pulls the toes down and presses on the tendon, so leaving it loose is a small change people notice. From about 28 weeks of pregnancy the NHS advises going to sleep on your side rather than on your back, because it says sleeping on your back after that point can double the risk of stillbirth. So use the side position with a pillow under the shin, and leave lying on your back until after the birth. The NHS also says not to worry if you wake up on your back: settle onto your side again and carry on.
Why does my Achilles hurt at night or in bed?
Some ache in bed after a busy day is common with a sore tendon, and it is usually the day catching up with you rather than something new. Pain that is there at night and at rest as well as with activity, and that keeps getting worse, is different, and it has its own line and its own timing on the warning list on this page. That line asks you to see your doctor within a few days, and sooner if you have had cancer now or in the past, or are losing weight without trying.
Is a night splint the same as a boot?
No, and the two should not be confused. A night splint is a soft or semi-rigid support worn in bed. A walker boot is a rigid device used to protect a tendon or bone while it heals, and whether anyone needs one is a decision for the clinician examining the tendon, not something to try at home. AAOS OrthoInfo mentions a walking boot for a short spell when the pain is severe, and in the same breath says extended use is discouraged because it can weaken the calf muscle. Nothing on this page is advice to use a boot or to immobilize a sore Achilles. If you felt a pop or snap and push-off went suddenly weak, that is the first line on the warning list, and can Achilles tendinopathy become a rupture? covers that question.
References
- de Vos RJ, Weir A, Visser RJ, de Winter T, Tol JL. The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial. British Journal of Sports Medicine. 2007;41(7):e5. https://doi.org/10.1136/bjsm.2006.032532
- Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy: a randomized trial with 1-year follow-up. Scandinavian Journal of Medicine and Science in Sports. 2004;14(5):286-295. https://doi.org/10.1111/j.1600-0838.2004.378.x
- Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clinical Journal of Sport Medicine. 2009;19(1):54-64. https://doi.org/10.1097/JSM.0b013e31818ef090
- de Vos RJ, van der Vlist AC, Zwerver J, Meuffels DE, Smithuis F, van Ingen R, van der Giesen F, Visser E, Balemans A, Pols M, Veen N, den Ouden M, Weir A. Dutch multidisciplinary guideline on Achilles tendinopathy. British Journal of Sports Medicine. 2021;55(20):1125-1134. https://doi.org/10.1136/bjsports-2020-103867
- Wheeler PC. The addition of a tension night splint to a structured home rehabilitation programme in patients with chronic plantar fasciitis does not lead to significant additional benefits in either pain, function or flexibility: a single-blinded randomised controlled trial. BMJ Open Sport and Exercise Medicine. 2017;3(1):e000234. https://doi.org/10.1136/bmjsem-2017-000234
- Silbernagel KG, Thomee R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. American Journal of Sports Medicine. 2007;35(6):897-906. https://doi.org/10.1177/0363546506298279
- Silbernagel KG, Hanlon S, Sprague A. Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. Journal of Athletic Training. 2020;55(5):438-447. https://doi.org/10.4085/1062-6050-356-19
- Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, Martin RL. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision - 2024. Journal of Orthopaedic and Sports Physical Therapy. 2024;54(12):CPG1-CPG32. https://doi.org/10.2519/jospt.2024.0302
- Koc TA Jr, Bise CG, Neville C, et al. Heel Pain - Plantar Fasciitis: Revision 2023. Journal of Orthopaedic and Sports Physical Therapy. 2023;53(12):CPG1-CPG39. https://doi.org/10.2519/jospt.2023.0303
- American Academy of Orthopaedic Surgeons. Achilles tendinitis. OrthoInfo. https://www.orthoinfo.org/en/diseases--conditions/achilles-tendinitis/
- Guy's and St Thomas' NHS Foundation Trust. Achilles tendinopathy. Patient information, resource number 4609/VER3. Last reviewed October 2024. https://www.guysandstthomas.nhs.uk/health-information/achilles-tendinopathy
- Kent Community Health NHS Foundation Trust. Achilles insertional tendinopathy. Patient leaflet 01271. Published 2 December 2024. https://www.kentcht.nhs.uk/leaflet/achilles-insertional-tendinopathy/
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- National Institute for Health and Care Excellence. Diabetic foot problems: prevention and management. NICE guideline NG19. Published 26 August 2015, last updated 11 October 2019. https://www.nice.org.uk/guidance/ng19
- Medicines and Healthcare products Regulatory Agency. Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate. Drug Safety Update. 22 January 2024. https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-must-now-only-be-prescribed-when-other-commonly-recommended-antibiotics-are-inappropriate
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Written and checked by the PocketPhysio editorial team. Last updated 2026-10-17.
This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.