Part of Achilles tendinopathy
Achilles tendonitis not healing: the reasons we find most often
Warning signs, and when to get help
Why is Achilles tendonitis not healing?
The course of the condition is long, months rather than weeks: the Guy's and St Thomas' NHS leaflet tells patients that most people need 6 to 9 months of rehabilitation before they can return to full activities without pain, and that flare-ups along the way are normal. How long Achilles tendonitis lasts covers the timeframes and the long-term follow-ups. This page starts from the other side: it has been longer than that, you have done the exercises, and nothing has changed.
Most of what we find in that situation is unglamorous. In order of how often it turns out to be the answer: the load was too light, it was not done often enough or for long enough, the program was aimed at the wrong part of the tendon, or the loading outside the program kept provoking it. Further down that list sit the rest. Strength was never regained before the return to activity, the work stopped the week the pain stopped, or it is not a tendinopathy at all.
Now the explanation you have almost certainly met instead. Search results for a stalled Achilles are full of an argument about a stretch of the tendon with a poorer blood supply. That stretch is real as anatomy: AAOS OrthoInfo describes the middle part of the tendon, roughly 2 and a half inches above the heel bone, as thought to have a poorer blood supply than the rest. What we have no source for is the next step, the one the argument depends on, that this is why a particular person's recovery has stalled or why a particular treatment is needed. So it does not appear on our list, and a treatment sold on the back of it deserves more skepticism than usual.
The checklist below runs in the order to work through. None of it is a telling off. Most of these happen because of advice that was reasonable at the time, or because real life got in the way.
Have you given it enough load, often enough, for long enough?
Was the load ever heavy enough? Progression is the part guidelines keep insisting on. The 2024 US clinical practice guideline recommends tendon loading as the first-line treatment on strong evidence, and the phrase it uses for the load is as high as tolerated, which is the part most stalled programs are missing; it also asks for that loading at least 3 times a week (Chimenti and colleagues, 2024). The Dutch multidisciplinary guideline calls for progressive calf muscle strengthening and lets the pain score and muscle fatigue set the speed of that progression (de Vos and colleagues, 2021).
Progressive is the word to sit with. A set of calf raises on two feet that was challenging in month one is not challenging in month four, and a program that never got heavier has stopped being a stimulus. Most people who stall have stopped progressing, not stopped exercising. The weighted calf raise and the single leg heel raise are where the load usually needs to go next.
Was it often enough? The 2024 US clinical practice guideline asks for tendon loading at least 3 times a week (Chimenti and colleagues, 2024), and the programs that have been tested range from twice daily to a few heavier sessions a week. That guideline's own review found the frequency made little difference to how people ended up, anywhere in that range, which is useful to know before you blame the schedule. Twice a month is not a dose.
And did it run long enough, without gaps? Alfredson and colleagues (1998) ran 12 weeks. Beyer and colleagues (2015) ran 12 weeks and followed people to a year. Those trials describe what 12 weeks of actually doing it produces, and the honest question is how many of your own weeks were complete.
Beyer's trial is useful here for a second reason: the group doing fewer, heavier calf raise sessions completed 92 percent of the sessions it was set against the daily heel drop group's 78 percent, and both groups ended up in the same place. If your program is the one you keep abandoning, swapping it for one you will do is a legitimate clinical move rather than a compromise.
People stop when the pain stops, which is the most understandable mistake on this page and one of the most expensive. A tendon that has been painful once needs its strength work to continue after it has stopped hurting. The 2024 guideline is against the other extreme too, advising on moderate evidence that complete rest is not indicated and that you carry on with activity within your pain tolerance (Chimenti and colleagues, 2024), and Silbernagel and colleagues (2020) note that a rushed return to sport is a common reason the pain comes back. Heel drops explained covers the dose and the technique in detail.
Is it the type of Achilles pain you think it is?
If your pain is on the bone at the very back of the heel, the standard advice you have been following was written for a different part of the tendon. The 2024 clinical practice guideline states its scope as midportion Achilles tendinopathy (Chimenti and colleagues, 2024). Programs for insertional pain remove the ankle-up part of the movement: Jonsson and colleagues (2008) had people lower only to floor level and never below it. So someone with insertional pain, dutifully doing below-step heel drops twice a day for four months, has been pressing the sore tendon into the heel bone hundreds of times a week while following the instructions correctly.
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. Insertional or midportion Achilles tendinopathy sets out how to tell which you have.
The other half of this question is whether it is the Achilles at all. Pain under the heel rather than behind it, two sore heels without a training explanation, a heel that hurts when squeezed from both sides, or burning and numbness in the sole all point somewhere else, and several of those patterns have their own line and their own timing on the warning list below. Heel pain: Achilles, plantar fasciitis or bursitis goes through the alternatives.
What are you doing between sessions?
Six exercise sessions a week is maybe two hours. The other 110 waking hours are also load, and they are where a stalled tendon usually hides.
The pain monitoring model gives you a way to read them. Pain during activity up to 5 out of 10, pain afterward back to its usual level by the next morning, and pain and morning stiffness not building from one week to the next (Silbernagel and colleagues, 2007). That third clause is the one for a stalled recovery, because it is about the week rather than the session. A tendon whose stiff spell is a bit longer every Monday is being overloaded by the shape of the week, even if no single day broke the rule.
The things to look at are the ones nobody counts as exercise. Hills and stairs, which load push-off hard and often cannot be avoided at home or at work. A job that has you on your feet on hard floors. Walking much further than you used to because running stopped.
Then there is a return to running or sport that happened as soon as the pain eased rather than when the strength came back. And for insertional pain, the Kent leaflet advises avoiding walking uphill or on inclines and sticking to flat ground, which is daily load rather than exercise.
Achilles pain when running covers how to shape a training week around this, and running with Achilles pain covers the decision about whether to run at all and the readiness checks before you add it back.
Do you need a scan, an injection or shockwave?
The three month mark is where the guidelines put this conversation, which is roughly when most people start asking. The Dutch multidisciplinary guideline says that after 3 months of education, structured exercise therapy and following the loading advice, if there is still no improvement, the additional treatment options are discussed, along with the uncertainty about what they add (de Vos and colleagues, 2021). So reaching this section is not you jumping the gun.
On scans, the Kent leaflet says that for insertional pain, if loading exercises have not improved symptoms after three months, an ultrasound should be considered, to rule out a more severe injury to the tendon. A scan is usually more useful for questioning the diagnosis than for confirming it, and the decision belongs to the clinician assessing you.
Shockwave appears in the Guy's and St Thomas' leaflet among the other treatment options to consider if symptoms do not improve in 6 to 9 months even after following an appropriate exercise program, and the order in that sentence matters: after the program, not instead of it. A systematic review of 16 randomized trials in midportion tendinopathy concluded that eccentric exercise has the most evidence of effectiveness. The review is careful about the rest of the options: shockwave came out equivalent to eccentric exercise in one trial, better than a wait-and-see approach in another and no better than placebo in a third; a sclerosing injection beat placebo in the single trial that tested it; and local steroid treatment helped in 2 of the 3 trials that tested it. The authors' own verdict was that all of those need more investigation (Magnussen and colleagues, 2009).
The Kent leaflet advises against steroid injections for insertional pain, saying they may give temporary relief but are not a cure and could lead to tendon rupture. Can Achilles tendinopathy become a rupture? covers that question with the sources behind it.
We are not recommending or ruling out shockwave, platelet-rich plasma, steroid injection, laser or surgery. Those are decisions for you and the clinician examining your tendon, and the reason this section exists is so that you can ask about them having read what the NHS leaflets and the review actually say rather than what a clinic website says.
What should a reassessment cover?
If you are going back to someone, these are the things to get out of the appointment.
- Where exactly the tenderness is now, and whether that has changed since the first assessment. Insertion or midportion changes the program.
- Calf strength compared side to side, not just whether you can do a heel raise. A gap is the thing the program exists to close, and it is measurable.
- Whether the diagnosis still fits. After months with no change, that question is overdue, not rude.
- The actual load on your current program, in sets, repetitions, weight and frequency, measured against the guideline's loading at least 3 times a week at loads as high as the tendon tolerates, and whether any of those four has gone up in the last month.
- The week outside the program: your job, your floors, your stairs, how far you walk, what sport you went back to and when.
- What the plan is for the next 12 weeks, and what should have changed by then. A review with no checkpoint is how another six months disappear.
- Any fluoroquinolone antibiotic you have taken, or a steroid injection around the tendon, which belongs on the table whether or not anyone asks.
One last thing. The Dutch multidisciplinary guideline asks clinicians to tell patients the long-term picture: most people recover, but symptoms can persist, with 23 to 37 percent still having some up to 10 years later despite treatment, and 85 percent of athletes get back to sport, though it is not known whether at their original level or without symptoms (de Vos and colleagues, 2021). It also says prognostic factors for the long term have not been identified, so nobody can tell you which group you are in. How long Achilles tendonitis lasts sets the follow-up studies out with their sources. Fixing one item on this checklist is not a guarantee, and it is still the best available move.
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. Go back if 3 months of consistent loading has changed nothing, which is the situation this page is written for, and ask for the diagnosis to be revisited rather than for the same program again.
Go sooner if anything on the warning list below applies, because each line carries its own timing and those come ahead of any program question. Two in particular belong in this conversation: tendon pain that started on a fluoroquinolone antibiotic, which needs talking to your doctor straight away, and pain at night or at rest that keeps getting worse, which is not how a stalled tendinopathy usually behaves.
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.
- 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
- The whole heel hurts when you squeeze it from both sides, especially after a sudden increase in running or walking, or if you have thin bones (osteoporosis). Stop running and jumping, cut down on walking and standing, and see a doctor within a few days, as this can be a stress fracture of the heel bone rather than plantar fasciitis. An X-ray can look normal for the first 2 to 3 weeks, so a normal early X-ray does not rule it out.
- 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.
Common questions
Why is my Achilles tendonitis not healing?
In clinic the answer is usually something mundane: the load was never heavy enough, it was not done often enough or for long enough, the program was written for a different part of the tendon, the loading outside the program kept provoking it, or it stopped the week the pain stopped. The 2024 US clinical practice guideline asks for tendon loading at loads as high as the tendon tolerates, at least 3 times a week (Chimenti and colleagues, 2024), and the Dutch multidisciplinary guideline asks for progressive calf strengthening for at least 12 weeks (de Vos and colleagues, 2021), and the trials behind the standard programs ran 12 weeks with people training either daily or in heavier sessions a few times a week. Measured against that, a lot of what people call failed treatment turns out to have been a gentler and shorter version of the treatment.
How long is too long for Achilles pain to last?
Longer than you would expect, which is why a timeframe is not a good trigger on its own. The useful trigger is the direction, not the duration: go back for a review if 3 months of consistent loading has changed nothing at all, because that is a different situation from slow but real progress. How long Achilles tendonitis lasts sets out the timeframes and the long-term follow-up studies, including the honest finding that a fair minority still have some symptoms years later.
Should I get a scan or an MRI?
Not usually to confirm the diagnosis, which is made by examination. The Kent Community Health NHS leaflet does name a scan at a particular point for insertional pain: if loading exercises have not improved symptoms after three months, an ultrasound should be considered. That is a scan for a tendon that has not responded, which may well be you. A scan is more useful for questioning the diagnosis than for proving it, and the decision belongs with the clinician assessing you.
Am I doing the exercises wrong?
Possibly, and the usual errors are small. Rising on the sore leg instead of only lowering on it. Dropping the heel quickly rather than taking a few seconds. Leaning on the counter so the calf does less. Letting the heel sink below a step when the pain is at the insertion, which is the one that makes people worse rather than just slower. Never adding weight, so the exercise stays at the load it started at. Heel drops explained goes through the technique and the dose properly.
Could it be something other than tendinopathy?
It is worth asking after a few months with no change, and it is one of the main reasons to be reassessed. Pain under the heel rather than behind it, pain in both heels without a training explanation, a heel that hurts when squeezed from both sides after a jump in training, and burning or numbness in the sole all point elsewhere. Heel pain: Achilles, plantar fasciitis or bursitis sorts the structures out, and several of those patterns have their own line and their own timing on the warning list on this page.
Has resting it made it worse?
Waiting it out is the one approach the guidelines argue against. The Dutch multidisciplinary guideline tells patients with chronic Achilles tendinopathy that little or no improvement is expected in the short term from a wait-and-see approach, and puts progressive calf strengthening first instead (de Vos and colleagues, 2021). A systematic review found eccentric exercise beat a wait-and-see approach in both trials that compared them (Magnussen and colleagues, 2009). A tendon given nothing to do does not get better at doing things, so months of avoiding everything that hurt tends to leave you with the same pain and a weaker calf. That is worth knowing without turning it into a reason to blame yourself, because avoiding what hurts is a reasonable instinct and it is also the advice plenty of people were given.
References
- 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
- 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
- Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine. 1998;26(3):360-366. https://doi.org/10.1177/03635465980260030301
- American Academy of Orthopaedic Surgeons. Achilles tendon rupture (tear). OrthoInfo. https://www.orthoinfo.org/en/diseases--conditions/achilles-tendon-rupture-tear/
- Beyer R, Kongsgaard M, Hougs Kjaer B, Ohlenschlaeger T, Kjaer M, Magnusson SP. Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. American Journal of Sports Medicine. 2015;43(7):1704-1711. https://doi.org/10.1177/0363546515584760
- 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
- Silbernagel KG, Crossley KM. A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation. Journal of Orthopaedic and Sports Physical Therapy. 2015;45(11):876-886. https://doi.org/10.2519/jospt.2015.5885
- Jonsson P, Alfredson H, Sunding K, Fahlstrom M, Cook J. New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. British Journal of Sports Medicine. 2008;42(9):746-749. https://doi.org/10.1136/bjsm.2007.039545
- 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
- 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/
- 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
- NHS. Deep vein thrombosis (DVT). Page last reviewed 30 April 2026. https://www.nhs.uk/conditions/deep-vein-thrombosis-dvt/
- NHS. Symptoms: Ankylosing spondylitis. Page last reviewed 5 January 2023. https://www.nhs.uk/conditions/ankylosing-spondylitis/symptoms/
Written and checked by the PocketPhysio editorial team. Last updated 2026-10-16.
This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.