Have you been struggling with stubborn Achilles pain for months—or even years? Maybe you’ve tried everything: rest, ice, stretching, or even physical therapy. But no matter what you do, the pain keeps coming back. If that sounds familiar, you might be shocked to learn you could be treating the wrong problem entirely.
It’s true. Misunderstanding your Achilles issue could be the reason nothing’s working. Today, I’ll walk you through the crucial differences between Achilles tendinitis and tendinosis—and share how the latest treatments can finally get you back on your feet, pain-free.
I'm Dr. Andrew Schneider, a podiatrist from Houston, Texas. Every day, I meet patients who have put up with Achilles pain far longer than necessary—all because they've been going after tendinitis when their real problem is tendinosis, or the other way around.
Before we dive in, I want to offer you my in-depth, easy-to-read book on running injuries—including all you need to know about the Achilles. You can get it for free at www.runninginurybook.com. And if you find this post helpful, please like, comment, and share with someone who needs it—let’s help others live pain free!
Clearing Up the Achilles Confusion: Tendinitis vs. Tendinosis
Let's start with a bit of a reality check. When it comes to Achilles pain, not all diagnoses mean the same thing. There are some terms you’ve probably heard:
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Tendinitis
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Tendinosis
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Tendinopathy
Sometimes, these words get thrown around interchangeably. But they’re not the same!
What’s the Difference?
Tendinitis (the “-itis” means inflammation) pops up fast—think days or weeks. The tendon gets inflamed, swollen, and painful, but the actual structure of your tendon is still okay.
Tendinosis is a whole different animal. Here, your tendon isn’t just inflamed—it’s degenerating. Imagine your Achilles as hundreds of tiny parallel cables. With tendinosis, those cables turn into a jumbled, weakened mess. It’s usually the result of months or even years of repeated damage or untreated pain.
Why the Difference Matters: How Your Achilles Heals
The way your Achilles heals depends entirely on whether you’re dealing with inflammation or degeneration. Get this part wrong, and you could spend months—or even years—chasing the wrong fix.
How Tendinitis Heals (Inflammation)
Think of tendinitis as your body’s fire alarm. Something goes wrong—a sudden jump in activity, maybe—and inflammation rushes in, bringing blood flow, nutrients, and all the good stuff needed to repair tissue.
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What works: Rest, ice, anti-inflammatory medication.
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Why: These treatments dial down inflammation and let your body do its repair job.
How Tendinosis Heals (Degeneration)
Tendinosis is sneakier. The structure of your tendon changes—collagen fibers (the building blocks) get messy and weak. Blood supply is poor, and the body’s so-called “healing” tools can’t get where they need to go effectively.
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What doesn’t work: Rest and anti-inflammatories.
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What does: Rebuilding—and often advanced therapies to “restart” the healing process.
How to Tell Which One You Have
The first clue is how long you’ve been hurting.
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Tendinitis: Recent pain (a few days to weeks), usually after a specific tweak like upping your running mileage or starting a new activity.
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Tendinosis: Long-term pain (months to years), often coming on slowly, with no exact “injury moment.” Multiple failed treatments? That’s another clue.
Key Symptoms: Spotting the Differences
Let’s get specific. Here’s how to differentiate them with a quick self-check:
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Tendinitis
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Sudden onset (days/weeks)
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Sharp, acute pain
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Swelling and apparent warmth in the area
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Pain often improves with rest, worsens with activity
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Looks inflamed and puffy
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Tendinosis
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Gradual onset (months/years)
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Dull, aching pain
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Area may feel thickened or lumpy
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Usually not warm to the touch
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Pain can improve with activity warm-up, but often returns after
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Appears thicker, sometimes bumpy—like a twisted rope
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Where It Hurts: What Achilles Pain Location Tells You
Location, location, location—it matters here.
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Mid-portion Tendinosis: Most common. Pain is about 2–6 cm above where your Achilles attaches to your heel bone.
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Insertional Tendinosis: Pain right at the heel bone. The characteristics shift a bit, but the “degenerative” theme stays the same.
Treating Achilles Tendinitis the Right Way
If your diagnosis is acute tendinitis, the job is to calm inflammation and protect the tissue:
The RICE Protocol
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Rest: Take a break from aggravating activities, including running or jumping.
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Ice: Apply ice packs 15–20 minutes at a time several times a day.
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Compression: Use wraps or sleeves to limit swelling.
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Elevation: Prop up your leg to decrease fluid build-up.
Other Helpful Steps
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Anti-inflammatories: Such as ibuprofen to cut down swelling/pain.
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Gentle stretches: Light calf/Achilles stretches—but don’t overdo it.
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Gradual return to activity: Test things slowly—don’t race back.
With the right approach, tendinitis usually clears up within a few weeks.
Why Tendinosis Needs a Whole New Strategy
If you’re facing tendinosis, most of what worked for tendinitis is a waste of time.
What’s the Real Problem?
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There’s almost no inflammation.
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The tendon structure is damaged and weak.
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Blood flow is limited, and the body can’t easily “repair” itself anymore.
That’s why ice, rest, and anti-inflammatories won’t fix you.
So what will?
Eccentric Exercises: Remodeling Your Tendon
Central to tendinosis recovery is eccentric exercise. This isn’t just a fancy gym term—it’s a proven way to jumpstart tendon healing.
Why do they work?
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They trigger your tendon to remodel itself, reorganizing the fibers for strength.
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They stimulate blood flow to the tendon.
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Consistency and slow progress are key—these are not “quick burn workouts.”
How to Do Achilles Eccentric Heel Drops
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Stand with the balls of your feet on a step, heels off the edge.
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Rise up with both feet, shift weight to the affected leg, and slowly lower the heel below the step level.
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Use both feet to help rise up again—always lower with one leg.
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Start with sets of 15 reps, twice daily; add weight as you get stronger.
It’s totally normal—and even expected—to feel a dull ache, not sharp pain. That means it’s working.
Regenerative Medicine: Shockwave and PRP
Here’s where modern treatment really shines for stubborn Achilles pain. If rest, exercise, and time haven’t worked, two game-changing options can make all the difference: Shockwave therapy and Platelet-Rich Plasma (PRP).
1. Shockwave Therapy (Extracorporeal Pulse Activation Technology, EPAT)
Don’t let the name spook you! This is NOT electrical shocks—but rather, acoustic pressure waves delivered into the tissue. It works by creating tiny, controlled “micro-injuries” that jumpstart your natural healing response.
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Increases blood flow
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Breaks up scar tissue and calcification
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Triggers growth factor release (your body’s built-in repair crew)
What to Expect
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Feels like a pulsing, tapping sensation.
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Pain level is very tolerable—usually 4–5 out of 10 at most.
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10–15 minute sessions, usually 3 treatments, one week apart.
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Improvement often starts after the very first session!
2. Platelet-Rich Plasma (PRP) Therapy
PRP uses your own blood’s healing powers. Here’s the process:
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Draw a small tube of your blood (just like a normal lab draw).
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Spin it in a centrifuge so the platelets concentrate.
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Inject those powerful growth factors right into your damaged tendon area.
It’s like giving your body’s repair crew a “mega dose” of what they need, right where they need it.
Combining Forces: The Two-Step Power Combo
Best results often come from combining both:
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PRP first: Jumpstarts repair at the site.
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Shockwave after: Activates and stimulates those healing factors even further.
Doctors are seeing success rates of 85–95% or better with this strategy—even when all else has failed.
Real Results: What Studies Show
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Shockwave therapy alone: 82% complete symptom resolution in studies.
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PRP + Shockwave therapy: Success rates reach as high as 95%.
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These aren’t “quick fixes”—healing takes a few months, but the results last.
Expectations, Timelines, and Insurance
Let’s set realistic expectations:
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No quick fixes: These regenerative treatments aren’t like cortisone shots. You’re triggering real healing—not just covering up pain.
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When does it work?
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Most people notice improvement in 2–4 weeks
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Full healing takes 3–6 months (tendinosis is slow by nature)
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Insurance Coverage: Sadly, most insurance plans don’t pay for regenerative treatments like Shockwave and PRP—they’re “cash pay” only. That’s a big decision, but many find the long-term impact and chance to avoid surgery worth the investment.
Common Mistakes (and How to Avoid Them)
Even with the best plan, it’s easy to go wrong. Here are the pitfalls:
1. Giving Up Too Soon
Tendinosis takes months to heal. Your tendon spent months or years degenerating—be patient as it rebuilds. Expect at least 12 weeks of rehab, sometimes as long as 6 months.
2. Returning to High Activity Too Quickly
When pain improves, it’s tempting to jump back in. Resist! The tendon is still healing even when it stops hurting. Ramp up slowly to avoid setbacks.
3. Skipping the Diagnosis
Don’t self-diagnose or “wait and see” for months—especially with long-term pain. The longer tendinosis goes untreated, the more stubborn it becomes.
Prevention: Stopping Future Achilles Trouble
After you heal, prevention is key:
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Check your biomechanics: Are you an overpronator? Flat feet? Calf or hip muscle imbalances? These can set you up for repeat trouble.
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Smart training: Avoid huge jumps in activity or intensity. Respect recovery days!
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Listen to your body: Soreness is a warning; don’t push through persistent pain.
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Proper footwear: Supportive shoes and, if needed, custom orthotics can help.
Final Thoughts and How to Get Help
The good news? Both tendinitis and tendinosis can be managed—and you can get back to pain-free living. The number one key is getting the right diagnosis and following the best treatment plan for your condition.
Don’t let confusion, frustration, or “Google guesswork” keep you sidelined. If you’re hurting, get a professional evaluation—and if you’re in Houston, come see me. We’ll figure out exactly what’s going on and build a plan that works for you.
Want even more details? Download my free book about running injuries at www.runninginurybook.com, and join the community by subscribing, commenting, and sharing this post with someone who needs it.
Thanks for reading, and here’s to your recovery!
