Achilles Tendinopathy in Amsterdam: Why Your Achilles Still Hurts (and a Loading Plan That Works)

Is the back of your heel stiff when you get out of bed, then easing off after a few minutes of walking? Does it warm up during a run around the Vondelpark or the Amsterdamse Bos, only to ache more that evening and the next morning? Perhaps you rested for weeks, bought new shoes, did some calf stretches or even had a few physio sessions, and the pain still comes back as soon as you increase your running.

You are probably dealing with Achilles tendinopathy. It is one of the most common running injuries, and also one of the most misunderstood. This article explains what is going on in the tendon, why it so often lingers, and what an evidence-based recovery plan looks like.

What is Achilles tendinopathy?

The Achilles tendon connects your calf muscles (gastrocnemius and soleus) to your heel bone. It is the strongest tendon in the body and stores and releases energy with every step, which is why running, jumping and hills load it so heavily.

When the tendon is loaded more than it can adapt to, it becomes painful and its structure can change. Research has found little evidence of ongoing classic inflammation in these tendons, which is why clinicians now use the term “tendinopathy” rather than “tendinitis”. That matters for treatment: the goal is to rebuild the tendon’s capacity to tolerate load, not just to calm an inflammation.

Two types: mid-portion and insertional

• Mid-portion Achilles tendinopathy: pain and sometimes thickening about 2 to 6 cm above the heel. This is the most common type in runners.
• Insertional Achilles tendinopathy: pain right where the tendon attaches to the heel bone. It is often aggravated by uphill running, deep stretching and shoes that press on the back of the heel.

The distinction is important, because the two types respond differently to some exercises, especially stretching and exercises that drop the heel below the level of a step.

Who gets it?

Achilles problems are very common in runners. In a Finnish study of former elite male athletes, about half of the former middle- and long-distance runners had experienced Achilles tendinopathy during their lifetime (Kujala et al., 2005). But you don’t have to be an elite athlete. In our clinic in Amsterdam Zuid we see it most often in:

• Recreational runners who increase their distance quickly, for example while training for the Amsterdam Marathon or the Dam tot Damloop
• People returning to running after a break, an injury or having a baby
• Padel, tennis and football players, with lots of quick starts and stops
• Desk workers in their 30s to 50s who are active at weekends but sit most of the week
• People who recently changed to flatter or more minimal shoes

Other factors that can increase the risk include older age, a higher body weight, certain medical conditions such as diabetes or raised cholesterol, and some medications, especially fluoroquinolone antibiotics. If your Achilles pain started shortly after a course of antibiotics, mention this to your doctor or physiotherapist.

Typical symptoms

• Morning stiffness at the back of the heel or lower calf
• Pain at the start of a run that may ease once you’re warm, then returns afterwards or the next day
• Pain or tenderness when you squeeze the tendon
• Sometimes a visible or palpable thickening of the tendon
• Less power when pushing off, for example on stairs or when doing a single-leg calf raise

When to see someone quickly

A sudden snap or a feeling of being kicked in the back of the leg, followed by difficulty walking or pushing off, can be an Achilles rupture. That needs prompt medical assessment, not a home exercise plan. Pain at the heel with swelling in several joints, or heel pain that is worse at night, also deserves a proper check.

Why Achilles pain so often keeps coming back

Many people who come to us have already tried physiotherapy or rested for a long time. These are the most common reasons the pain lingers.

1. Complete rest, then too much too soon

Rest calms the pain, but an unloaded tendon loses capacity. When you then go back to your usual 10 km, the load is suddenly too high again and the pain returns. A Swedish trial showed that people with Achilles tendinopathy who kept running and jumping, guided by a simple pain-monitoring rule, did just as well as those who rested from these activities (Silbernagel et al., 2007). Staying active in a controlled way is usually better than stopping completely.

2. Exercises that are too light, too short, or the wrong type

A few calf raises with body weight for two weeks is rarely enough. Tendons adapt slowly, and studies of loading programmes typically run for 12 weeks or longer. The classic eccentric heel-drop programme (Alfredson et al., 1998) and heavy, slow resistance training (Beyer et al., 2015) both improved pain and function in mid-portion tendinopathy, and people in the heavy, slow resistance group were more satisfied and stuck with it better. What these programmes have in common is progressive, sufficiently heavy load over months.

3. Treating only the tendon

The calf, the foot and ankle, the knee and hip, your running technique and even the stiffness of your big toe all influence how much the Achilles has to do. If your hip muscles tire early in a run, or your ankle mobility is limited after an old sprain, the tendon may take more load with every step. Looking at the whole body, not just the painful spot, often explains why a “standard” programme didn’t work.

4. Hoping for a quick fix

Passive treatments can relieve pain in the short term, but on their own they don’t rebuild tendon capacity. A Dutch randomised trial found that platelet-rich plasma (PRP) injections combined with exercise were no better than a placebo injection with the same exercise programme (de Vos et al., 2010). Corticosteroid injections into or around the Achilles tendon are generally avoided because of concerns about tendon weakening.

What an evidence-based recovery plan looks like

Clinical practice guidelines from the American Physical Therapy Association (Martin et al., 2018) recommend progressive loading exercise as the core treatment, supported by education and load management. A typical plan has four parts.

Step 1: Find your current load tolerance

We look at what you can do now without a flare-up the next morning: walking, hopping, single-leg calf raises, running pace and distance. A useful rule from the research is that pain up to about 3 to 5 out of 10 during activity is acceptable, as long as it settles by the next morning and doesn’t build week after week.

Step 2: Build strength progressively

• Isometric holds (holding a calf raise position) can help on painful days
• Slow, heavy calf raises, standing (for gastrocnemius) and seated with a knee bend (for soleus), progressing from body weight to added load over the weeks
• For insertional pain, we usually keep the heel above floor level at first and avoid deep stretching into the painful area

Step 3: Restore spring and speed

Once strength improves, we add hopping, skipping and plyometric drills so the tendon can tolerate the fast, springy loading of running again.

Step 4: Return to running with a plan

We set a gradual running progression, for example walk-run intervals on flat ground first, then longer runs, then hills and speed work. We also look at weekly mileage, shoes and cadence where relevant.

Where acupuncture and manual therapy fit in

At Alter Physio & Acupuncture we combine physiotherapy with Japanese acupuncture. Research specifically on acupuncture for Achilles tendinopathy is still limited, so we don’t present it as a cure. We use it, together with hands-on treatment, as a way to reduce pain and calf tension so that you can do the loading programme that actually rebuilds the tendon. For some clients we also use ultrasound-guided acupuncture to place needles precisely around the calf and tendon.

How long does recovery take?

For most people, meaningful improvement takes 8 to 12 weeks of consistent loading, and full recovery can take 3 to 6 months or longer, especially if the problem has been going on for a long time. The good news is that most people can keep some form of running or sport going throughout, as long as the load is managed.

Prevention tips for Amsterdam runners

• Increase your weekly distance gradually rather than in big jumps
• Be careful when switching to new or flatter shoes; introduce them over several weeks
• Keep calf strength training in your routine year-round, not just when you’re injured
• Plan easier weeks during marathon training blocks
• Take early morning stiffness seriously; it’s often the first sign that the tendon needs a lighter week

For more on other running problems, read our guides to running injuries in the Vondelpark and Amsterdamse Bos, shin splints and recurring ankle sprains.

FAQ

Should I stop running with Achilles tendinopathy?

Usually not completely. Research suggests that continuing to run with a pain-monitoring rule (pain up to about 3 to 5 out of 10 that settles by the next morning) gives results similar to resting. You may need to reduce distance, pace or hills for a while.

Is stretching good for Achilles pain?

Gentle calf stretching may feel good for mid-portion pain, but it doesn’t replace strengthening. For insertional Achilles pain, deep stretching over the edge of a step often makes symptoms worse.

Do I need a scan?

Most Achilles tendinopathy can be diagnosed with a clinical assessment. Imaging may be useful if the diagnosis is unclear, if a partial tear or rupture is suspected, or if symptoms don’t improve with good treatment.

Do I need a GP referral to see a physiotherapist in the Netherlands?

No. In the Netherlands you can book a physiotherapist directly without a GP referral. Coverage depends on your supplementary insurance (aanvullende verzekering).

I already had physio and it didn’t help. Is it worth trying again?

Often, yes. If your previous programme was too light, too short or focused only on the tendon, a more thorough assessment and a properly progressed plan can make a real difference. That’s exactly what our second opinion appointments are for.

Book an assessment in Amsterdam Zuid

If your Achilles has been bothering you for weeks or months, you don’t have to keep guessing. At Alter Physio & Acupuncture in Amsterdam Zuid we offer English-speaking physiotherapy and Japanese acupuncture, with a thorough assessment of your whole body and a clear, progressive plan to get you running again.

Book an appointment or get in touch with any questions.

---

References

• Alfredson H, et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360-366.
• Beyer R, et al. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2015;43(7):1704-1711.
• de Vos RJ, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA. 2010;303(2):144-149.
• Kujala UM, et al. Cumulative incidence of Achilles tendon rupture and tendinopathy in male former elite athletes. Clin J Sport Med. 2005;15(3):133-135.
• Martin RL, et al. Achilles pain, stiffness, and muscle power deficits: midportion Achilles tendinopathy revision 2018. J Orthop Sports Phys Ther. 2018;48(5):A1-A38.
• Silbernagel KG, et al. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy. Am J Sports Med. 2007;35(5):897-906.