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Achilles Tendinopathy: Causes, Symptoms & Non-Surgical Treatment in SF

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Conditions We Treat

Achilles Tendinopathy: Causes, Symptoms & Non-Surgical Treatment in SF

Achilles tendinopathy is overuse pain and thickening in the tendon that connects your calf to your heel, and most people improve with loading exercises, activity changes, and targeted care rather than surgery. Here is what causes it, how to know what you are dealing with, and what actually works.

Medically reviewed by Dr. Supreet Shah, DC, MS, CCSP · Truspine, San Francisco

What Is Achilles Tendinopathy?

Achilles tendinopathy is pain, stiffness, and gradual degeneration of the Achilles tendon, the thick band of tissue that connects your calf muscles to your heel bone. It shows up in two forms. Non-insertional tendinopathy affects the mid-portion of the tendon, roughly two to six centimeters above the heel, and is most common in runners. Insertional tendinopathy affects the point where the tendon attaches to the heel bone, and often comes with a bone spur.

Both are overuse injuries. They build up from repeated small tears and failed healing, not from one bad step, which is why the pain tends to creep in over weeks rather than show up all at once.

Why This Matters For San Francisco Runners And Walkers

Between the hills, the stairs, and a city full of people who run the Embarcadero or train for Bay to Breakers, we see a steady stream of mid-portion Achilles tendinopathy at both Truspine locations. The hills in particular load the calf and Achilles harder than flat ground, which is often the piece people training here are missing.

What Causes Achilles Tendinopathy?

The most common driver is a sudden increase in activity, whether that is mileage, hill work, or simply standing and walking more than your tendon is used to. Other contributors include:

Tight or weak calves

Less give in the gastrocnemius and soleus means more direct load on the tendon itself.

Worn or changed footwear

A new shoe, a flatter shoe, or worn-out cushioning changes how force travels through the heel.

Haglund's deformity

A bony enlargement at the back of the heel that can irritate the insertional tendon.

Age-related change

Tendon tissue becomes less elastic over time, which is part of why insertional tendinopathy is more common after 40.

What Are The Symptoms Of Achilles Tendinopathy?

The hallmark symptom is pain and stiffness along the tendon that is worst first thing in the morning or after you have been sitting a while, then eases slightly once you warm up, then returns after activity or the next day. You may also notice:

  • Thickening or a noticeable lump along the tendon
  • Tenderness to the touch two to six centimeters above the heel, or directly at the heel for insertional cases
  • Pain that worsens with running, hill climbing, or pushing off to walk quickly
  • Heel pain aggravated by stiff-backed shoes, for insertional tendinopathy
A sudden, sharp pain or an audible pop in the back of the calf or heel, or an inability to bear weight or push off, can mean a tendon rupture. That needs same-day medical evaluation, not a wait-and-see approach.

How Is Achilles Tendinopathy Treated Without Surgery?

Most Achilles tendinopathy responds to conservative care. We typically build a plan around the following, in roughly this order:

  • Eccentric loading exercises: slow, controlled heel drops are the backbone of rehab for non-insertional tendinopathy, started under supervision so the loading progresses correctly rather than aggravating the tendon.
  • Activity modification: short-term swaps to low-impact cross training like cycling or swimming while the tendon calms down, without going fully sedentary, which slows healing.
  • Shockwave therapy: for cases that are not progressing with exercise alone, extracorporeal shockwave therapy (ESWT) has moderate-quality evidence behind it for mid-portion Achilles tendinopathy specifically, with research showing meaningful improvement in validated pain and function scores when added to standard care. It is one of the more evidence-backed options we offer for stubborn tendon pain, and it is where we usually start once a straightforward loading program has not been enough.
  • Orthotics and heel lifts: small changes to shoe setup that reduce tendon strain during the day.

We generally steer away from cortisone injections near the Achilles given the added rupture risk, and we are selective about extended boot immobilization, since too much rest weakens the calf and can slow the return to activity.

Related Conditions We See Alongside Achilles Tendinopathy

Achilles pain rarely shows up alone. It is worth a broader foot and ankle assessment if you are also dealing with heel pain in the morning, which often points to plantar fasciitis and responds to the same Graston technique approach we use for the plantar fascia, or with general training overload, which falls under sports medicine care rather than a single-tendon fix.

Achilles Tendinopathy FAQs

Common Questions

How long does Achilles tendinopathy take to heal?

Mild cases often improve within four to six weeks of consistent eccentric loading. More established cases, especially insertional tendinopathy, can take three to six months of steady rehab. Shockwave therapy tends to shorten that timeline when added early rather than after months of plateau.

Can I keep running with Achilles tendinopathy?

Usually yes, within limits. We typically reduce mileage and hills, avoid speed work, and watch for pain that persists more than a few hours after a run. Pain that lingers into the next morning is the signal to back off further and bring in loading exercises or shockwave therapy.

Is Achilles tendinopathy the same as Achilles tendinitis?

They describe the same area but different stages. Tendinitis implies active inflammation, which is really only present in the earliest days. Most of what we see clinically is tendinopathy, meaning degeneration and failed healing of the tendon tissue rather than ongoing inflammation, which is part of why rest alone rarely resolves it.

Do I need an MRI to diagnose Achilles tendinopathy?

Not usually. A clinical exam, looking at tendon thickness, tenderness location, and how the pain behaves with activity, is enough in most cases. Imaging becomes useful if symptoms are not improving as expected or if we need to rule out a partial tear.

What is the difference between insertional and non-insertional Achilles tendinopathy?

Non-insertional affects the mid-tendon and is more common in runners. Insertional affects where the tendon meets the heel bone, often alongside a bone spur, and needs a different approach to loading exercises since aggressive heel drops can aggravate it rather than help.

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This information is educational and does not replace a one-on-one evaluation. If you are dealing with Achilles pain, we would rather see you for a quick assessment than have you guess at a home program that is not built for your specific case.

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Thoracic Outlet Syndrome

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Home » arm pain

The term thoracic outlet syndrome (TOS) is given to a group of disorders that occur when blood vessels or nerves in that space are compressed. The thoracic outlet is what occupies the space between the ribs and the collarbone. Depending on which structure is affected, you can feel pain, swelling, numbness, blood clots, or skin discoloration in the neck, shoulder, arm, or hand.

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Tennis Elbow: Causes, Symptoms & Non-Surgical Treatment in SF

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Tennis Elbow: Causes, Symptoms & Non-Surgical Treatment in San Francisco

Tennis elbow, or lateral epicondylitis, is pain and tenderness on the outside of the elbow where the forearm tendons attach, usually from repeated gripping and wrist extension rather than tennis itself. Most cases improve without surgery using activity changes, targeted soft tissue work, and shockwave therapy. Here is what causes it, how to tell it apart from golfer's elbow, and what actually helps.

Medically reviewed by Dr. Supreet Shah, DC, MS, CCSP · Truspine, San Francisco

What Is Tennis Elbow?

Tennis elbow is an overuse injury of the tendons that attach to the lateral epicondyle, the bony bump on the outside of your elbow. These tendons control wrist extension, the motion of bending your wrist backward, and repeated strain causes small tears and degeneration in the tendon fibers rather than classic inflammation. That is why it is more accurately called a tendinopathy than tendinitis.

In San Francisco, most of the tennis elbow we see has nothing to do with tennis. It shows up in people who spend all day on a laptop and mouse, climbers working the crimps at Dogpatch Boulders or Movement, people who just picked up pickleball, and anyone doing repetitive manual work with their hands. Only a minority of cases come from racquet sports, and most of those are from technique issues like leading with the elbow on a backhand rather than the sport itself.

What Causes Tennis Elbow?

Repetitive wrist extension

Typing, mousing, and gripping tools all load the same forearm tendons thousands of times a day, which adds up even without a single acute injury.

Poor ergonomic setup

A mouse positioned too far away, a keyboard that forces wrist extension, or a chair with no forearm support all increase tendon load during ordinary desk work.

Racquet and paddle sport technique

A late or off-center backhand, an undersized grip, or over-tight strings transfer more force through the wrist extensors than a clean stroke does.

Sudden increase in grip-heavy activity

Starting a new climbing routine, a home renovation project, or any task with a lot of gripping and lifting before your tendons are conditioned for it.

What Are The Symptoms Of Tennis Elbow?

  • Pain and tenderness centered on the bony bump on the outside of the elbow, sometimes radiating down the forearm.
  • Pain that worsens with gripping, shaking hands, lifting a coffee cup, or twisting a doorknob.
  • A weaker grip on the affected side, especially when the wrist is extended.
  • Stiffness in the elbow that is often worse first thing in the morning.
  • Symptoms that build gradually over weeks, rather than appearing after one specific injury.

See a doctor sooner if: you have significant swelling, numbness or tingling into the hand, or elbow pain following a fall or direct blow. Those point toward a different problem, such as a fracture or nerve involvement, rather than tennis elbow.

How Is Tennis Elbow Treated Without Surgery?

The large majority of tennis elbow resolves without surgery. At Truspine we lean on two therapies in particular because they target the degenerated tendon tissue directly rather than just managing the pain around it:

  • Shockwave therapy: focused acoustic wave pulses delivered to the damaged tendon fibers to stimulate blood flow and collagen repair. This is usually our first-line treatment for tennis elbow that has not settled with rest and activity changes alone, since it is well supported in the research specifically for lateral epicondylitis that has become chronic.
  • Graston technique: instrument-assisted soft tissue work along the wrist extensor tendons to break up restricted tissue and improve local blood flow. We typically pair it with shockwave therapy and loading exercise rather than using it alone.
  • Activity modification and bracing: short-term changes to grip-heavy tasks, ergonomic adjustments at your desk, plus a counterforce brace to offload the tendon during activities you cannot avoid.
  • Progressive strengthening: starting with gentle stretching, then moving into eccentric and isometric loading of the wrist extensors. Exercise therapy has strong evidence behind it and is what makes the gains from shockwave and Graston stick.

Most people notice meaningful improvement within six to eight weeks of consistent treatment. Surgery is reserved for the small percentage of cases that do not respond after several months of conservative care.

Could It Actually Be Golfer's Elbow Instead?

If your pain is on the inside of the elbow rather than the outside, you are likely dealing with golfer's elbow instead of tennis elbow. The two conditions are close cousins, affecting the opposite side of the same joint, and we treat both with the same two therapies, Graston technique and shockwave therapy. It is worth confirming which one you have before starting a stretching or strengthening routine, since the exercises are mirror images of each other.

Tennis Elbow FAQs

Common Questions

How long does tennis elbow take to heal?

Mild cases often improve in a few weeks with activity changes and bracing. More established cases typically take six to twelve weeks of consistent treatment, including shockwave therapy and a loading exercise program, before symptoms settle.

Can I still work out with tennis elbow?

Usually, yes, with modifications. Lower body training, cardio, and exercises that do not load the wrist extensors are generally fine. Gripping, pulling, and heavy upper body pressing movements should be scaled back or swapped out until your tendon tolerates the load again.

Do I need an X-ray or MRI for tennis elbow?

Most cases are diagnosed from your history and a physical exam alone, no imaging required. Imaging is reserved for cases that do not respond to several months of conservative treatment, or when a doctor suspects something else, like a fracture or nerve entrapment.

Does shockwave therapy actually help tennis elbow?

For tennis elbow that has become chronic, yes. Shockwave therapy has some of the best evidence of any non-surgical treatment for lateral epicondylitis, particularly when symptoms have been present for several months and have not responded to rest alone.

Will a brace cure my tennis elbow on its own?

No. A counterforce brace reduces strain on the tendon during activity and can ease day-to-day pain, but it does not address the underlying tendon degeneration. It works best alongside treatment like shockwave therapy and a progressive strengthening program, not as a standalone fix.

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Ready to get your elbow pain evaluated?

Dr. Supreet Shah and the team at Truspine see tennis elbow and golfer's elbow regularly at both San Francisco locations. Book a visit and we will confirm the diagnosis and build a treatment plan around shockwave therapy and Graston technique.

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