Shockwave Therapy for Achilles Tendon Pain in Cape Town

It usually starts as a warning rather than an injury. The first kilometre feels stiff, the tendon loosens up as you run, and by the end of the session you have almost forgotten about it. The next morning the first few steps out of bed tell a different story. A few weeks later the stiffness has stopped disappearing mid run, and hills have started to feel like a bad idea.

Achilles tendinopathy is one of the most common reasons Cape Town road runners end up in a physiotherapy room, and it has a habit of arriving in a training block rather than in the off season. If you are building toward Two Oceans, or any goal race, the temptation is to back off for two weeks and hope it resolves. That approach works less often than people expect, and the reason why tells you a lot about how tendons actually behave.

What is the difference between midportion and insertional Achilles tendinopathy?

Both involve the same tendon, but they behave differently enough that treating them the same way is a mistake.

Midportion tendinopathy sits in the body of the tendon, roughly two to six centimetres above where it attaches to the bone. If you pinch the tendon between your fingers there, it is tender, and often slightly thickened. This is the more common of the two, and generally the more predictable to treat.

Insertional tendinopathy sits right at the bottom, where the tendon anchors into the back of the calcaneus. The tenderness is lower down, closer to the bone, and it is often worse when the shoe counter presses against it or when the ankle is pushed into a deep dorsiflexed position. There is frequently some involvement of the small bursa sitting between the tendon and the bone, and sometimes a bony prominence at the attachment.

Working out which one you have is not academic. It changes what we do with you in week one.

Why does that difference change the treatment plan?

The insertional presentation involves compression. When your ankle bends deeply, the tendon is squashed against the back of the heel bone, and compressive load on an already irritated insertion tends to make things worse rather than better.

That is why some of the standard advice people find online backfires. Dropping the heel off a step, aggressive calf stretching against a wall, and hill work all push the ankle into that compressed position. For midportion tendinopathy those are often useful. For insertional tendinopathy, early on, they are usually the thing keeping you sore.

So with an insertional presentation we tend to start loading in a shortened to neutral range, keep the heel from dropping below level, sometimes add a small heel raise in the shoe temporarily to reduce the compression, and hold off on hills and speed for longer. With a midportion presentation we can usually work through a fuller range from the start and progress faster.

Insertional tendinopathy also tends to be slower. Not untreatable, just slower, and telling someone that up front matters more than promising a quick fix.

Why does rest alone tend to fail with tendons?

Because rest treats the symptom and removes the stimulus at the same time.

Tendon pain settles when you stop loading it, which feels like healing. What is actually happening is that you have dropped the demand below the tendon's current capacity, so it stops complaining. Meanwhile the tendon is getting weaker, not stronger, because tendon tissue adapts to load and detrains without it. Two weeks off can leave you with a tendon that is less capable than the one you started with.

Then you go back to your usual mileage, the demand jumps straight back over the line, and the pain returns within a run or two. Most runners have been round this loop at least twice before they seek help, and each cycle costs training time.

Tendons respond to progressive, tolerable load. The job is not to avoid loading the tendon. The job is to find the level it can handle right now and build from there, deliberately, week by week.

How does shockwave therapy stimulate the tendon's own repair response?

A tendinopathic tendon is not inflamed in the way a sprained ankle is. The tissue shows disorganised collagen, an altered matrix, and small new blood vessels and nerve endings growing in, which is part of why it hurts. In longer standing cases the normal repair process has effectively stalled.

Shockwave therapy delivers rapid acoustic pressure waves into the tendon through a handpiece. That controlled mechanical stimulus appears to restart the repair response in tissue that has gone quiet, increase local blood flow, and change how the tendon signals pain. In practical terms, patients often report that the tendon tolerates load better within a few sessions, which is what makes the strength work possible.

That last point is the whole argument for using it. Shockwave is not a cure for Achilles tendinopathy and it will not rebuild your tendon by itself. What it does well is open a window where the tendon is less irritable, so that the loading programme can actually be progressed rather than constantly being pulled back because everything flares. The treatment and the rehabilitation programme work as one plan, delivered by the physiotherapy and biokinetics team together.

What does a course of shockwave therapy involve?

Sessions run about five to ten minutes over the tendon and the calf, with gel to conduct the energy. It feels like firm, rapid tapping, and it is more tender directly over the sore part of the tendon than elsewhere. Intensity is built up to what you can tolerate and can be turned down at any point.

Most courses run to between three and six sessions, roughly a week apart, and we reassess as we go. There is no injection and no downtime. You may feel achy over the tendon for a day or two afterwards, and we usually ask you to keep high impact loading down for about forty eight hours after each session.

If you have had four sessions with a properly progressed loading programme and nothing has changed, the answer is not more sessions. The answer is to look again at the diagnosis, because pain at the back of the ankle can also come from the plantaris tendon, the bursa, the posterior ankle joint itself, or in some cases a stress reaction in the bone.

What does a return to running progression look like?

The tendon gives you an unusually clear feedback signal, and we build the progression around it. The rule most of our runners work to is the twenty four hour rule. Some discomfort during a run is acceptable. What matters is how the tendon feels the next morning. If the first steps out of bed are worse than the previous day, the last session was too much and the next one steps back.

A typical progression starts with the strength work established and running reintroduced on alternate days, often as a walk and run mix on flat ground. Volume comes back before intensity. Once the weekly distance is stable and the morning check stays clean, we add pace. Hills and any real speed work come last, and for insertional presentations they come later still.

The strength programme does not stop when you start running again. That is the most common mistake we see. The calf and tendon work continues right through the return to running and past the point where the pain has gone, because that is what raises the ceiling and keeps you from repeating the whole thing in your next training block.

Where do you start at Peak Movement?

Peak Movement is on Strand Street in the Cape Town City Centre, with physiotherapy and biokinetics under the same roof, which is what allows the shockwave sessions and the loading programme to run as one coordinated plan rather than two separate appointments.

The first appointment is an assessment. We work out whether the presentation is midportion or insertional, test how your calf, ankle and hip are handling load, and go through what changed in your training before the symptoms started. If shockwave suits your presentation, we will explain why and what a course looks like. If it does not, we will say so.

Payment is settled at the time of your session. You receive a full invoice including ICD-10 codes, which you then submit to your medical aid yourself.

Frequently asked questions

Can I keep running with Achilles tendinopathy?

In many cases yes, with the volume and the surface adjusted, and with hills and speed work paused for a period. Complete rest is rarely the answer because tendons lose capacity without load. The guide is how the tendon feels the morning after a run rather than how it feels during it.

How many shockwave sessions will I need for my Achilles?

Most courses run to between three and six sessions, spaced about a week apart, alongside a progressive strength programme. Insertional presentations often need longer than midportion ones. We reassess through the course rather than committing to a fixed number up front.

Will this be sorted before Two Oceans?

It depends on how long you have had it and how much time is left in your build. A midportion tendon caught early often settles inside six to eight weeks while you keep training in an adjusted form. A long standing insertional presentation can take three months or more. The earlier you get it assessed, the more of your training block you keep.

If your Achilles has been talking to you for more than a couple of weeks, book an assessment with the physiotherapy team at Peak Movement on Strand Street before it starts costing you sessions.