Achilles Tendinitis

Your Achilles tendon is the thick cord you can feel at the back of your heel. It joins your calf muscles (gastrocnemius and soleus) to your heel bone (the calcaneus). When your calf muscles tighten, the Achilles pulls on your heel bone and points your foot and ankle down towards the ground. This movement is called plantar flexion.

Tendinitis happens when a tendon becomes inflamed or irritated. Achilles tendinitis, which is inflammation of the Achilles tendon, is fairly common. It can affect people at any age, but it becomes more common as you get older.

For most people, Achilles tendinitis is short lived and easy to treat with rest and pain relief from the chemist. Sometimes the inflammation damages the tendon. This can cause long lasting pain or a tear (Achilles tendon rupture).

Symptoms

The symptoms often come on slowly. They include:

• A dull ache or pain when you push off your foot to walk or rise onto your toes
• Tenderness over your Achilles tendon
• Stiffness that lessens as your tendon warms up
• Mild swelling or a “bump” on your tendon
• A crackling or creaking sound when you touch or move the tendon

The tendon may be sore when you get up in the morning or after rest. It improves a little once you start moving, then gets worse again when you do more.

Sudden pain and swelling near your heel, with trouble bending your foot down or walking normally, may mean you have ruptured your Achilles tendon (see Achilles tendon rupture). If the tendon has ruptured completely, you cannot rise onto your toes on that leg. It may feel as if you have been kicked in the back of the ankle. See your doctor straight away if you think you have ruptured the tendon.

Causes

If the Achilles tendon takes a lot of stress too quickly, tiny tears can make it inflamed. A sudden increase in a repeated activity that uses the tendon is often to blame. Other things can cause Achilles tendinitis too, including:

• Improper conditioning. Achilles tendinitis is most common in athletes who are not properly conditioned for their sport or activity. Calf muscles that are not flexible or strong enough can overload the tendon. Frequent stops and starts, and activities with a lot of jumping, such as basketball or tennis, can also raise your risk.
• Too much, too soon. Overuse can cause Achilles tendinitis when you start a new exercise routine. If you are starting a new program, stretch before and after exercise, start slowly and build up over time. Do not push yourself too fast. If you are a runner, too much hill running can add to the problem.
• Flattened arch. A flat arch (excessive pronation) can raise your risk, because it puts extra stress on the Achilles tendon when you walk. If you have excessive pronation, wear shoes with good support to avoid making it worse.
• Trauma or infection. Sometimes the Achilles tendon is inflamed because of injury or infection near the tendon.

Risk Factors

Things that may raise your risk include:

• Age and overuse – as you get older, years of wear and tear take a toll. The fibres of the tendon get injured and die, so the tendon becomes weak and prone to injury and inflammation.
• Poor shoes – shoes that strain the tendon can speed up inflammation.
• Foot deformity – people with a foot deformity, such as flatfoot, are more likely to develop Achilles tendinitis.
• Weight

Investigations

In many cases, your doctor or physiotherapist can diagnose Achilles tendinitis just by listening to you and examining your feet.

If you need more tests, your doctor may order:

• Plain X-rays – X-rays do not usually show tendons. In Achilles tendinitis they may show small calcium deposits in the tendon. This points to long term overuse and damage to the tendon fibres. They may also show small bony spurs where the tendon attaches.
• Ultrasound – a useful way to check the swelling and inflammation in the Achilles tendon
• MRI – an MRI shows a lot of detail about muscles and tendons, but it is not always needed to diagnose Achilles tendinitis

Complications

Achilles tendinitis can progress to a wear and tear condition called Achilles tendinosis. The tendon loses its organised structure and becomes weaker and more scarred. If the stress on the tendon continues, it could tear (rupture). This may need surgery to repair.

Treatment

If self-care such as rest, ice and pain relief from the chemist has not worked, your specialist may suggest other treatments:

• Orthotic devices. A temporary foot insert (orthotic device) that raises your heel inside your shoe may relieve strain on the stretched tendon. Your specialist may also prescribe heel pads or cups to cushion and support your heel, or a night splint that keeps the Achilles tendon stretched while you sleep.
• Boot and crutches. In severe cases, you may be given a walking boot or a gait aid such as a crutch to let the tendon heal.
• Surgery. Non-surgical treatment, including physiotherapy and perhaps a change to your exercise program, should let the tendon heal over a few weeks. If these do not work, surgery to remove inflamed tissue around the tendon may be needed. This is usually a last resort.

If the tendon is left untreated and keeps getting small tears from exercise and repeated movement, it can rupture under heavy stress.

Looking After Yourself

If you think you have Achilles tendinitis, you can help your recovery and prevent more problems with these steps at home:

• Rest. Avoid activities that increase the pain or swelling. Do not work or play through the pain, because tissues need rest to heal. This does not mean complete bed rest. You can do other activities that do not stress the tendon, especially low impact ones such as cycling.
• Ice. Ice eases pain, muscle spasm and swelling. Apply it to the area for up to 20 minutes, several times a day. Ice packs, ice massage or ice water slush baths all help. For an ice massage, freeze water in a foam cup so you can hold the cup while you rub the ice directly on your skin.
• Compression. Swelling can reduce movement in an injured joint, so compress the area until the swelling stops. Wraps or elastic bandages are best.
• Elevation. Raise the ankle above the level of your heart to reduce swelling. This is especially important at night.

Keep moving

Rest is an important part of treatment, but long periods of inactivity can make your joints stiff. Move the ankle through its full range of movement and do gentle Achilles stretches to keep the joint flexible.

Anti-inflammatory medications

You can also try non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen, or products that contain paracetamol, to ease the discomfort.

Talk to your doctor if you need NSAIDs for a long time. Some of these drugs should only be used for short periods (about 7 to 10 days) to avoid complications.

Taking NSAIDs often, or more than the recommended dose, can cause stomach pain, stomach bleeding and ulcers. Rarely, long term use can affect how the kidneys work. If you have liver problems, talk to your doctor before using products that contain paracetamol.

Physiotherapy for Achilles Tendinitis

At first, the physiotherapist will prescribe strengthening and stretching exercises.

Long term, tendinopathy can be treated with eccentric training of the Achilles. You balance on your toes on a stair, then lower your heels slowly below the step.

Surgery

Operations are rarely needed for Achilles tendinitis. They are considered when physiotherapy fails. Options include:

• Debridement – trimming away badly damaged parts of the tendon. This is the most common operation and often gives very good results.
  • If large parts of the tendon are damaged, a tendon graft may be needed as well as the debridement.
• Removal of bursa
• Osteotomy (bone reshaping)

Tight calf muscles can add strain to the Achilles tendon. If months of exercises do not help, a small operation to lengthen the calf muscle can ease the pain.

Seeking Advice

Physiotherapy

Your first stop for suspected Achilles tendinitis should be a physiotherapist. Your physio can:

• Diagnose your problem
• Recommend treatment to control symptoms first, then to improve function and lower the chance of re-injury
• Help you find other support, such as gait aids from occupational therapists
• Refer you to other doctors, either GPs, sport medicine specialists or orthopaedics

Your Family Doctor (GP)

Your family doctor can diagnose your problem and help treat it. They can:

• tell you about your problem
• advise you of the best treatment methods
• prescribe you medications
• and if necessary, refer you to Specialists (Consultants) for further treatment

When to seek medical advice

If you have pain around the Achilles tendon that gets worse with activity, call your doctor to have it checked and to talk about treatment.

See your doctor if you have lasting pain at the back of your heel near the Achilles tendon, especially if it does not clearly improve within one to two weeks of self-care. See your doctor straight away if you have signs of an Achilles tendon rupture.

Prevention

You may not be able to prevent Achilles tendinitis, but you can lower your risk:

• Increase your activity level gradually. If you are just starting to exercise, do not expect to be marathon ready in record time. Starting slowly helps you find your limits and follow a sensible program.
• Take it easy. Avoid activities that put too much stress on your tendons, especially for long periods. Before strenuous activity, warm up by exercising at a slower pace. If an exercise causes pain, stop and rest.
• Choose your shoes carefully. Shoes for exercise should cushion your heel well and have firm arch support to reduce tension in the Achilles tendon. Replace worn shoes. If your shoes are in good condition but do not support your feet, try arch supports in both shoes.
• Stretch daily. Stretch your calf muscles and Achilles tendon in the morning, before exercise and after exercise to stay flexible. This is especially important to stop the problem coming back.
• Strengthen your calf muscles. Exercises such as toe raises, with a slow return to the ground after each one, train the muscle and tendon to cope with more load.
• Cross-train. Mix high impact activities, such as running and jumping, with low impact ones, such as cycling and swimming.

F.A.Q. | Frequently Asked Questions

Should I stop running?

Not completely. Cut back to a level that does not make the pain worse the next morning, and build up slowly. Stopping altogether weakens the tendon. Swapping some runs for cycling or swimming keeps you fit while it settles.

What exercises help?

Slow heel drops off a step, done daily for about 12 weeks, are the treatment with the best evidence. A physiotherapist can show you how to do them and how to progress.²

Should I have an injection?

Cortisone injections into or around the Achilles are avoided because they can weaken the tendon and raise the risk of it rupturing. Other injections have weak evidence.

How long does Achilles tendinitis take to get better?

Most people improve over 3 to 6 months with a loading programme. Tendons heal slowly, so progress is measured in weeks rather than days.

References

1. Arshad Z, Al Shdefat S, Iqbal AM, Bhatia M. Gastrocnemius release is an effective management option for Achilles tendinopathy. A systematic review. Knee Surg Sports Traumatol Arthrosc. 2022, 30(12), 4189-4197. PMID 35821527.
2. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360-366.