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Achilles Tendonitis

Achilles tendonitisAchilles Tendonitis or achilles tendinopathy which is probably a more accurate term is an overuse injury causing pain, inflammation and or degeneration of the achilles tendon at the back of the ankle.

The term achilles tendinopathy is probably a better term to describe the range of conditions that can cause achilles tendon pain.


Symptoms can be either acute or chronic. Acute tendonitis is usually more painful and of recent onset. Chronic injuries will have come on gradually and over weeks, not necessarily preventing activity.

Acute symptoms

  • Symptoms of acute achilles tendonitis will be a gradual onset of pain at the back of the ankle, just above the heel bone which may develop over a period of days.
  • The achilles tendon may be painful and stiff at the start of exercise and first thing in the morning.
  • As the tendon warms up the pain will go often for it to return later in the day or towards the end of a prolonged training session.
  • The tendon will be very tender on palpation or pressing in on the achilles tendon or squeezing it from the sides.

Chronic symptoms

Achilles palpationChronic injuries may follow on from acute achilles tendonitis if it goes untreated or is not allowed sufficient rest. Chronic achilles tendinosis is a difficult condition to treat, particularly in older athletes who appear to suffer more often.

  • There will be a gradual onset of achilles tendon pain over a period of weeks, or even months.
  • The pain will come on during exercise and is constant throughout the training session.
  • Pain will be felt in the tendon when walking especially up hill or up stairs because the achilles has to stretch further than normal.
  • An MRI or Ultrasound scan can determine the extent of the injury and indicate a precise diagnosis.

There is likely to be stiffness in the tendon especially in the morning or after a long period of rest. This is thought to be due to adhesions between the tendon sheath and the tendon itself. Nodules or lumps may be found in the achilles tendon, particularly 2-4cm above the heel and the skin will appear red.

Pain and tenderness will be felt when pressing in on the achilles tendon which is likely to appear thickened or swollen. A creaking sensation known as crepitus may be felt when press the fingers into the sides of the tendon and moving the ankle.

  • Download the VISA questionnaire which is an excellent tool for measuring long term chronic achilles tendon pain.


The achilles tendon is the large tendon at the back of the ankle. It is the joint tendon of the calf muscles made up of the gastrocnemius and soleus and inserts into the back of the heel bone or calcaneus. It provides the power in the push off phase of walking and running where huge forces are transmitted through the achilles tendon.


Achilles tendonitis is often now referred to as achilles tendinopathy or which covers all types of overuse achilles tendon injuries. Strictly speaking tendonitis suggests an inflammatory condition of the tendon but in reality few injuries are actually down to pure inflammation.

The main finding, particularly in older athletes is usually degeneration. Other very similar conditions may actually be due to inflammation or degeneration of the tendon sheath which surrounds the tendon rather than the achilles tendon itself.

In addition to being either chronic or acute, achilles tendonitis can also be at the attachment point to the heel called insertional achilles tendonitis or in the mid-portion of the tendon typically around 4cm above the heel.

Achilles tendonitis is an overuse injury. Too much too soon is the common cause of overuse injuries, however other factors can contribute to developing the condition.

  • An increase in activity, either distance, speed or a sudden change to running up hills. As a rule of thumb distance runners should increase their mileage by no more than 10% per week.
  • A change of footwear or training surface for example suddenly running on soft sand can cause the heel to drop lower than normal making the tendon stretch further than it is used to.
  • Weak calf muscles can tighten or go into partial spasm which again increases the strain on the achilles tendon by shortening the muscle.
  • Running up hills - the achilles tendon has to stretch more than normal on every stride. This is fine for a while but will mean the tendon will fatigue sooner than normal.
  • Overpronation or feet which roll in when running can place an increased strain on the achilles tendon. As the foot rolls in (flattens) the lower leg also rotates inwards which places twisting stresses on the tendon.
  • Wearing high heels constantly shortens the tendon and calf muscles. When exercising in flat running shoes, the tendon is stretched beyond its normal range which places an abnormal strain on the tendon.

Expert Interview

Professional Football Physiotherapist Neal Reynolds explains early stage treatment, exercises and returning to full training. See also Neal's interview on achilles injury prevention.

Achilles tendonitis treatment

Healing of the achilles tendon is often slow, due to its poor blood supply. Treatment is based around initially reducing pain and inflammation, stretching, strengthening along with a gradual return to activity. No one single approach may cure an achilles injury, particularly a chronic condition but a combination of treatment approaches and patience will work best.


Acute injuries require rest. Continuing to train on a painful achilles tendon could lead to the injury becoming chronic and more difficult to treat. Avoid activities such as running which are likely to increase pain. You may be able to swim or cycle to maintain fitness. If the injury is severe then a plaster cast might be applied to completely immobilize the tendon.

Ice & heat

Applying ice or cold therapy as soon as possible to a painful achilles tendon will reduce pain and inflammation. After the first 24 to 48 hours alternating hot and cold or just heat may be more beneficial. Tendons work better when they are warm but if they are painful then rest and ice may be more effective.

Heel pads

Wear a heel pad to raise the heel and shorten the calf muscles which in turn reduces some of the strain on the achilles tendon. This should only be a temporary measure while the achilles tendon is healing.


Achilles tendon tapingAn achilles tendon taping technique can aid rest by supporting the tendon with elastic bandages. This is an excellent way of taking the load off the tendon if you have to walk around on your feet as well as protecting the tendon when returning to full fitness.

See achilles taping video.

Footwear & Orthotics

Over pronation and orthotic shoe insertsMake sure you have the right running shoes for your foot type and the sport. If you are a runner that over-pronates then a motion control or support running shoe may be needed. Visit a specialist running shop for advice. Gait analysis along with a physical assessment will identify any possible biomechanical factors such as over pronation which may have contributed to the achilles tendonitis and training methods will be considered. Biomechanical problems can be corrected with the use of orthotic inserts and selection of correct footwear.


Heel drop end positionEccentric strengthening exercises have been shown to be probably the most effective treatment method for recovering from achilles tendon pain. The Hakan Alfredson's heel drop protocol exercises involve the patient dropping the heel to horizontal in a slow and controlled manner. An eccentric muscle contraction is one where the muscle gets longer as it contracts rather than shortening. They have been advocated since the early 1980's as a treatment method for achilles pain although but made three innovations have been advocated:

  1. If the achilles pain gets worse this is not necessarily a bad thing. It could just be part of the normal healing process.
  2. Heel drop exercises should be performed both with the leg straight and bent.
  3. A total of 180 repetitions should be done every day for 12 weeks. This is a lot more than most achilles rehab programs would advocate.

See more on eccentric exercises.

Download your 12 week eccentric achilles tendon exercise tick sheet.


Applying sports massage techniques can mobilze the tissues or the tendon itself and help stretch the calf muscles.


Treatment options might include anti-inflammatory medication such as ibuprofen which might help with acute achilles inflammation and pain but has not been proven to be beneficial long term and may even inhibit healing.


Use of electrotherapy such as ultrasound treatment, laser therapy and extracorporeal shock wave therapy (ESWT) may be beneficial in reducing pain and encouraging healing.


Some might give a steroid injection however an injection directly into the tendon is not recommended. Some specialists believe this can increase the risk of a total rupture of the tendon in future.