Achilles pain is very common in sport and usually occurs gradually from overuse. A complete rupture of the Achilles tendon requires immediate medical attention. Here we explain the causes of pain at the back of the ankle.
Did your ankle or Achilles pain occur suddenly, or develop gradually over time?
Gradual onset (chronic) Achilles pain
The following injuries are common causes of gradual onset and chronic pain at the back of the ankle:
Achilles tendonitis (also known as Achilles tendinopathy or Achilles tendinosis) is an overuse injury causing pain, inflammation, and or degeneration of the Achilles tendon at the back of the ankle. Symptoms of acute Achilles tendonitis include:
- Gradual onset of pain at the back of the ankle, 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.
- Pain often eases off as your tendon warms up, only for it to return later in the day or towards the end of a prolonged training session.
- The tendon will be very tender when squeezing it from the sides and there may be a nodule or lump felt in the middle of the Achilles tendon.
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Achilles tenosynovitis is an inflammatory condition of the sheath or layer surrounding the Achilles tendon. It is sometimes also known as paratenonitis.
- Symptoms are virtually identical to those of Achilles tendonitis. It is practically impossible to differentiate between the two without MRI or ultrasound scans.
- In a large number of cases, both conditions exist together.
- The Achilles tendon will be painful to touch.
- Pushing up onto tiptoes or stretching the calf muscles may be painful and the tendon may appear swollen or thickened.
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This largely affects children aged 8-15 years old, especially if they do a lot of sport.
- Pain and tenderness at the back of the heel which gets worse with exercise is the main symptom of this injury.
- Sometimes a lump is seen at the back of the heel.
- Squeezing the sides of the back of the heel will feel particularly tender.
- Sever’s disease is often linked to a growth spurt when the muscles and tendons can’t keep up with the bone changes.
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When retrocalcaneal bursitis exists at the same time as Achilles tendonitis in the same leg, this is known as Haglund’s Syndrome.
- Both these conditions need to be treated in order to recover from Haglund’s syndrome.
- Heel pain, tenderness, and swelling are the main symptoms.
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Posterior impingement syndrome
Impingement syndrome occurs when soft tissue becomes trapped or pinched between bones.
- Pain is usually felt at the back of the ankle.
- There will be tenderness behind the bottom tip of the fibula bone.
- Pain will most likely be worse at the end of the movement when the foot is pointed down into plantar flexion with the foot pointing downwards.
- Going up onto tiptoes may be painful. An X-ray can show up any bony spurs on the talus (heel bone) and end of the tibia (shin bone).
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Insertional Achilles Tendonitis
Insertional Achilles Tendonitis occurs at the back of the heel where the Achilles tendon inserts into the heel bone. The injury is similar to Sever’s disease in children but affects adults. Symptoms of:
- Pain and inflammation at the back of the heel.
- Symptoms get worse with exercise.
- Sometimes you may see a lump at the back of the heel, where the Achilles tendon inserts into the calcaneus (heel bone).
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Achilles bursitis, also known as Retrocalcaneal bursitis is common in athletes, particularly runners. Bursitis is inflammation and swelling of a small sack of fluid, called a bursa.
- It may be mistaken for Achilles tendonitis, or it can occur at the same times as Achilles tendonitis ( this is known as Haglund’s syndrome).
- The bursa becomes inflamed, normally from overuse.
- You will have pain, swelling, and tenderness at the back of your heel.
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Referred Achilles tendon pain
- Pain in the Achilles tendon may be caused by nerve injury or entrapment elsewhere in the body, such as the lumbar spine, sacroiliac joint, or hip.
- The sciatic nerve becomes impinged and pain can radiate down the back of the leg and into the ankle.
Sudden onset (acute) Achilles tendon pain
The following are common sudden onset/acute Achilles tendon injuries:
Achilles tendon rupture
A total rupture of the Achilles tendon is a complete tear and typically affects men over the age of 40 involved in a sport. Symptoms consist of:
- Sudden sharp pain in the Achilles tendon, often described as if being struck by an object or implement.
- A loud snapping noise or bang may be heard at the time.
- Sharp pain may be felt but sometimes patients may be unaware that they have torn the Achilles tendon and limp on thinking it isn’t serious.
- If a complete rupture of the Achilles tendon is suspected then seek emergency medical attention immediately.
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Partial Achilles rupture
A partial Achilles tendon rupture can occur in athletes from all sports, but particularly in running, jumping, throwing, and racket sports. The tendon will not completely tear and it may not be noticed until the activity is stopped.
- Symptoms may include sharp pain in the Achilles tendon at the time of injury, but not always.
- Sometimes you may not feel pain until later on or the next day when the tendon has cooled down and stiffened up.
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When should I see a doctor about my Achilles tendon pain?
- If you suspect you have an Achilles tendon rupture then seek medical attention as soon as possible.
- Surgery is usually indicated, especially for active people and especially for athletes.
- An Achilles tendon rupture is not always obvious. Thompson’s test is used to check for a torn Achilles tendon.
References & further reading
- Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med 2016;50(5):273–80.
- Robinson JM, Cook JL, Purdam C et al. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. BJSM 2001;35(5):335-41
- Alfredson H, Lorentzon R. Chronic Achilles Tendinosis – recommendations for treatment and prevention. Sports Med 2000;29(2):135-46
- Alfredson H, Piettila T., Jonsson P et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine 1998;26(3):360-6