Achilles pain is very common in sport. Most Achilles pain is gradual onset or chronic, resulting from overuse or degeneration of the tendon, such as Achilles tendonitis or Achilles tendinosis.
A complete rupture of the Achilles tendon is an acute Achilles injury and requires immediate medical attention.
On this page:
- When to see a doctor
- Achilles tendonitis (tendinopathy)
- Achilles tenosynovitis
- Sever’s disease
- Haglund’s deformity
- Posterior impingement syndrome
- Insertional Achilles tendonitis
- Achilles bursitis
- Achilles tendon ruptures (acute Achilles injuries)
- Immediate first aid for Achilles pain
When should I see a doctor about my Achilles pain?
If an Achilles tendon rupture is suspected, medical help is needed immediately as surgery is often required. The longer the injury is left, the lower the chances are of making a full recovery. Without medical help, the Achilles tendon pain is more likely to become chronic and a recurring long-term problem.
Gradual onset Achilles tendon pain:
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. Achilles tendinopathy is probably a more accurate term for the majority of Achilles injuries as it infers a chronic long-term degeneration of the tendon rather than an acute ‘inflammation’.
Symptoms of acute Achilles tendonitis include a 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, but ease off as the 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.
Chronic symptoms may follow on from acute Achilles tendonitis symptoms 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. Gradual onset of Achilles tendon pain will develop over a period of weeks or even months. The pain will come on during exercise and is constant throughout the training session.
Read more on Achilles tendonitis.
Achilles tenosynovitis is an inflammatory condition of the sheath or layer surrounding the Achilles tendon. It is sometimes also known as paratenonitis. It is an overuse injury which affects the sheath surrounding the Achilles tendon, rather than tendonitis which is the degeneration of the tendon itself. Read more on the causes, symptoms, and treatment of this Achilles injury.
Achilles tenosynovitis symptoms: In terms of symptoms, they are very very similar and it is practically impossible to differentiate between the two conditions without investigations such as MRI or ultrasound scans. In a large number of cases, both conditions exist together. As a treatment for the two conditions is much the same, exact diagnosis is often not necessary. Symptoms of Achilles tenosynovitis include pain in the Achilles tendon. The Achilles tendon will be painful to touch. Pushing up onto tiptoes or stretching the calf muscles may cause pain in the Achilles tendon. The tendon may appear swollen or thickened and a creaking sensation called crepitus may be felt when moving the ankle.
Causes: Achilles tenosynovitis is an overuse injury which occurs due to repeated microtrauma of the sheath which surrounds the tendon. It is most common in runners and those involved in repetitively pushing up on the toes or marching in heavy boots.
It may suddenly develop for the following reasons:
- Tight calf and Achilles complex.
- A sudden increase in training or hill walking/running.
- A change in footwear which is less supportive.
- Going from wearing high heels every day to flat shoes.
Treatment: Rest from the activity (or activities) which aggravate the condition. Apply ice or cold therapy products to the tendon for 15 minutes every 3-4 hours to ease pain, swelling, and inflammation. Providing it is comfortable to do so, gently stretch the calf muscles.
A Doctor or sports injury professional may prescribe anti-inflammatory medication in tablet or gel form. They may also use electrotherapy treatments such as ultrasound or laser. Sports massage to loosen the calf muscles may be beneficial also. Specific sports massage called frictions can be applied to the tendon itself to encourage blood flow and break down adhesions.
A sports injury professional will advise on a rehabilitation program. Eccentric calf exercises such as heel drops are the best exercise for Achilles injuries. If conservative treatment fails, a corticosteroid injection may be administered.
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.
Read more on Sever’s disease.
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. We explain the symptoms and possible treatment options available.
Haglund’s syndrome symptoms: Symptoms of Achilles bursitis include pain at the back of the heel especially when running uphill or on soft surfaces. There will be tenderness and swelling which might make it difficult to wear certain shoes on the feet and hen pressing fingers in both sides of the heel a spongy resistance may be felt. Achilles tendonitis symptoms include pain and inflammation in the Achilles tendon at the back of the heel. The Achilles tendon will be painful to touch.
Haglund’s deformity: Retrocalcaneal bursitis is inflammation of the bursa at the back of the heel bone and Achilles tendonitis is inflammation of the Achilles tendon. Over time a bony growth can appear at the back of the heel bone. This growth is called an exostosis (a benign cartilaginous growth) and is known as Haglund’s deformity.
Treatment of Haglund’s syndrome involves treating both injuries or conditions. See Achilles tendinitis and retrocalcaneal bursitis for more information. An initial period of rest, cold therapy and anti-inflammatory medications are usually recommended. Gently stretching the calf muscles should help. Wearing a calf raise on a temporary basis can help ease the strain on the tendon.
Posterior impingement syndrome
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).
Tissues in the ankle joint can become trapped between bones in the ankle. This is known as impingement and occurs when the ankle is bent fully up or down. Posterior impingement in the back of the ankle is more common in ballet dancers and can be due to a bony protrusion at the back of the ankle.
Treatment involves rest for up to 4 weeks. A plaster cast or splint may be fitted to restrict movement of the ankle. Cold therapy or ice can be applied to reduce pain and inflammation. A doctor may prescribe NSAID’s (nonsteroidal anti-inflammatory medication). If conservative treatment does not work then surgery may be considered.
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 causing pain and inflammation which becomes worse with exercise. Sometimes a lump where the Achilles tendon inserts into the calcaneus or heel bone.
Read more on Insertional Achilles tendonitis.
Less common causes of Achilles pain
Achilles bursitis, also known as Retrocalcaneal bursitis is common foot pain in athletes, particularly runners, and may be mistaken for Achilles tendonitis, or it can occur at the same times as Achilles tendonitis (this is known as Haglund’s syndrome). With bursitis, the bursa (which helps tendons move over bones) becomes inflamed, normally from overuse. This can cause tenderness and swelling at the heel.
Read more on Achilles bursitis.
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
Achilles tendon rupture
A total rupture of the Achilles tendon is a complete tear of the tendon 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. Surgery is usually the best option but it must be performed as soon as possible after the injury. Thompson”s test is one test a professional therapist would use to diagnoses a total Achilles tendon rupture.
Read more on torn Achilles, including treatment, surgery, and rehabilitation.
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 the athlete may not feel pain until later on or the next day when the tendon has cooled down and stiffened up.
Read more about partial rupture of the Achilles tendon.
Immediate first aid for Achilles injuries
Acute Achilles tendon pain should be treated using the P.R.I.C.E. principles (protection, rest, ice, compression, and elevation).
Protection- Stop training or playing immediately to protect the Achilles from further damage. Putting as little weight as possible on the foot and Achilles is vital to stop the injury getting worse.
Rest – Resting is important to ease Achilles pain and help recovery. Stopping activity like running and jumping will allow the Achilles to recover quicker. Continuing to train, even if the pain doesn’t feel that bad, can cause more serious damage.
Ice – Apply ice or cold therapy to reduce any pain and any inflammation. Ice the area for 10 minutes every hour initially for the first 24 to 48 hours, reducing frequency to 3 or 4 times a day over the next few days. Do not apply ice directly to the skin. Wrap ice in a wet tea towel or use a commercially available cold pack instead.
Compression – The use of compression support or compression bandages on the ankle and foot can help reduce swelling.
Elevation – Elevating the ankle and Achilles above heart level whenever possible can help reduce any symptoms of swelling.
For more long-term and chronic Achilles tendon pain, applying heat for 10 minutes every couple of hours instead of ice may be more beneficial. read more on heat treatment and when to use it.