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. This achilles injury can be both acute and chronic, with the main symptoms being pain and stiffness in the tendon at the back of the ankle. It can be a difficult injury to treat so catching it early will help prevent further damage.
If not caught early this can be a difficult injury to cure but with the right treatment and particularly eccentric strengthening exercises, a full recovery can usually be achieved.
Symptoms consist of pain and stiffness in the Achilles tendon at the back of the ankle. It is likely to have come on gradually over time and will often be worse first thing in the morning. Achilles tendonitis can be either acute or chronic. Acute tendonitis is usually more painful and of recent onset for example over a period of days.
The Achilles tendon may be painful and stiff at the start of exercise. 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 (feeling/pressing in) or squeezing it from the sides. There may be a nodule or lump felt in the middle of the Achilles tendon.
Chronic Achilles tendonitis will follow from an acute injury which has not been allowed to heal. A chronic injury may not necessarily prevent activity but can niggle away affecting performance and in the long term may be a precursor for something more serious such as a total rupture. The VISA Achilles tendon pain questionnaire has been designed to measure symptoms during rehabilitation. An MRI or Ultrasound scan can determine the extent of the injury and indicate a precise diagnosis.
Read more on assessment and diagnosis.
What is Achilles tendonitis?
The Achilles tendon is the large thick band of tissue at the back of the ankle which connects the calf muscles to the back of the heel and provides the pushing off the force for walking and running. Tendonitis suggests an inflammatory condition of the tendon ('itis' means inflammation) but in reality, few injuries are actually down to cure inflammation. The main finding, particularly in older athletes is usually degeneration of the tendon. The term Achilles tendinopathy is probably a better term to describe the range of conditions that can cause Achilles tendon pain.
The main cause, particularly in older athletes is degeneration or wear and tear of the tendon. Other very similar conditions may actually be due to inflammation or degeneration of the tendon sheath which surrounds the tendon (called Tenosynovitis) rather than the Achilles tendon itself.
Although overuse is the primary cause, there are a number of factors which can increase your risk of sustaining the injury.
Foot biomechanics - If the athlete over pronates when running then this can cause the foot to flatten which in turn causes the lower leg to rotate inwards. If the lower leg rotates inwards this, in turn, twists the Achilles tendon which increases the stresses on it making it more susceptible for overuse. A podiatrist can perform gait analysis to identify any biomechanical issues and correct them with orthotic inserts which are worn inside shoes, or for less severe cases advising on correct footwear for your running style.
Correct footwear - make sure you have the right running shoes for your foot type and the sport. Many specialists running shops will do gait analysis and have experience of advising the correct shoes. A worn out shoe or one that does not provide enough support can increase the strain on the Achilles tendon. If you overpronate then you would probably be more suited to a 'motion control shoe' or a shoe with 'medial support'. This simply means that the midsole of the shoe is harder on the inside that it is on the outside enabling it to resist rolling in or overpronating.
High heels - anyone who regularly wears high heels may cause the Achilles tendon to adaptively shorten over time. Then when they put their flat running shoes on the Achilles tendon may be stretching more than is normally comfortable increasing the likelihood of injury.
Training - avoiding overuse and modifying training methods is important to prevent the injury from returning. For example running on soft surfaces, especially sand is not good for the Achilles tendon as it allows the heel to sink causing additional stretch on the tendon. If you are a runner then increase your weekly mileage gradually and by no more than 10% per week.
Uphill / treadmill running - if you regularly run uphill or on a treadmill which is set at an incline then this forces the Achilles tendon to work in a continually overstretched position, increasing the strain on it and therefore the likelihood of sustaining an injury.
Achilles Tendonitis Treatment
For an acute injury applying ice for 10 minutes every hour or so reducing frequency as required for the first 2 to 3 days can help reduce pain and inflammation. Rest is important so try to stay off your feet as much as possible.
Wearing a heal lift or heel pad (in both shoes) can help reduce the strain on the tendon by shortening the calf muscle very slightly, although this should only be done as a short-term measure. A simple Achilles tendon taping technique can be used to take the strain off a painful Achilles tendon allowing it to rest more easily, especially if you have to be on your feet.
A long-term chronic Achilles tendon injury may respond better to the application of heat, again applied for 10 minutes every couple of hours as required. Applying gentle self-massage to the Achilles tendon may also be beneficial. If Achilles tendonitis has been a persistent problem then the Hakan Alfredson's heel drop protocol exercises have been shown to be effective in up to 90% of patients. They involve performing a heel drop exercises 180 times every day for 12 weeks during which time pain may actually get worse before it gets better.
Gentle calf stretching exercises can help stretch the muscles and aid recovery. A plantar fasciitis night splint is worn in bed and is excellent for preventing calf muscles tightening up overnight.
A professional practitioner or Doctor may prescribe 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. Application of electrotherapy such as ultrasound can also help reduce pain and inflammation and sports massage can help mobilize the tissues of the tendon and relax the calf muscles. They can also identify possible causes such as biomechanical problems with the foot which may be contributing to the chance of injury.
Read more on treatment and rehabilitation.
The Hakan Alfredson's heel drop protocol exercises have been shown to be effective in up to 90% of patients suffering from Achilles tendon pain and involve the patient dropping the heel to horizontal in a slow and controlled manner.
The athlete performs an eccentric heel drop exercise on a step going up with both legs and slowly lowering the heel to the horizontal position. Eccentric exercises are those where the muscles (in this case the calf muscles) get longer as they contract. Exercises are performed twice a day to a total of 180 repetitions and continued for 12 weeks. Pain may often get worse over the 12 weeks before it starts to get better.
Read more on Achilles tendon heel drop exercises.
We have a number of resources to help in the recovery of Achilles tendonitis including our 12-week exercise check sheet and our downloadable VISA Achilles pain questionnaire which is a great way to monitor how bad your injury is.
Download free Achilles tendonitis exercise record sheet (pdf)