Achilles tendonitis (also known as Achilles tendinopathy or Achilles tendinosis) is an overuse injury causing pain, inflammation or degeneration of the Achilles tendon at the back of the ankle. Symptoms include pain and stiffness in the Achilles tendon. Treatment involves reducing pain and inflammation, massage, taping, stretching and eccentric strengthening exercises
- Symptoms & diagnosis
- Causes & anatomy
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.
Achilles tendonitis symptoms & diagnosis
Symptoms of Achilles tendonitis (play assessment video) consist of pain and stiffness in the Achilles tendon at the back of the ankle. Symptoms will most likely have developed gradually over time and will often be worse first thing in the morning. Achilles tendonitis can be either acute or chronic.
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 when palpating (feeling) or squeezing it from the sides. There may be a nodule or lump felt in the middle of the tendon.
Chronic injuries 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. 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 uphill or upstairs because the Achilles has to stretch further than normal.
Chronic injuries do 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 of the Achilles tendon. An MRI or Ultrasound scan can determine the extent of the injury and indicate a precise diagnosis.
How bad is my Achilles tendonitis?
The VISA Achilles tendon pain questionnaire (download PDF) has been designed to measure progress during rehabilitation. The athlete simply answers a number of questions and their score can give an estimate of how bad the injury is.
Achilles tendonitis causes & anatomy
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 overpronates 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
Treatment for acute injuries includes rest and application of ice or cold therapy to reduce pain and inflammation. More chronic injuries may respond better to heat treatment with a strict 12-week heel drop exercise program which has been shown to be effective.
What can the athlete do?
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
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 (play video) 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 (play video) 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.
What can a sports injury professional do?
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.
Achilles tendonitis exercises
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.
Expert interview (play video): Sports Physiotherapist Neal Reynolds explains his approach to Achilles tendon rehabilitation exercises.
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)
- 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,
PiettilaT., 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