Achilles tendonitis is an overuse injury causing pain at the back of the ankle. If not caught early, it can be a difficult injury to cure. Here we explain the symptoms, causes and important exercises for treating acute and chronic achilles pain.
Achilles tendonitis symptoms & diagnosis
The main symptom is Achilles tendon pain. However, Achilles tendonitis is either acute or chronic:
- Acute Achilles tendonitis symptoms develop gradually over a few days.
- You will feel pain and stiffness in the Achilles tendon at the back of the ankle.
- It is particularly painful first thing in the mornings, or after a period of rest. Then, as your tendon warms up the pain reduces. However, pain is likely to return later in the day, or after a prolonged training session.
- Your Achilles will be very tender when palpating (feeling) or squeezing it from the sides.
- You may also feel a nodule or lump in the middle of the tendon.
- Chronic injuries may follow on from acute Achilles tendonitis symptoms, especially if your injury goes untreated or is not rested.
- Long term tendonitis/tendinopathy is difficult 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.
- You will have pain when walking, especially uphill or upstairs because the Achilles has to stretch further than normal.
Chronic Achilles pain does not necessarily prevent activity but can niggle away affecting performance. In the long-term, this may be a precursor for something more serious, such as a total rupture. 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. Simply answer a few questions to get a score out of 100. This is an estimate of how bad your injury is and can be a good way of measuring progress.
What is Achilles tendonitis/tendinopathy?
Achilles tendonitis is also referred to as Achilles tendinopathy or Achilles tendinosis. It is an overuse injury causing pain, inflammation or degeneration of the Achilles tendon at the back of the ankle.
The Achilles tendon is the large thick band of tissue at the back of the ankle. It connects the calf muscles to the back of the heel. Huge forces are transmitted through the tendon when walking and running.
Tendonitis or tendinopathy?
Tendonitis suggests inflammation of the tendon (‘itis’ means inflammation). But in reality, few injuries are actually down to pure inflammation. The main finding, particularly in older athletes is usually degeneration of the tendon. Therefore, the term tendinopathy is probably a better term to describe the range of conditions that can cause Achilles pain.
The main cause, particularly in older athletes is degeneration or wear and tear of the tendon. Another condition which has identical symptoms is Tenosynovitis. This is inflammation of the sheath surrounding the Achilles tendon.
What causes Achilles tendinopathy?
Overuse is the primary cause. However, there are a number of factors which can increase your risk of injury.
- Poor foot biomechanics – Overpronation is when your foot rolls in too much (flattens). As your foot flattens, your lower leg rotates and as a result, your Achilles tendon twists. This makes it more susceptible to overuse injury.
- Incorrect footwear – Make sure you choose the right running shoes for your foot type and the sport. A worn-out shoe or one that does not provide enough support can increase the strain on your Achilles tendon.
- Wearing high heels – If you wear high heels regularly, this causes your Achilles tendon to adaptively shorten over time. Then, each time you wear your flat running shoes your tendon is being asked to repeatedly overstretch.
- Training errors – Avoid overtraining, increase your weekly running mileage gradually and by no more than 10% per week. Running on soft surfaces, or sand is not great, because it allows your heel to sink. As a result, the Achilles tendon is forced to stretch further.
- Uphill/treadmill running – If you regularly run uphill or on a treadmill set at an incline, your Achilles tendon is continually overstretching. This again increases the risk of 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. A strict 12-week heel drop exercise program which has been shown to be effective in chronic, stubborn cases.
What can the athlete do?
- Apply ice/cold therapy – 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 – This may mean complete rest, or simply modifying your training activities.
- Wear a heel lift/heel pad – this will help reduce the strain on your Achilles tendon by temporarily shortening the calf muscle.
- Achilles taping – A simple Achilles tendon taping technique can be used to take the strain off a painful tendon, allowing it to rest more easily, especially if you have to be on your feet.
- Apply heat – Long-term chronic injuries may respond better to the application of heat. Apply for 10 minutes every couple of hours as required.
- Self-massage – Applying gentle self-massage to the Achilles tendon may also be beneficial. Heel drop exercises – If your Achilles tendonitis has been a persistent problem then a strict 12-week program of exercises may help.
The Hakan Alfredson’s heel drop protocol exercises have been shown to be effective in up to 90% of patients
- Stretching exercises – Gentle calf stretching exercises can help stretch the muscles and aid recovery.
- Wear a night splint – The Plantar fasciitis night splint is worn overnight and is excellent for calf muscle flexibility, preventing them tightening up overnight.
What can a sports injury professional do?
- Medication – A professional practitioner or Doctor may prescribe anti-inflammatory medication, such as ibuprofen. This might help with acute Achilles inflammation, but has not been proven to be beneficial long-term and may even inhibit healing.
- Electrotherapy – Application of Electrotherapy, such as ultrasound can also help reduce pain and inflammation.
- Sports massage – this can help mobilize the tissues of the tendon and relax the calf muscles.
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. Exercises are performed twice a day to a total of 180 repetitions and continued for 12 weeks.
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.
- 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