Achilles tendinopathy

What is Achilles tendinopathy?

Achilles tendinopathy is pain, swelling or weakness affecting your Achilles tendon, the tough band of tissue that connects your calf muscles to your heel bone. It happens when the tendon can’t keep up with the strain placed on it, causing small amounts of damage that it then tries to heal.

You may hear it called Achilles tendonitis, but doctors tend to avoid this term now, since ‘itis’ means inflammation, and the tendon isn’t always inflamed. It’s a common problem that affects both very active people and those who do little exercise.

What are the symptoms of Achilles tendinopathy?

Symptoms can appear gradually or suddenly, and you might have one or several of them. The most common are:

• an aching or sharp pain around the heel, worse with activity or pressure on the area
• morning stiffness at the back of the ankle, which usually eases after a few minutes of walking, and can also follow long periods of sitting
• tenderness or swelling over the tendon, sometimes with a painful lump that rubs against your shoes
• a grating or creaking feeling (crepitus) when you move your ankle

Some people find the pain settles once they get moving, then increases again afterwards. As symptoms progress, pain can occur during everyday activities like walking, especially uphill or on uneven ground, and in severe cases it may be hard to put weight on the leg at all.

Signs of a tendon rupture

If you feel a sudden, sharp pain in your heel or calf, hear a snap or pop, and struggle to bear weight on your leg, this could mean your Achilles tendon has torn (ruptured) rather than just being irritated. Seek urgent medical advice if this happens.

What are the causes of Achilles tendinopathy and who is at risk?

The exact cause isn’t fully understood, but it’s generally linked to repeated strain on the tendon, most often from sport or exercise. Activities commonly involved include:

• running, including football, tennis, badminton and middle or long-distance running
• jumping sports such as basketball, dancing, gymnastics and tennis
• cycling, if your saddle is set too low

A number of other factors can raise your risk, including:

• getting older, particularly from your 30s onwards, and being male
• tight or weak calf muscles, poor calf endurance, or poor core stability around the hip and knee
• stiff joints in the foot or ankle
• having a high-arched or flat (or overpronated) foot, where your foot rolls inwards as you walk
• being overweight
• wearing unsupportive footwear, or regularly wearing high heels
• a family history of Achilles tendinopathy, or a previous injury to the tendon
• long-term conditions such as diabetes, high cholesterol, thyroid problems, or inflammatory types of arthritis, including rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis
• hormonal changes
• certain medicines, including statins, corticosteroids (steroid medicines), and a group of antibiotics called quinolones (or fluoroquinolones)

Training errors also play a part caused by the physical load increasing at a faster rate than the tendon can adapt to, such as increasing running distance and/or intensity too quickly without adequate recovery. Also, too much uphill running, and wearing old or poor-quality footwear.

Are there different types of Achilles tendinopathy?

There are two main types, based on where the pain sits:

• Non-insertional (mid-portion) tendinopathy affects the tendon around 2 to 6cm above where it meets the heel bone. This is the more common type, and tends to affect younger, more active people.
• Insertional tendinopathy affects the lower part of the tendon, right where it attaches to the heel bone. This type is more common in older people and those who are less active or overweight and can be more complex to treat.

Are there different stages of Achilles tendinopathy?

Achilles tendinopathy is often graded by how severe it is:

• Mild: pain during a particular activity, such as running, or shortly afterwards
• Moderate: the tendon may swell, and a hard lump (nodule) can sometimes form
• Severe: any weight-bearing activity causes pain, and in rare cases, the tendon can rupture (tear)

How is Achilles tendinopathy diagnosed?

Your GP or physiotherapist will usually be able to diagnose Achilles tendinopathy from your symptoms and a physical examination alone, so you won’t normally need X-rays or scans.

They’ll ask about your symptoms, activity levels, footwear and medical history, and may check the tendon for tenderness, thickening or pain when you move your ankle or squeeze your calf muscle. If imaging is needed, for example if your symptoms are severe, aren’t responding to treatment, or a rupture is suspected, this is usually an ultrasound scan, or occasionally an MRI scan. Blood tests are occasionally used to check for an inflammatory condition.

How is Achilles tendinopathy treated?

Non-surgical treatment

Most people improve with conservative treatment, though this can take time, often around 12 weeks, and sometimes 3 - 6 months or more. Complete rest isn’t recommended, since this can weaken the tendon further and slow your recovery.

• Activity changes: reduce or adapt whatever triggered your symptoms, but stay as active as you comfortably can, using low-impact options such as swimming, cycling or aqua-jogging to maintain fitness
• Ice: applied wrapped in a damp towel for around 20–30 minutes at a time, a few times a day, to ease pain and swelling
• Painkillers: paracetamol, or a short course of anti-inflammatories such as ibuprofen, taken on the advice of a pharmacist or GP
• Stretching: gentle calf stretches, holding each for 30 seconds to a minute
• Isometric exercises: holding a static position, such as a heel raise, without movement; often a good starting point if your tendon is too painful for other exercises
• Eccentric exercise: a structured, progressive loading programme (where the calf muscle lengthens under tension, such as slowly lowering your heel from tiptoes) that is considered the main treatment for this condition
• Orthotics: shoe inserts or heel lifts, if the shape of your foot or the way you walk is contributing

Around 7 in 10 people are able to gradually return to sport or full activity by around 3 months into an eccentric exercise programme. Between 1 in 10 and 3 in 10 people do not respond well to this approach; if that happens to you, your physiotherapist can discuss alternatives.

If self-help measures and exercise haven’t helped enough, further options include extracorporeal shockwave therapy (a machine that sends shockwaves through the skin to the tendon), injections using a small amount of your own blood or plasma, and dry needling (passing a fine needle into the tendon to encourage healing). Steroid injections are not usually recommended, since the evidence for benefit is inconsistent and they may increase the risk of the tendon rupturing.

Surgical treatment

Surgery is a last resort, used only if other treatments have been tried for several months without success. It involves removing damaged parts of the tendon and repairing what’s left, sometimes using tissue from elsewhere in the tendon or a nearby tendon.

Recovery takes time and will leave scarring. Most people can resume normal activities around 10 weeks after surgery, with a return to competitive sport typically taking 6 – 12 months. Surgery does not work for everyone, and is not guaranteed to relieve your symptoms.

When should I see a doctor?

See your GP or a physiotherapist if you have ongoing heel or tendon pain, stiffness or swelling that doesn’t improve with rest and self-help measures.

Seek urgent medical advice if you feel a sudden sharp pain or hear a snap in your heel or calf, or if you’re unable to bear weight on the leg, as this can be a sign of a ruptured tendon.