Pain in the Achilles

Tendon Specialist, Professor Hakan Alfredson explains different types of Achilles Tendon pain and how to manage it.

What is it? 

First localise the pain: is it in the tendon-bone insertion? Or is it a couple of centimeters up in the tendon (in the mid-portion).

“Pain in the Achilles tendon-bone insertion” 

  1. Pain can come from the superficial bursa (“friction bumper”). Pain  is often made worse by tight-fitting shoes. There is often swelling, tenderness and a  burning sensation on the heel. 
  2. Pain can arise from a sharp bone edge or loose peace of bone in the posterior aspect of the heel. This pathology uses produces more localised sharp pain when loading (brisk walk, running, jumping).
  3. Pain can arise from the deep bursa (retro-calcaneal) and usually presents as swelling and tenderness anterior to the distal Achilles (in the angle between the Achilles and the heel bone).
  4. Pain can arise from the distal Achilles tendon and presents as thickening of the tendon (tendinopathy) and worsened by activity but usually the day after.

“There is Often a combination of bursa, bone and tendon pathology”

What can I do?

First try to off-load the bursa by using shoe with open heel or shoe with comfortable back. Try to off-load the tendon and deep bursa by using a 1 cm heel lift in the shoe. Treat the local area with regular  ice. Perform a graduated loading program for your Achilles tendon using calf raises starting from floor level (not on a step).

If pain persists after  4-6 weeks, we suggest a review at the tendon clinic for an  ultrasound and Doppler examination to establish accurate diagnosis. Depending on localisation of pathology,  different types of treatment are indicated. 

What shouldn't I do?

Don´t get a cortisone injection as it destroys tissue and can harm the Achilles tendon. 

“Pain higher up in the Achilles” 

Pain in the mid-portion is likely from tendinopathy. It presents as pain after activity (walking and running)  and  local swelling and tenderness on the deep (anterior) side of the tendon. 

If  pain on the inside (medial side) of the Achilles,  it may come from the plantaris tendon.
Sometimes there is a combination of tendinopathy in the Achilles and plantaris tendon involvement.

What can I do?

Could it be a rupture? 

In young and middle-aged individuals who have  gradual onset of pain,  rupture is rare. However, in older individuals, partial rupture may commence with gradual onset of pain. We suggest a review at the tendinopathy clinic for  an ultrasound and Doppler examination to get an accurate diagnosis. If there is a partial rupture, the  tendon should be off-loaded and not subjected to heavy loading regimens. 

If tendinopathy alone and no partial rupture, then the heavy eccentric loading regimen is the first line of treatment (see link).

If poor result after  eccentric training, sometimes remaining pain on the inside (medial side) of the Achilles, there might be suggestive of  plantaris tendon involvement. We suggest a review at the tendinopathy clinic for an accurate diagnosis and information about treatment.

What shouldn't I do?

Again, don't get a cortisone injection. This destroys tissue and can harm the Achilles.