Pain in the Achilles

What is it? #

First we need to 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” 

• 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. 
• 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).
• 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).
• 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 an open heel or shoe with a 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 regularly with ice. Perform a gradual 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 with a Sport & Exercise Medicine Consultant for an ultrasound and Doppler examination to establish accurate diagnosis. Depending on localisation of pathology, different types of treatment are available. 

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.

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 tendon 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 regiments.

If it is tendinopathy alone and there is no partial rupture, then the heavy eccentric loading regiment is the first line of treatment.

If you experience a poor result after eccentric training, such as remaining pain on the inside (medial side) of the achilles, there might be suggestive of plantaris tendon involvement. We suggest a review in one of our 7 London based clinics for an accurate diagnosis and information about treatment.