Achilles
Tendon Injuries

What is an Achillies tendon injury?

There are several different types of tendon injuries. For the Achilles tendon, the main types include: tendinopathy, describing pain and dysfunction of the tendon; Achilles tendon rupture, which involves complete disruption of the tendon; and overload of the gliding tissue over the tendon. There are also several bursa – sacs of fluid that allow gliding, bending and movement -which can become irritated in the area. Each of these conditions may require different treatment, and accurate diagnosis is important. This information will focus on Achilles tendinopathy.

Until recently, Achilles tendinopathy was referred to as Achilles tendinitis. However, the changes in the tendon are not the same as an ankle sprain or muscle strain, for example, where an inflammatory cycle occurs. Experts around the world agree the best term to use is tendinopathy, as the term tendinitis is inaccurate and may encourage people to seek passive treatments like rest, ice and anti-inflammatory medication – none of which are effective for Achilles tendinopathy.

Anatomy: The Achilles tendon is a large tendon at the back of the ankle. It is an extension of the gastrocnemius and soleus (calf muscles), running down the back of the lower leg and attaching to the calcaneus (heel bone). The Achilles tendon connects the leg muscles to the foot and enables push-off during walking and running. You can think of your Achilles tendon as acting like a spring. This is why Achilles tendinopathy can occur in a broad range of people, from the very active to the less active. Even as we age, we continue to use our Achilles tendon as a spring when walking downstairs, for example.

Risk factors

The biggest risk factor for Achilles tendinopathy is a sudden change in activity – for example, going from complete rest to starting a daily running program. Not everyone who changes their activity will develop tendinopathy; other factors contribute as well. We know very little about the risk factors that lead to Achilles tendon rupture, because most people who rupture their Achilles tendon didn’t have pain beforehand. They may have had structural changes in the tendon but usually no symptoms.

The best way to reduce risk is to have sufficient strength in your calf muscles for the activity you want to perform, and to gradually increase your loading. If you have other risk factors (such as diabetes), you should consult your health practitioner.

Less commonly, illness or medications – such as steroids or certain antibiotics – may weaken the tendon and contribute to ruptures.

Signs and symptoms

Achilles Tendinopathy

• Morning pain and stiffness that worsens if you were more active the day before.
• If you lifted weights (rather than performed spring-type loading), you are likely to feel better the next morning.
• Your tendon “warms up” – you may feel stiff or sore at first, but it improves with activity.
• If stiffness lasts longer than 30 minutes or pain does not improve with activity, consult a health care practitioner.

Achilles tendon rupture

The Achilles tendon can occasionally rupture completely. A complete rupture causes pain and sudden loss of strength and movement. The pain is often described as feeling like a hit or kick to the back of the leg. Consult a health care practitioner, who will arrange imaging and advise whether surgery may be required (it is not always necessary).

Management

The most important first step is accurate diagnosis. Conditions involving the sliding tissue around the tendon require completely different management to tendinopathy.

For tendinopathy, your immediate management can safely include isometric (static holds) and isotonic (through-range calf raises). Examples include:

• Standing calf raise holds: use a wall for balance and stay standing with your heels elevated on the balls of your feet (both feet if unable to do single-leg). For tendinopathy, this should be pain-free. Try 5 × 45-second holds.
• Calf raises: stand with a straight knee and raise your body up and down.

To help prevent tendon injuries:

• Participate in regular strengthening exercises. These may include endurance exercises such as standing calf raises, and strength exercises such as seated calf raises with weights or standing calf raises with weights.
• Gradually increase the intensity and duration of your activity. For example, if you are new to running, consider building a strength and endurance base for your calf muscles before starting. Progress to slow stair climbing up and down, and gradually increase the pace before running. This helps train your Achilles tendon to act like a spring, as it does during running. Another benefit of improving strength and confidence on stairs is that this remains highly functional as we age.
• Allow adequate recovery time between workouts or training sessions. For example, running every second day and doing calf strength exercises on alternate days allows the tendon time to settle and adapt. This also helps you gauge whether your tendon tolerated the previous session.

Note: If your tendon doesn’t “warm up” and gets worse the longer you are active, or if your morning stiffness lasts longer than 30 minutes, consult a health care practitioner. You may have another condition contributing to your pain.

A sports medicine professional should be consulted as soon as possible to determine the extent of the injury, provide treatment advice, and advise whether you need to modify your current activity.

One of the advantages of Achilles tendinopathy is that you can start isometric and isotonic calf raises immediately. Your morning pain and stiffness should begin to improve. A health practitioner can guide your graded return to activity.

There is no evidence to support the use of ice, crutches, medications or injections. Adjunct therapies can be costly and lack research support. Your health care practitioner can guide you.

Return to activity should be gradual and guided by your symptoms.

Resources

5 Things to Look for When Seeing a Health Professional for Achilles Tendon Pain
https://www.jospt.org/doi/10.2519/jospt.2023.9002
Journal of Orthopaedic & Sports Physical Therapy, January 1, 2024 Volume 54, Issue 1 Pages 96-96

How to Self-Manage Achilles Tendon Pain and When to See a Health Professional
https://www.jospt.org/doi/10.2519/jospt.2023.9001
Journal of Orthopaedic & Sports Physical Therapy, January 1, 2024 Volume 54, Issue 1 Pages 95-95