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Ankle Pain

Achilles Tendinitis: Achilles Tendon Pain

Minute Read


Posted 1 year ago


Last updated: 03/12/2022


by James McCormack

Where is the Achilles Tendon?

The Achilles Tendon is a long fibrous band of tissue that attaches the calf muscle group (Soleus muscle and Gastrocnemius muscle) to the heel bone. Like all tendons, they work as a spring. It absorbs force when walking, running, or hopping to propel you forward. It is the strongest tendon in the human body, but it is common to get Tendinitis due to the amount we use it during daily activities.

The Achilles Tendon sits at the back of your lower leg. The long thick structure at the back of your heel bone reaches up towards your calf muscle. It attaches to the calf muscle at the musculotendinous junction.

The musculotendinous junction is a common injury site, but fortunately, it quickly has a relatively high blood supply and heels. As you move down towards the heel bone, there is less blood supply, leading to slower healing times.

Achilles Tendon Problems diagram

What causes Achilles Tendon Pain?

Achilles Tendinopathy often occurs from overuse. It is frequently seen in sports such as running, basketball, tennis, and track and field as they place a lot of stress on your tendons. The risk of tendon pain is ten times more common in runners than in those who do not do running-based sports, but there remains a high prevalence in the general public. Several risk factors include:

  • A history of lower limb injuries
  • Calf Muscle Weakness
  • Change in activity levels
  • Changes in the training environment such as introducing hill training, hard surfaces, or change in footwear
  • Altered Biomechanics
  • Moderate Alcohol Use
  • Antibiotics use such as fluoroquinolone
  • Medical Conditions such as psoriasis or high blood pressure

Achilles Tendon Pain: Differential Diagnosis

Numerous issues can cause Achilles tendon pain, and below we cover the most common symptoms for each. There is some debate regarding the level of inflammation in tendon pain issues. As a result, the term Achilles Tendinitis while still prevalent in the USA is more commonly referred to in the UK as Achilles Tendinopathy. As a result, we will use them interchangeably throughout the article.

Acute Achilles Tendonitis

It is common to have Achilles Tendon pain when walking with this injury. A sudden increase in activity levels typically causes this phase. It can result in an inflamed tendon that gives acute pain and swelling along the entire length of the tendon and often involves the paratenon.

Mid-portion Achilles Tendinitis

This is often seen in the subacute phase of tendinopathy, where the pain is isolated to the middle of the Achilles Tendon only. It is common to have a sore Achilles Tendon in the morning, but your range of motion and pain should improve within 20 minutes.

Insertional Achilles Tendinitis

Insertional Achilles Tendon pain is when pain is located where the tendon attaches to the heel bone with no pain higher up the tendon. It is common to have a sore tendon in the morning with an insertional Achilles tendinitis.

Achilles Tendon Tear

A torn Achilles Tendon differs from Achilles Tendinopathy in that it typically has a sudden onset of pain that causes a partial tear of Achilles fibres. Someone may feel a sudden, sharp pain anywhere along the tendon when doing an activity.

Achilles Tendon Rupture

An Achilles rupture is a complete tear of the fibres of the tendon. People often hear an audible pop or crack, describing the sensation of being kicked or hit with a small ball on their tendon.

Pain on Palpation of the Achilles Tendon

Clinical examination by a medical professional involves palpating the tendon 2-6cm above the heel bone. If there is pain, then the test is positive.

Arc Sign

A Therapist will palpate along the tendon to identify a painful lump on the tendon. The tester pinches the lump and asks the patient to pump their foot up and down. If the examiner feels the nodule moving, then this is a positive test.

Achilles Tendon Pinch Test

The examiner applies the Achilles tendon pinch test to identify the most painful location of pain along the tendon. The patient dorsiflexes their foot and the examiner pinches the same location. If there is less pain, then the test is positive.

Picture of an achilles tendon examination

Achilles Tendon Rupture Test

Thompson Test

The patient lies on their front with their foot relaxed and over the edge of a bed. The examiner squeezes their calf muscle, and if their foot doesn’t plantarflex, this is a positive test for a Tendon Rupture.

Achilles Tendonitis Radiography Tests

MRI and ultrasound scans are the most accurate scans for establishing the diagnosis of Achilles tendon pain. They are helpful for identifying thickening and inflammation within the tendon and paratenon.

An Ultrasound is usually the first option as it is cheaper and can be carried out in the clinic as part of an assessment.

X-rays are not used for Achilles Tendinitis are they can only detect bony injuries.

Picture of Ultrasound Achilles Paratenonitis

Achilles Tendonitis Treatment

Strengthening Exercises are the single most effective form of treatment for Achilles Tendinitis. There are two evidence-based rehabilitation protocols for Achilles Tendonitis: The Alfredson Protocol and the Heavy Slow Resistance Protocol.

Physical Therapy

Exercise Modification to reduce the amount of stress going through your Achilles tendon by reducing your daily step count and time on your feet

Heel raises inside your shoes shortens your Achilles Tendon to provide pain relief

Insoles for Achilles Tendonitis: There is moderately good evidence that insoles can reduce pain levels and facilitate rehabilitation by providing additional Achilles Tendon Support.

Achilles Tendon Taping such as KT Tape is quite common in clinical practice. There is little evidence to indicate its effectiveness

Achilles Tendon Stretches for your calf muscles with a knee-to-wall stretch can elongate the calf muscle and provide short-term pain relief

An aircast walking boot may be advised if your Achilles Tendon is too painful to walk on.

Home Treatment

Home Treatment for Achilles Tendinitis can provide short-term pain relief but is beneficial if you don’t have access to a Physical Therapist.

Icing the tendon for 10-15 minutes until the area is numb can provide pain relief

Anti-inflammatory gel reduces pain levels and inflammation within the tendon

Wearing a heeled boot or trainer take pressure of the Achilles Tendon

Achilles Tendonitis brace or night splint can help reduce morning pain and stiffness.

Other Treatment Options

GTN Patches

GTN patches can be applied directly to the Achilles tendon and have been clinically shown to reduce Achilles Tendon Pain levels allowing you to stay physically active and improve outcomes from Achilles Tendon Strengthening Exercises.


Some injections can be helpful such as PRP. Steroid injections can help to reduce pain levels in Tendinopathy but there is growing evidence that it can cause medium-term harm to the tendon.

Achilles Tendon Surgery

There are very few instances where surgery is required for Achilles tendinopathy. In rare instances, there can be Plantaris tendon issues contributing to Achilles Tendon pain and in this instance, surgery could be beneficial.

Physiotherapy with James McCormack

This is not medical advice. We recommend a consultation with a medical professional such as James McCormack. He offers Online Physiotherapy Appointments for £45.

Related Article: Achilles Tendonitis Exercises 

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