Achilles Tendon Injuries
The Achilles tendon connects the calf muscles to the heel bone and is the thickest tendon in the body. It carries very high loads while walking, running and jumping. Two different problems occur in this tendon: tendinopathy, which develops over time, and rupture, which occurs suddenly. Their symptoms and treatment differ from one another.
What Does the Achilles Tendon Do?
The gastrocnemius and soleus muscles of the calf attach to the heel bone through the Achilles tendon. This tendon produces the movement that pushes the foot downwards (rising onto the toes). Loads of several times body weight pass through it when walking, and considerably more when running and jumping. The blood supply is relatively poor in the part of the tendon approaching the heel; this is where problems most often arise.
Achilles Tendinopathy (the Gradual Problem)
This is wear and structural change in the tendon tissue resulting from repeated loading. It used to be called “tendinitis”; however, because the tissue shows degeneration rather than marked inflammation, the term tendinopathy is preferred today. This distinction also changes treatment: because the problem is not simply inflammation, rest and painkillers alone are not enough.
Symptoms
- Pain and tenderness 2–6 cm above the heel
- Marked stiffness and pain on the first steps in the morning
- Pain that eases once warmed up and returns after activity
- A thickening or nodule felt in the tendon
- Difficulty rising onto the toes
Risk factors
- A sudden increase in training load (distance, speed or incline)
- Tightness of the calf muscles and restricted ankle movement
- Unsuitable footwear or a change of surface
- Differences in foot alignment
- Certain medications (fluoroquinolone antibiotics, corticosteroids) — be sure to say if you are taking these
- Diabetes, obesity and older age
Treatment
The cornerstone of treating Achilles tendinopathy is eccentric strengthening exercise — controlled “lowering” movements in which the muscle lengthens while contracting. For this programme to be effective it must be continued regularly for weeks; results should not be expected within a few days.
- Temporarily reducing the activity that triggers pain (not stopping it altogether)
- An eccentric calf strengthening programme
- Improving calf and ankle flexibility
- A heel raise or appropriate footwear support
- Load management: gradual adjustment of training volume
- In resistant cases, additional treatment options may be considered after medical assessment
Important: injection of corticosteroid into the Achilles tendon is generally not recommended, as it may increase the risk of rupture. Any decision about injection is made only after medical assessment and according to the site to be treated.
Achilles Tendon Rupture
This is most often seen in people aged roughly 30–50 who do not train regularly but occasionally take part in high-intensity activity — during sports involving sudden acceleration and jumping such as football, basketball and tennis. The classic description is distinctive: feeling as though someone kicked you from behind, hearing a “snap”, and then being unable to rise onto the toes.
Symptoms
- Sudden, sharp pain and a sense of something “giving way”
- Inability to rise onto the toes and loss of push-off strength
- Being able to walk on the heel but not normally
- A gap or depression felt along the line of the tendon
- Swelling and bruising
In partial ruptures, or where swelling is marked, the diagnosis can be missed. For this reason the Achilles tendon should be examined in detail in every patient presenting with this description.
Diagnosis
The diagnosis is usually made on examination; the absence of foot movement when the calf is squeezed (Thompson test) suggests a rupture. Where needed, ultrasound or MRI is used to assess the site of the rupture, whether it is complete or partial, and the gap between the ends.
Treatment options
Both surgical and non-surgical (functional cast/brace) treatment can be used for an Achilles rupture. Good results are reported with both approaches today, and the choice is made by assessing age, activity level, occupational and sporting goals, the pattern of the rupture, accompanying conditions and how soon treatment began.
- Non-surgical treatment: follow-up in a brace or cast, positioned with the foot pointing downwards and brought gradually to neutral. Early controlled weight-bearing protocols may be used.
- Surgical treatment: repair of the tendon ends with sutures, using open or minimally invasive techniques.
With either approach, adherence to the rehabilitation programme directly affects the outcome. Early, uncontrolled loading increases the risk of re-rupture.
The Recovery Process
Achilles healing is staged: protection → controlled movement → loading → strengthening → sport-specific work. The length of these stages varies with the individual, the treatment applied and the course of healing. Loss of calf muscle strength may persist for a time, so strengthening work is carried out over a long period.
Return to Sport
The decision to return to sport is made with measurable goals, not with the calendar. Time alone is not a sufficient criterion; returning early increases the risk of re-injury.
- Full, pain-free range of movement
- Muscle strength and endurance close to the uninjured side
- Regained balance and position sense (proprioception)
- Ability to perform sport-specific movements without pain and under control
- The athlete feeling ready — psychological readiness is also a criterion
These criteria are assessed by your physician and physiotherapist. Outcomes vary from person to person; no guarantee of a specific timeframe or result is given on this page.
When to Seek Medical Help Without Delay
- Being unable to bear any weight on the injured area, or unable to take a few steps
- Obvious deformity (a bone or joint appearing out of place)
- Rapidly developing, tense and painful swelling
- Bluish discolouration, paleness, coldness or increasing numbness in the fingers or toes
- Hearing a “snap/pop” followed by loss of strength
- Joint redness and warmth together with fever
- A sudden “snap” in the Achilles region followed by inability to rise onto the toes
- One-sided pain, swelling and tenderness in the calf (this may indicate a clot)
These findings require urgent assessment. Outside office hours, go to the nearest emergency department.
Frequently Asked Questions
My Achilles tendon has ruptured — must I have surgery?
No. Both surgical and non-surgical treatment can be used for an Achilles rupture, and good results are reported with both. The choice is made by assessing your age, activity level, the pattern of the rupture, how soon treatment began and any accompanying conditions. This decision is made together with your physician after examination.
I can walk on my heel, so it cannot be ruptured — is that right?
That is not a reliable test. Even with a completely ruptured Achilles tendon you may still be able to walk on your heel, because other surrounding muscles compensate. The distinguishing finding is being unable to rise onto the toes. If in doubt, be examined.
My Achilles pain is worst in the morning and eases during the day — is that normal?
Marked stiffness and pain on the first steps in the morning, easing as you warm up, is the typical description of Achilles tendinopathy. It should not be ignored because “it passes”; an exercise programme started early makes the process easier.
Is rest enough for tendinopathy?
Usually not. Complete rest may reduce pain temporarily, but it does not increase the load-bearing capacity of the tendon tissue, so symptoms return when activity resumes. The basis of treatment is gradual loading and eccentric strengthening exercise.
Can I have a corticosteroid injection into my Achilles tendon?
Injection of corticosteroid into the tendon is generally not recommended because it may increase the risk of rupture. Any decision about injection is made only after medical assessment, according to the site to be treated and the clinical situation.
Will I be able to do sport again after treatment?
Return to sport varies with the treatment applied, the course of healing and the demands of the discipline. The decision is made not by the calendar but by criteria: pain-free range of movement, regained calf strength and the ability to perform sport-specific movements safely.
Academic Work
Assoc. Prof. Bertan Cengiz, MD has scientific work published in national and international peer-reviewed journals in the field of Achilles tendon surgery and foot and ankle injuries and related areas. The publication list and verifiable academic sources are available on the Publications page.
Related Pages
The information on this page is for general guidance and does not replace an in-person medical examination. Diagnosis and treatment require a physician’s clinical assessment. Outcomes of any treatment or surgical intervention may vary from person to person; no guarantee of a specific result or timeframe is given on this page.