Achilles Tendon Pain: Symptoms, Causes, and Treatments

Achilles tendon pain stems from the fact that, like all tendons, the Achilles tendon is strong, but not very flexible. The Achilles tendon connects muscles in your calf and lower leg to your heel bone, and it can only stretch so far. When it goes beyond its limits, it becomes inflamed (tendonitis) or tears (rupture).

Stress or injury to the Achilles tendon can cause discomfort that can range from a slight ache and stiffness to severe Achilles tendon pain.

In this article, you'll learn more about Achilles tendonitis, tendinosis, and rupture and how they can cause Achilles tendon pain. You'll also leave this article knowing when to see a healthcare provider, how they will diagnose you, and how Achilles tendon pain can be treated.

Causes of Achilles Tendon Pain

The two most common causes of Achilles tendon pain are Achilles tendonitis and Achilles tendinosis. While these conditions sound similar, they describe two different problems.

Though rare, an Achilles tendon rupture can also be the cause of this type of pain.

Achilles Tendonitis

Achilles tendonitis is an inflammatory injury of the Achilles tendon. It most commonly affects athletes, particularly runners, and people who play sports like tennis that require lots of starts, stops, and turns.

Achilles tendon pain is the most obvious symptom of this form of tendonitis. It is often described as a burning that gets worse with activity. The exact site of the pain may vary. It can be felt closer to the bottom of the calf muscle, along the actual tendon, or lower down near the heel bone.

Mild swelling and warmth over the affected area may come with Achilles tendon pain. You also may feel stiffness in the morning at both the heel and calf. It typically eases as you warm up and stretch your ankle and leg.

This condition also can happen when people don't warm up the calf muscles before exercising, or suddenly increase how much exercise they are doing overall. The tighter the calf muscles, the more tension that's placed on the Achilles tendon.

Exercising in worn-out sneakers, or in shoes that aren't designed for the activity, also can cause Achilles tendonitis.

Other factors that may be triggers include:

• Cold weather training
• Misaligned feet or flat fleet
• Poor running form
• Leg length differences

Sometimes, Achilles tendonitis is caused when a bony growth develops on the heel or calcaneus bone, which is at the back of the ankle. This may be a bone spur from arthritis. It also may be a Haglund's deformity that comes from wearing ill-fitting shoes. The growth may rub on the Achilles and cause pain and inflammation. And putting pressure from laying down on the bed on the back of the heel can hurt.

Obesity puts pressure on the lower body, which can cause Achilles tendon pain. Other medical conditions, such as psoriasis and high blood pressure, also have been linked to a higher risk of Achilles tendonitis.

Achilles Tendinosis

Achilles tendinosis describes a chronic (long-term) tendon condition. It results from untreated tendonitis. With tendinosis, the collagen fibers that make up the tendon break down.

This degenerative damage causes Achilles tendon pain too. It also causes scar tissue to form, which may lead to permanent thickening.

Achilles Tendon Rupture

An Achilles tendon rupture happens when the tendon fibers tear and separate, either completely or in part. This can occur when a sudden force is exerted upon the tendon, which often happens with sudden pivots of the foot (e.g., when playing basketball). Even a sudden step off a curb or a simple trip can sometimes be enough to overstretch and tear the tendon.

When the Achilles does rupture, some people hear a "pop" or "snap" along with severe heel pain. This is so common, that many people feel as if someone kicked them in the back of the heel and they turn around to find that no one is behind them.

There may be a visible gap where the tendon is torn. Usually, with a tendon rupture, a person cannot walk or bear weight on their foot, although a small subset of people still can.

Achilles tendon ruptures are rare. In unusual cases, a class of antibiotic drugs called fluoroquinolones has been associated with Achilles tendonitis and rupture.

Symptoms of an Injured Achilles Tendon

The pain caused by Achilles tendonitis and Achilles tendinosis is similar, but there is one key difference between the two: Achilles tendonitis causes inflammation in the tendon whereas Achilles tendinosis does not.

If you have Achilles tendonitis, you may experience pain or burning, in addition to warmth, redness, and swelling in and around the tendon itself. If you have Achilles tendinosis, you may also experience pain or burning in the tendon area, but without warmth, redness, and swelling.

In general, signs you may have injured your Achilles tendon include:

• Achilles tendon pain
• Pain down the back of your leg
• Pain near your heel
• A stiff, sore Achilles tendon when you first wake up
• Achilles tendon pain after exercising
• Achilles tendon pain that worsens throughout the day
• Thickening of your tendon
• Bone spurs on your heel bone
• Difficulty flexing your foot and impaired range of motion
• Sharp pain and a pop sound if the Achilles tendon ruptures

When to See a Healthcare Provider

It's important to seek out medical attention if you develop Achilles tendon pain. This may be pain in the back of your leg, anywhere from your heel to your calf.

Other symptoms that warrant a healthcare provider visit include:

• Leg or ankle stiffness or soreness
• Swelling over the Achilles tendon
• Difficulty standing on your tiptoes
• Signs of an infection, like redness or warmth at the site

Some symptoms suggest a possible Achilles tendon rupture. They include sudden, severe pain at the back of the leg and/or trouble bearing weight on it. If that's the case, seek immediate medical care.

Reaching a Diagnosis

A medical history and physical exam are needed to diagnose Achilles tendon pain. Your healthcare provider will also ask you questions about your symptoms.

They may order imaging tests. An X-ray may be ordered to examine the bones. And injuries to the tendon can be identified with magnetic resonance imaging (MRI) or an ultrasound.

Physical Exam

A thorough physical exam of your foot and ankle can help determine the cause of your Achilles tendon pain.

Important elements of the exam include inspecting and pressing the area around the Achilles tendon. This is done to check for swelling, warmth, and tenderness. There may also be crepitus, a popping sound, or feeling the tendon as it moves.

With Achilles tendinosis, there is pain when the site is touched. The tendon may feel thick, or there may be small bumps along it that signify fibrosis and scar tissue.

A healthcare provider can sometimes diagnose an Achilles tendon rupture by feeling the tendon because there may be a gap. Another clue for an Achilles rupture is bruising over the tendon. This is especially true if the blood extends beneath the malleolus, the bone that sticks out on each ankle.

Specific testing techniques can help identify Achilles tendon weakness or rupture.

Matles Test

During this test, you lie belly down on a table and your provider moves your knee to 90 degrees. If your Achilles tendon is intact, your toes will point up, but if your Achilles tendon is ruptured, your toes would point downward.

Thompson Test

As part of the exam for Achilles tendon pain, your healthcare provider will perform the Thompson test. This also is called the calf squeeze test. During this test, a person lies flat on the exam table with their feet hanging over the edge.

The healthcare provider will then squeeze on the calf muscle, which should flex the toes downward. This is called plantar flexion. If it does not occur, the test is positive for an Achilles tendon rupture.

Imaging

Imaging for chronic Achilles tendon symptoms usually is done with an X-ray of the foot. This will help to identify any issues like bone spurs or degenerative damage, and it can identify a fracture. An ultrasound or an MRI is used to make or confirm a diagnosis of an Achilles tendon rupture.

Differential Diagnoses

When you see a healthcare provider for Achilles tendon pain, they will consider several other conditions. Some of the more common ones are an ankle sprain, stress fracture, or calcaneus (heel) bursitis.

Bruising at the Achilles tendon can happen with an ankle sprain or a stress fracture, as well as an Achilles tendon rupture. An X-ray is needed to see the differences among the possible causes.

With heel bursitis, the site where the tendon inserts into the heel bone is usually tender. On the other hand, with Achilles tendonitis, the tendon pain is usually higher up—about 2 to 6 centimeters above the insertion site.

Other conditions to consider may include:

• Osteoarthritis
• Inflammatory arthritis (for example, rheumatoid arthritis or gout)
• Fibromyalgia
• Blood clot in the calf (called deep venous thrombosis)
• Infection (for example, osteomyelitis or cellulitis)
• Bone cyst or cancer (rare)

In the above cases, blood tests or imaging tests may be used along with a thorough physical exam. For example, a Doppler ultrasound can rule out a blood clot in the calf, and an X-ray can reveal osteoarthritis changes in the ankle.

With rheumatoid arthritis (RA), a person will usually have an elevated anti-cyclic citrullinated peptide (anti-CCP) blood level. This test looks for an antibody that is very specific for RA. It goes along with other symptoms of RA like fatigue and joint pain.

Blood tests may help if a healthcare provider is worried about an infection in the heel bone or in the skin near the tendon. An elevated white blood cell count and other tests can confirm signs of infection and inflammation.

Treatment for Achilles Tendon Pain

There are quite a few ways to treat Achilles tendon pain. They include changes in your activity level, physical therapy sessions, medication, and surgery. The key to healing and recovery is to stay on top of your care and follow your treatment plan from start to finish.

Self-Care

Self-care strategies can be used to treat Achilles tendonitis. They also may help in the immediate care of a possible Achilles tendon rupture.

Reduce Activity or Rest

It is not necessary to stop all activity if you are diagnosed with Achilles tendonitis. You do, however, need to make changes in response to muscle soreness. Be sure to do gentle calf stretches after exercise, when the muscle and tendon are still warm and flexible.

Rest is not optional for initial care of an Achilles rupture, though. You must stop activity until you have further guidance from your healthcare provider or an orthopedic surgeon.

Ice

For Achilles tendonitis, applying ice when the pain begins may help. You also may think about icing the tendon after exercise.

Support

Using ice and resting may help, but you also want to keep your tendon from moving around too much. Wrap your ankle with an elastic bandage or tape if you have Achilles tendonitis.

For a tendon rupture, an orthopedic surgeon will use a splint or other method to immobilize your ankle until you have surgery for the tendon rupture.

Orthotics

For both tendonitis and tendinosis, shoe orthotics can be used. They are meant to correct foot misalignments, such as flat feet, that may contribute to your tendon injury. For anyone with either tendonitis or tendinosis, heel lift orthotics can reduce stress on the tendon and ease the pain.

Medication

To reduce the pain from any Achilles tendon problem, talk to your healthcare provider about taking a nonsteroidal anti-inflammatory drug (NSAID). You also should know that corticosteroid injections are not recommended for Achilles tendon pain.

Physical Therapy for the Achilles Tendon

For Achilles tendonitis, it's a good idea to begin exercises that strengthen the calf muscle as soon as your healthcare provider thinks you're ready. Toe raises, balancing on your toes, and wall stretching are useful exercises.

Eccentric strength training, which works to lengthen muscles, is a popular and helpful therapy option. So is deep friction massage of the muscles that attach to the Achilles tendon.

For Achilles tendinosis, you may need a special rehabilitation program. It's important to talk with your healthcare provider about programs that focus on slow, progressive, heavy-load exercise.

Instrument-assisted soft tissue mobilization (IASTM) is sometimes used to treat Achilles tendinosis. IASTM works by using an instrument to stimulate the body's inflammatory response. This prompts the body to produce new collagen protein to strengthen the tendon.

Surgery may be needed for an Achilles tendon rupture. After surgery, physical therapy is critical for a full recovery, which can take three to six months.

Surgery for Ruptured Achilles Tendon

An Achilles tendon rupture may need surgical repair within days of the injury. An orthopedic surgeon will suture (stitch) the two ends of the tendon back together.

Keep in mind that a partial tendon tear is sometimes treated like Achilles tendinosis. This may depend on your age, medical history, your normal level of activity, and how severe the tear is.

Partial tendon tears tend to be especially painful. If the tear is not treated with surgery, a controlled ankle motion (CAM) boot with a hell lift may be recommended. It will be used along with physical therapy or home exercises to prevent loss of muscle strength in the foot and ankle.

Preventing Achilles Tendon Pain and Injury

People tend to ignore early warning signs and push through the pain. If your Achilles tendon is sore or aches, you need to pay attention and rest it immediately.

Prevention is possible if you try some of these strategies. For example, night splints as recommended by your provider can help if you have Achilles tendonitis.

Stretching

Stretching before you exercise will help you to avoid Achilles tendon pain and injury. Some basic stretches include:

• Achilles tendon stretch
• Calf stretch
• Plantar fascia stretch (Flexibility in the bottom of the foot can help with Achilles tendon health.)

Besides stretching, be sure you begin to exercise slowly. A proper warm-up will help you to safely ramp up the pace of your activity.

Strengthening

Some experts think that eccentric training can help. It may strengthen the Achilles tendon, as well as the muscles it connects (the gastrocnemius and soleus muscles).

This may reduce the risk of Achilles tendonitis and calf strain.

Other tips that may help to prevent an Achilles tendon injury include:

• Always wear shoes that provide adequate cushioning for your heel and good arch support
• Avoid running on hard surfaces
• Avoid exercising outside in cold weather
  

Summary

It can be hard to know what's causing your Achilles tendon pain. A sudden injury may mean tendonitis, which can respond well to self-care measures at home. Tendonitis, though, also may be related to health conditions like obesity or arthritis.

If it's not treated, you may develop the more serious and chronic condition of Achilles tendinosis. This degenerative condition can cause permanent changes. People with tendinosis may need a special rehabilitation program. They also may need to use different shoes or make other lifestyle changes.

The sudden, severe pain of an Achilles tendon rupture requires immediate medical attention. A healthcare provider is likely to recommend surgery to repair the rupture as soon as possible. For any Achilles tendon pain, though, it's a good idea to speak to a professional so that you can get the right diagnosis and treatment before the condition gets worse.