Causes of Achilles Tendon Pain and Treatment Options

Everything you need to know about Achilles tendon pain

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The Achilles tendon is the largest tendon in the body. It connects the gastrocnemius (calf) muscle and the soleus muscle of the lower leg to the heel bone of the foot.

Tendons are very strong but not very flexible, and the Achilles tendon is no exception. This means that the Achilles tendon can only stretch so far before it becomes inflamed (known as tendonitis) or tears. This can cause discomfort, from a slight ache and stiffness to severe pain.

This article will help you understand what causes Achilles tendon pain and when to see a healthcare provider about it. It explains how the condition is diagnosed and some possible treatment options.

achilles tendon pain causes

Verywell / Alexandra Gordon

Causes

It's important to be familiar with the different conditions that affect the Achilles tendon. Many are common causes while others tend to be more rare. They each require specific attention and therapy, some more urgently than others.

Common

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. One is more acute, such as a sudden injury, and the other is more long-term.

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.

Pain is the most obvious symptom of Achilles 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 Achilles tendon may come with the pain. You also may feel a 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 fail to 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 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.

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

What's tricky is that some people have tendonitis without pain. They don't actually know there is a problem so they don't seek help for the Achilles tendon. It does not heal with proper care, which can allow it to progress into tendinosis.

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

Rare

An Achilles tendon rupture is rare. This happens when the tendon fibers tear and separate, either completely or in part. In unusual cases, a class of antibiotic drugs called fluoroquinolones has been associated with Achilles tendonitis and rupture.

Achilles Tendon Rupture

An Achilles tendon rupture can occur when a sudden force is exerted upon it. This often happens with sudden pivots of the foot, such as in strenuous forms of exercise, like 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. 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.

Recap

Tendonitis is inflammation that is more common in some sports, like tennis, or among those whose exercise routines lack safe gear and proper warmups. Tendinosis is tissue damage and scarring in the tendon due to long-term tendonitis. A tendon rupture is more rare and extremely painful. It means that tendon fibers have torn and separated, and likely require surgery to repair.

When to See a Healthcare Provider

It's important to seek out medical attention if you develop 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.

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 to look for injuries to the tendon. This usually will mean magnetic resonance imaging (MRI) or an ultrasound.

Physical Exam

A thorough physical exam of your foot and ankle can help determine what is behind your Achilles tendon pain.

Important elements of the exam include inspecting and pressing on 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 as the tendon 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. 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.

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. 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:

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.

Recap

A healthcare provider can determine the cause of your Achilles tendon pain. They will talk to you about your symptoms and medical history, and examine the affected foot and leg. They may order imaging tests and blood labs that help to identify a cause. A Thompson test may be needed to confirm an Achilles tendon rupture. The right diagnosis will help you to get the right care.

Treatment

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.

For a suspected Achilles tendon rupture, be sure to place ice immediately on the injury site. Keep your leg elevated while you're on the way to the emergency room.

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 do much the same thing. They 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 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 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

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 through surgery, a controlled ankle motion (CAM) boot 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.

Prevention

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.

Stretching

Stretching before you exercise will help you to avoid an Achilles tendon 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, 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 another health condition 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.

A Word From Verywell

Know that you are not alone if you or a loved one is experiencing Achilles tendon pain. It's a frustrating but quite common condition. The good news is that with proper treatment, the vast majority of people get better.

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Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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