Achilles tendinitis and Achilles tendon injuries

Two different problems

Midportion tendinopathy affects the tendon a few centimeters above the heel. It is common in runners and in people who suddenly increase their activity, and the tendon can feel thickened and tender.^[2]

Insertional tendinopathy affects the point where the tendon attaches to the heel bone. It is often associated with a bony prominence at the back of the heel and can be aggravated by shoes that press there.^[1]

The difference matters, because the exercises and the other treatments that work best are not quite the same.

How we evaluate it

We examine the tendon along its length, check calf strength and ankle motion, and watch how you walk and rise onto your toes. Imaging is not always needed; X-ray and ultrasound at the practice help when the diagnosis is uncertain, when there may be a tear, or when a treatment plan depends on the tendon’s structure.^[3,2]

Treatment at the practice

• Loading exercise. Clinical practice guidelines for midportion Achilles tendinopathy are built around exercise-based therapy.^[3] The most familiar is eccentric heel-drop training: in the original study, recreational athletes whose pain had not settled with other care returned to running after 12 weeks.^[4] A heavy, slow resistance program worked just as well in a randomized trial, and people were more likely to stick with it.^[5] Our article on Achilles heel-drop exercises shows how.
• Training changes. Reducing hill work, speed sessions and sudden jumps in mileage while the tendon recovers, rather than stopping activity altogether.
• Heel lifts, shoe changes and orthotics to reduce pressure on an insertional tendon. See custom orthotics.
• Shockwave therapy. For insertional tendinopathy the evidence favors shockwave, alone or with eccentric exercise.^[7] For midportion tendinopathy its added benefit is less clear.^[8] See shockwave therapy.
• Injections, used cautiously. A Cochrane review found little evidence that injection therapies improve function for Achilles tendinopathy,^[9] and in placebo-controlled trials platelet-rich plasma did not improve pain or function.^[10,11] We explain those results honestly before you decide.

Surgery is considered only after about six months of well-run treatment without enough improvement.^[3,1]

Common questions

Should I stop running?

Usually not completely. Most people do best by cutting back to a level the tendon tolerates, dropping hills and speed work for a while, and building up again as the exercises take effect. We give you simple rules for how much discomfort during and after a run is acceptable, and what to do if the tendon is worse the next morning.

How long before it gets better?

Tendons adapt slowly. In the studies behind the exercise programs, people followed them for about 12 weeks.^[4,5] Surgery is considered only if about six months of well-run treatment hasn’t helped enough.^[3]

Can I have a cortisone shot in the tendon?

Injections aren’t a first choice here. A Cochrane review found little evidence that injection therapies improve function for Achilles tendinopathy,^[9] and exercise, load management and, where it fits, shockwave therapy are better-supported options.

Achilles tendon rupture

A rupture usually happens during a sudden push-off, in basketball, tennis, pickleball or a sprint. People often describe a pop or the feeling of being kicked in the back of the leg, then weakness pushing off.^[6] Both surgical repair and non-surgical treatment in a boot can work well. Surgery lowers the chance of a second rupture but carries a higher risk of other complications, and the difference is small when non-surgical care includes early rehabilitation.^[12]

When to seek care