The Achilles tendon goes down the back of your leg to your heel. It’s formed by three separate tendons drawing together, connecting your calf muscles to the heel bone. The Achilles tendon gives us strength pushing down, which is important for climbing stairs, jumping, and other similar activities.

Achilles tendonitis and Achilles tendinosis

Achilles tendonitis is an acute inflammation of your Achilles tendon, caused by an injury or a quick increase in activity. It starts over the course of a few days. Achilles tendinosis is a degeneration of the Achilles tendon and it happens over the course of weeks or months. Prolonged tendonitis may lead to tendinosis.

If you haven’t been active for a while and suddenly start to be active again, you may be at risk of Achilles tendonitis. Improperly warming up or failing to stretch can also be causes of Achilles tendonitis. If you’re active but haven’t been doing high impact activities and suddenly start doing box jumps, heavy squats, stair climbing, or other higher impact activities, you may also be at risk.

Symptoms of Achilles tendonitis and tendinosis

You’ll have pain in the back of your leg below the calf muscles, going all the way down towards the heel. The back of your leg will feel tight. You may have swelling on your leg, and difficulty with pushing off or with coming up on your tiptoes.

Prevention of Achilles tendonitis and tendinosis

Stretching and strengthening the muscles in your legs will help. When you’re stretching, do a slow, even stretch instead of bouncing. Make sure that you allow time to get warmed up before you start an activity. Most Achilles issues happen to people in their 30s, 40s and 50s who used to be active but are now less active due to their other responsibilities. They try to cram a lot of activity into a small amount of time and they often forget to do the necessary stretching and strengthening.

Cross-training is very important for preventing Achilles issues. When runners come to me with Achilles tendonitis, I recommend that instead of running five days a week they switch one or two of the runs out for riding a bike or swimming so that they can continue to run for longer.

Be aware of your environment when you have or are at risk of having Achilles tendonitis: avoid a lot of hills and stairs. If you’re having issues with your Achilles tendon going up and down, especially up, is going to make the pain and inflammation worse.

Improper shoe wear can contribute to Achilles tendonitis. Runners and other active people should change their shoes about every three months. If you wear your shoes to the point where the heel is worn and there is something hard in your shoe pressing against your Achilles tendon, it may irritate your Achilles tendon and lead it to becoming inflamed.

Slowly increase your exercise intensity. If you try to ramp up activity very quickly, you’re setting yourself up for injury.

Treatment for Achilles tendonitis and Achilles tendinosis

Most of the treatments for Achilles tendonitis can be easily accomplished.

  • Rest/immobilization, including possibly wearing a boot and using crutches if needed
  • Ice
  • Cross-training
  • Anti-inflammatory medications, such as ibuprofen, Aleve, or prescription medications
  • Physical therapy, focused on stretching and strengthening of the Achilles tendon as well as on the mechanics of your running, jumping, etc.
  • Dry needling, offered through our physical therapy department
  • Shockwave therapy, using a special machine to send waves through the affected area

Achilles tendon rupture

The Achilles tendon is one of the most common tendons ruptured in the human body. There’s a place on the Achilles tendon about four to six centimeters from where it attaches to the heel where it has a very low blood supply, and it’s where most Achilles tendon ruptures occur.

Risk factors for Achilles tendon rupture

As with Achilles tendonitis, someone who is in their 30s or 40s who is intermittently trying to push themselves with activity they don’t regularly participate in is at risk for an Achilles tendon rupture. Men are at more risk than women. People who are taking certain antibiotics called fluoroquinolones, which includes the common medications Cipro or Levaquin, are at increased risk, as are people who have had steroid injections. If you’re taking medication, ask your doctor if it may cause a change in the types of recommended exercise you do while on the medication.

Symptoms of Achilles tendon ruptures

Achilles tendon ruptures are almost always associated with the sensation of a large pop, often accompanied by a loud sound. The rupture usually occurs when the person tries to push off strongly. For example, if they’re playing basketball, they’re going up for a rebound. The person will feel and hear a large pop and it may feel like someone hit them in the back of the leg with a rock. It is usually a non-contact injury.

If you’re looking at the leg of someone who has had an Achilles tendon rupture compared with the leg of someone who has not, their foot is at a different angle and squeezing their leg does not move their foot.

Treating an Achilles tendon rupture

If you suspect you’ve had an Achilles tendon rupture, see a doctor as soon as possible. Don’t wait for an MRI, as it can cause a delay in treatment and mean that different treatments are needed.

Achilles tendon ruptures may be treated with or without surgery. In the early to mid 2000s, additional research was done on a treatment called accelerated rehabilitation. Instead of a prolonged period of casting, it’s a shorter period of immobilization and very intensive physical therapy while the Achilles tendon strength is closely monitored and the range of motion is slowly increased.

The patient starts in a boot with a very high wedge, almost like you’re walking on an high-heeled shoe. Over time, the wedge is brought down so your foot becomes closer and closer to flat. With accelerated rehabilitation protocols, patients have excellent results, almost as good or as good as having surgery for their Achilles tendon rupture. However, there are several caveats.

Patients who wait over 24 hours to receive care for their Achilles tendon rupture are not candidates for accelerated rehabilitation and need to have surgery. Other reasons to have surgery include if the two ends of the tendon are not near each other, if the tendon ruptures where it is attached to the heel, or if you’re not able to go to physical therapy two to three times a week for the accelerated rehabilitation program.

The great thing about accelerated rehabilitation is that there are no risks of surgical complications.

While surgeries with open repairs and large incisions were used in the past, now Achilles tendon ruptures are done using a minimally invasive approach and a small incision. An instrument is used to grab the Achilles tendon and place sutures through the tendon on one side and then the other side. The tendon is pulled out of the incision and the two ends are attached together before the incision is closed.

By using a minimally invasive approach, which is what I use for my Achilles tendon repairs, wound healing complications are reduced because the wound is smaller.

If you need surgery for an Achilles tendon rupture, we schedule surgery for as soon as possible; less than a week after injury is ideal. The sooner the surgery the easier it is to return to normal movement.

Rehabilitation after the surgery is similar to the non-operative accelerated rehabilitation treatment. For the first two weeks, you won’t put any weight on that foot, followed by four weeks of partial weight bearing and increasing the weight on your foot. After six weeks you’re able to put your weight on it while wearing a boot with a heel lift, which starts out with a high wedge and gradually lowers down until your foot is flat.

Unfortunately, this injury has a long recovery, even for professional athletes. It takes about a full year for someone to recover after an Achilles tendon rupture. You’re able to walk normally or drive a car before then, but you won’t have your full level of function. An Achilles tendon rupture usually occurs for people who are playing sports and trying to be active, and getting back to the same level of activity takes time.

Frequently Asked Questions

Does being properly fitted for running shoes help Achilles tendonitis? Should I get stiff or flexible shoes?

Being properly fitted may or may not help. The problem in Achilles tendonitis is often starting above the shoe itself, so unless you’re wearing a high-top shoe that is controlling your ankle motion, you may not be affecting the Achilles tendonitis much by your shoe choice. However, if your shoes have a very tight heel, a running store may be able to help you get a shoe that fits better and reduces the irritation caused by the tight heel panel.

Stiff or flexible soles do not have an impact on tendonitis. A softer heel will lead to less tendonitis, but the running surface is more important. Stairs and inclines are more of a trigger for Achilles tendonitis than the specific shoes.

Does platelet-rich plasma (PRP) help with Achilles tendonitis?

PRP is a newer therapy where we draw your own blood, spin it in a centrifuge to concentrate some of the normal healing factors, and inject it back into you to help with specific conditions. While PRP has been studied for other conditions, it has not been well-studied for Achilles tendonitis or tendinosis so I do not recommend it for these conditions.

Do orthotics help with tendonitis?

Orthotics may help with certain tendonitis issues. A heel cup, which pads the end of the Achilles tendon right where it inserts into the heel and lifts the heel slightly to take some of the tension off the tendon, is helpful.

How serious is Achilles tendonitis, and does it mean that you’re more likely to have a rupture?

There is a large variance in how severe Achilles tendonitis may be. Some people have very mild symptoms where it is only symptomatic when they are extremely active, while other people are almost debilitated by the amount of pain they have from it, even with simple actions such as standing and walking. The treatment is varied and tailored to each individual patient depending on the amount of symptoms that you have.

However, having Achilles tendonitis does not mean that you are going to have an Achilles tendon rupture. If you have long-standing Achilles tendonitis and it develops into tendinosis, where you have thickening and degeneration of the tendon, you may be more likely to have a rupture but we do not have proof at this time.

Would a nighttime brace help an Achilles tendon heal?

Nighttime braces are often used for plantar fasciitis to stretch the plantar fascia throughout the night, but you may also use it for Achilles tendonitis. It’s a very reasonable extra treatment to the other treatments I have mentioned. It may not give you complete relief by itself, but it’s worth trying because stretching the plantar fascia also stretches the Achilles tendon.