Achilles tendonitis (also spelled tendinitis, no difference in meaning) is debilitating. You will experience heel pain when you walk, especially uphill, run, climb stairs or if your shoes rub on your injured Achilles through the day. Achilles tendonitis refers to the inflammation of the Achilles tendon when injured.  Achilles tendinopathy describes the pathology when tendinitis is neglected and becomes chronic. This article explains the pathology of Achilles tendon pain, the difference between Achilles tendonitis and tendinopathy and the treatment that you can expect at Cilliers & Swart Physiotherapy to recover from your Achilles injury.

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Are you experiencing pain at the back of your heel, when you’re walking up a hill or at the start of your jog? Each person’s case is unique, and we want to address your specific needs. If you would like us to investigate your Achilles tendon injury, contact us by clicking on the link below.

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Anatomy of the Achilles Tendon

Your calf is made up of two muscles (the Gastrocnemius and Soleus muscles) which join at your heel. These muscles are anchored and connected to your heel bone through the Achilles Tendon (tendon attaches muscles to bones in our bodies). The Achilles Tendon is named after the great greek hero, Achilles, who was dipped in the Styx river by his mother, Thetis, for protection. She held him on the heel and therefor he had a weak spot. This weak spot later caused his death, when he was shot trough the tendon by Paris in the Trojan War, giving the term Achille’s Heel it’s meaning.

What does the Achilles tendon do?

The Achilles tendon connects your calf muscles to your heel bone. When your calf muscles contract (shortens), the muscles pull on the Achilles tendon. When this happens, the Achilles tendon then pulls on your heel to make your toes point – like a ballet dancer. This muscle-tendon-heel bone pulling happens when standing on your toes and raising your heels off the ground.

The opposite action, for example pulling your toes towards your shin, will stretch (lengthen) your calf muscles because the heel bone is pulling on the Achilles tendon in the opposite direction. This also happens when you do heel drops (dropping your heel past the edge of a step while the rest of your foot remains on the step).

The Achilles tendon is essential for all ankle movements – specifically in pushing off or controlling your landing onto surfaces. Examples of pushing off movements include the push off phase when walking or running, pushing off the ground when standing on your toes, pushing harder off a surface to gather speed and in jumping. Opposite examples include your Achilles tendon absorbing the force of landing from a jump or exercising control when walking down an incline.

When your heel pains, it could mean that your Achilles tendon is starting to disintegrate from excessive tension. When this happens, we refer to it as Achilles Tendinitis or Achilles Tendonitis.

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What causes Achilles Tendonitis?

Achilles Tendonitis describes the wearing out and injuring of your Achilles tendon. Wearing out this tendon involves repetitive pulling on the tendon (referred to as ‘overuse’ e.g. jumping into the air) or putting the tendon under excessive force (referred to as ‘overload’ e.g. landing on hard surface from a jump).

Your Achilles tendons must be able to withstand the pulling from the calf muscles or push (of a force) from the heel. The tendon is elastic, meaning it can stretch and recoil. To illustrate using an example: Imagine a bungee cord with no elasticity. When the person at the end of the rope falls the lack of elasticity means the rope won’t recoil. This means that the cord might snap, because of the sudden jerk (force) without the ability to absorb the shock. The same principle applies in Achilles tendinitis. If a sudden force is placed on the tendon, when it is unable to absorb shock or recoil, it gets injured, “frizzles out” or worst case scenario snaps (Achilles tendon tear/rupture).

Note: Achilles tendon tears are explained in a different article.

Factors that contribute to Achilles Tendonitis:

  • A sudden increase in force
    eg. the pushing off the ground in the moment just before an athlete jumps over the pole in high jump
  • Running further and faster
    eg. sprinting the last 100 m of a 10 km race
  • A change in your activity
    eg. suddenly changing direction or speed while ballroom dancing
  • The surfaces on which you exercise
    eg. jumping and landing on hardwood floors vs. concrete floors
  • The shoes you wear when walking or running (exercising)
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Why is my heel pain not going away?

You can create a cycle of damage if you constantly overload or overuse the tendon before it heals. An overused or overloaded Achilles tendon causes pain, inflammation or disintegration of the tendon. It takes a long time to recover from this type of injury, which means early diagnosis is very important. In most cases (at Cilliers & Swart Physiotherapy), our patients make a full recovery.

Achilles tendonitis vs tendinopathy?

Tendonitis, when not treated correctly, can develop into tendinopathy. Tendinopathy causes more damage to the Achilles tendon. With continued loading, the tendon will become progressively more painful. The list below outlines the structural changes of the tendon over time and helps us determine which stage the tendon is in.

Stages of a tendinopathy:

  1. Reactive tendinopathy
  2. Tendon disrepair
  3. Degenerative tendinopathy

Two different areas where Achilles tendinopathy can develop

Insertional Achilles tendinopathy

Pain located at the base of your heel, where the Achilles tendon anchors its fibers to your heel bone.

Mid portion Achilles tendinopathy

Anywhere along the Achilles tendon that is more than 4 centimeters above the heel (before the Achilles and calf muscles connect). Pain in this area can be experienced on any side of the tendon e.g. inside border, outside border or middle/belly.

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Achilles Tenosynovitis

Inflammation in the sheath covering the Achilles Tendon will cause pain and swelling. The swelling along the sheath prevents the usual movement of the tendon, because there is “less space” for the tendon to slide along the sheath. With the narrowing of the sheath and loss of movement, the tendon becomes semi solid (a form of cellular death). Repetitive overloading of the tendon leads to this fibrous tissue forming.

Symptoms of Achilles Tendonitis

  • Pain behind the ankle.
  • Pain builds gradually over time, but is worst when taking your first step in the morning.
  • A dull ache in your ankle at the beginning of an activity, followed by a sharp or intense pain at the peak of the activity. Afterwards the pain lingers, and your heel feels tight or stiff after the activity or the next morning.
  • Stabbing pain in your heels when jumping.
  • Pain in your ankles when walking down a flight of stairs.
  • Tender to the touch.
  • The pain is worse when wearing heels or certain shoes.
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Phases of Achilles injury

Acute (instant)

When an acute injury occurs, you will immediately know it: during an overload force, the force will be too much for the achilles to handle, and then there will be an immediate, sharp/shooting pain at the back of your heel. It will be debilitating and you will not be able to continue with your activity due to your pain. For example when you attempt to sprint, without properly warming up.

Achilles tendon ruptures are different from tendonitis.

Chronic (Gradual)

Chronic tendinitis can develop slowly over time. Especially if you have had repeated injuries without getting treatment. Initially the pain feels dull and stiff, but then it lingers and just never seems to “go away”, even with basic activities like getting up from sitting.

Acute on Chronic

It can also get to a point where the pain spikes (sharp/shooting) when doing sudden ankle movements. This is an acute on chronic condition where you get a flare-up of your “old” symptoms.

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The do’s and dont’s of Achilles Tendon Injury

Once the tendon feels tight, people tend to stretch it. If you understand the pathophysiology as described above, this will make matters worse. Over stretching, thus overloading the tendon, can lead to small tears. Or in the worst case, a complete tear of the Achilles Tendon.

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What makes Achilles Tendonitis worse

There are a lot of factors that can contribute to your Achilles Tendon Injury. Our Physiotherapists can identify these contributing factors and prevent the injury from recurring.

  • Lacking flexibility in the calf muscles
  • Inadequate strength of the calf muscles during running and jumping activities, thus loading the tendon instead of the calf muscle.
  • Inappropriate footwear (high heels)
  • Inadequate warm-up before your activity
  • Sudden change in direction
  • Sudden change in speed & agility
  • Changing the surface on which you perform
  • Changing footwear
  • Sudden increase in mileage or pace
  • Use of cortisone
  • Pregnancy (Relaxin, a hormone circulating the body makes tendons and ligaments “looser” and thus increases the chances of overstretching)
  • Ankle over pronation and decreased arch (flat feet)
  • Decreased big toe extension

Test your own Achilles tendon

Sitting pinch test
  • Sit on a bed/bench, feet hanging over edge of bed
  • Bring one leg up over your knee
  • Pinch the tendon on all sides (using thumb and index finger with pressure onto the tendon)
  • If you feel tenderness, chances are good you have a tendinitis
Lying squeeze test
  • Lying on your stomach
  • Ask someone to squeeze your calf midway
  • If your foot doesn’t move in the direction of the calf pull, the tendinitis might be severe, or there might be a complete rupture
  • If there is pain, it indicates a tendinitis
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Standing length test
  • Standing against a wall with hands, in a pushup position
  • Stretching the calves with knees bent
  • Pain will be felt either at the base of the heel (insertional tendinitis)
  • Or in the middle of the achilles tendon (mid-portion tendinitis)
Standing tension test (concentric and eccentric)
  • Stand with legs shoulder width apart
  • Spread your weight evenly
  • Lift your heels simultaneously so you stand on your toes
  • Do ten repetitions, lowering the heels down slowly (eccentric) then going onto toes again (concentric)
  • The region of your pain will again indicate whether you have insertional or mid-portion tendinitis

Diagnosis

Our physiotherapists are able to make a diagnosis through physical examination, by palpating all the muscles and tendon attachments. We test all the surrounding structures in your calf and heel by contracting and stretching them in different positions to exactly determine the location and severity of your Achilles injury. This helps us form a clear picture of where and how bad it is. We will then be able to determine how long it will take to recover. In most cases other tests like X-rays, CT- or MRI scans are not necessary.

Ultrasound (diagnostic)

This is the preferred test to confirm if you have  Achilles tendinitis. We will be able to see that the tendon has a larger diameter in comparison to the non affected side. Ultrasound will also show changes of water content within the tendon, collagen integrity as well as bursa swelling. An ultrasound will be sufficient to determine what we need to know and confirm your diagnosis.

Doppler

A Doppler test will show neovascularization, this is when arteries grow into the tendon in an attempt to improve blood supply. This happens in chronic, neglected tendinitises that develop into tendinopathy.

MRI, CT or other imaging tests

Other imaging tests will not be necessary but may be useful to exclude other conditions. Doing an MRI for an Achilles tendinitis is expensive and unnecessary.

The VISA-A questionnaire:

This is a questionnaire that determines the severity of your Achilles tendinopathy. In this questionnaire, the term pain referred specifically to pain in Achilles tendon region.

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Physiotherapy treatment

We are able to implement a very effective and structured plan of action that treats all the aspects of the problem, physiological and bio-mechanical. We follow a protocol, according to the phase of your Achilles tendonitis. The aim is to get you back on the road/field/living your best life.

Every session we monitor your Achilles tendon to tell you when it is safe to progress to the next stage. This involves testing and measuring the Achilles tendon to take load. We’ll guide you through a rehabilitation program of gradual strengthening, lengthening and conditioning of the tendon.

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Physiotherapy Treatment of Achilles Tendonitis

How we work

We start with a subjective evaluation where we ask you questions to get clues to what contributed to your injury. This will include the history, mechanism of injury.We consider ourselves The Experts, why don’t you put us to the test.
Then we will perform an objective evaluation which involves movement tests of the hip knee and ankle to assess a variety of factors like:

  • Biomechanical abnormalities (To pick up any asymmetries between right and left)
  • Muscle imbalances
  • Wasting away of the muscles (Muscle atrophy)
  • Swelling
  • Joint range of motion testing
  • Strength of the gastrocnemius and soleus muscles
  • Muscle length and flexibility of the whole calf
    • We will also assess:
    • How much weight can be applied onto the foot on a weighing scale before the pain starts? (Your body weight is considered normal)
    • Number of heel rises / drops before the pain starts?
    • The number of heel drops with a specific weight in a backpack before the pain starts?
    • How far can you walk before the pain starts?

Treatment session will include the following:

    1. Manual therapy – we use joint mobilizations of the ankle or knee joint where movement is restricted.
    2. Soft tissue massage – we use a technique called deep cross frictions to restore normal muscle function and promote healing.
    3. Electrotherapy – Laser and Ultrasound to the tendon to decrease pain and inflammation.
    4. Dry needling – to release tension in the calf muscles and promote blood flow to the tendon.
    5. Taping – taping is used to correct bio-mechanical problems. Anti-pronation taping must be considered before orthotics.
    6. Advice on what to do at home: Night splints – we can advise you on night splints, these are casts that you wear at night when you sleep.
    7. Exercise protocol: Tendon loading program; Alfredson’s heel drop protocol- a very simple protocol to follow and practice at home.
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How long/how many sessions will I need to treat my Achilles tendinitis?

We are looking at anything between 3 to 6 weeks, keeping in mind there could be flare ups in between. But if the full rehabilitation program is followed, we aim to get you back as soon as possible. The first few weeks, while dealing with the acute phase, we will focus on pain management and healing, then we will progress to gradual tendon loading, and finally rehabilitation.

Other Medical management

Additional to physiotherapy, there are other options, if you feel the need for additional medical help. We can also give you advice on this:

  • Medication- usually anti-inflammatory medication
  • Corticosteroid injections- done by a General Doctor
  • Sclerosing injections
  • Platelet rich plasma injections

When is surgery necessary?

If your symptoms do not respond to physiotherapy treatment, as a last resort we must consider a surgical approach. We will refer you to a Orthopedic Surgeon if necessary. This is very seldom necessary.

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Other conditions it could be

  • Plantar fasciitis
  • Calcaneal stress fracture
  • Heel pad syndrome (deep bruises and pain in the center of the heel)
  • Sever’s disease (Hugland’s deformity)
  • Posterior ankle impingement
  • Medial tendinopathy
  • Retrocalcaneal bursitis
  • Posterior tibial nerve impingement
  • Referred pain from your lower back
  • Ankle osteoarthritis
  • Deep venous thrombosis
  • Partial Achilles tendon rupture
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It is a constant process of tendon degeneration

  • Decreased arterial blood flow – poor blood circulation slows down the healing process
  • Local hypoxia – a lack of oxygen supply to the tissue (oxygen is vital for every cell in our body to function)
  • Decreased metabolic activity – less chemical reactions occur in the cells, thus less growth, energy production and elimination of waste
  • Inadequate nutrition – inadequate ‘food’ to the cells
  • Persistent inflammatory response – inflammation occurs when tissues are injured, the damaged cells release chemicals that causes blood vessels to leak fluid into the tissues causing swelling

If these processess are continued, it will lead to chronic tendon overuse injuries and tendinopathy.

Reactive tendonitis (First Stage)

A non inflammatory response in the cell matrix, as a result of compressive or tensile overload. Straining the tendon during physical activities is the biggest stimulus that causes overload of the Achilles tendon. This loads the Achilles Tendon above its physiological limit and causes microtrauma (small tears).

Repetitive microtrauma cause unequal tension between the gastrocnemius and soleus muscles. This will lead to inflammation of the tendon sheath and degeneration.

If the tendon does not have the time to recover before it is loaded again it will progress to a tendinopathy.

Degenerative tendinopathy (Final Stage)

At this point the changes are irreversible and the chance of recovery is very poor. We even find that the membrane covering the tendon called the Peritendon, attaches itself to the Achilles tendon fibers.

These adhesions are patches of wound tissue (fibrous tissue) that attempts to heal the torn fibers. These adhesions contribute to the problem by preventing the tendons normal glide and slide (up and down).

Tendon disrepair (Second Stage)

If the tendon is not offloaded and allowed rest, further damage will occur.

In this stage protein production is increased, which results in separation of the collagen and disorganization within the cell matrix. This means that the fibres are not neatly arranged in bundles, but they tear away from each other, like a cable or rope where the individual strands break and seperate. Applying more force will cause more damage.

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