Achilles Tendonitis (Achillodynia): Symptoms, Treatment, and Pain in the Achilles Tendon

Achilles tendinopathy (ICD code M76.6) involves irritation of the Achilles tendon. This tendon runs between the calf muscles and the heel bone. Depending on body weight and activity level, significant forces are transmitted through it. The tendon is subjected to heavy strain and can become inflamed. This causes the tissue surrounding the tendon to thicken, leading to severe pain. Untreated Achilles tendinopathy can lead to an Achilles tendon rupture. Therefore, the diagnosis and treatment of Achilles tendinopathy are very important. 

The Achilles tendon is under heavy strain—Achillodynia must be treated. © bilderzwerg / Fotolia

A key symptom of Achilles tendinopathy is pain in the heel or calf. The pain originates from the Achilles tendon. At the same time, the tendon thickens, which may be palpable from the outside. Due to the pain, many patients have difficulty walking. A rubbing sound may occur as soon as the patient lifts their foot. Some patients only feel the pain when they put weight on the tendon for an extended period. Others, however, are more severely affected and rely on assistive devices when walking. In some cases, the symptoms are more pronounced in the morning. Pressing on the tendon may also cause pain.

Pain in the ankle? It could be Achilles tendon irritation. © cirquedesprit / Fotolia

In some cases, temporary, acute Achilles tendinopathy develops into a persistent problem. This chronic Achilles tendinopathy causes ongoing discomfort. Whether the condition is acute or chronic affects the treatment options. Therefore, to be on the safe side, you should see a doctor even if the pain only occurs in the morning or after long walks.

If you put a lot of strain on your Achilles tendon, the tissue will eventually wear down. This degenerative change becomes more likely as you get older.

Athletes are frequently affected because their Achilles tendon is subjected to greater stress. Achilles tendinopathy can result from a sports injury or develop due to continuous overuse. People who exercise a lot are therefore at higher risk. However, this also applies if you exercise only moderately but have poor posture.

Overweight individuals also have an increased risk of developing Achilles tendinopathy. There are two reasons for this: First, the extra weight places greater strain on joints, bones, and tendons. Second, being overweight or obese increases the risk of other health conditions, including various metabolic disorders. These metabolic disorders, in turn, can be a potential cause of Achilles tendinopathy.

Other risk factors include:

• anatomical misalignments
• poor blood circulation
• rheumatic diseases such as ankylosing spondylitis
• unfavorable terrain, for example when jogging
• shoes with poor cushioning

A doctor can often detect the thickening of the tendon at the heel simply by palpating the area. However, the doctor will usually perform additional tests to assess the damage more precisely. An ultrasound makes the tissue in the foot visible. The doctor may also order an X-ray, a CT scan, or an MRI. MRI provides particularly high resolution.

Using these images, the doctor rules out other possible causes of the symptoms through differential diagnosis. Imaging tests also reveal whether the Achilles tendinopathy has already led to further damage, such as Achilles tendinitis.

The duration of the condition varies widely. Acute Achilles tendinopathy may last only a few weeks, while chronic Achilles tendinopathy can persist for several months or years.

The first step is often to immobilize the Achilles tendon with tape, a bandage, or a cast. The doctor applies the bandage so that the foot is held in a pointed position, with the tip of the foot slightly lower than the ball of the foot. Insoles and special shoes can also help maintain this foot position.

Pain relievers and local anesthetics help alleviate symptoms. Depending on the cause, anti-inflammatory medications may also be considered.

Other treatment options include physical therapy and exercises that the patient performs on their own following appropriate instructions. These primarily include stretching and extension exercises. As an athlete, however, you should take it easy in your actual sport.

Other treatments include:

• Shockwave therapy: pain relief using sound waves
• Ultrasound therapy: the tendon is treated with ultrasound
• Electrotherapy: a weak electrical current passes through the tissue
• Autologous blood infiltration (ACP therapy with autologous conditioned plasma): the administration of blood plasma derived from the patient’s own blood supports regeneration

If treatment does not result in sufficient improvement, the treating physician often considers surgery. He discusses this option with the patient and explains the individual benefits and risks of this treatment. The appropriate treatment always depends on the individual case.

Achilles tendon irritation associated with achillodynia is not only painful; it also carries the risk that the Achilles tendon will irreversibly atrophy and become prone to tears. Prevention is primarily about reducing the risk factors that contribute to the development of achillodynia.

If you are overweight or obese, losing weight will benefit your body. A normal body weight not only helps prevent Achilles tendinopathy but also has numerous positive effects on your health.

The World Health Organization (WHO) defines a normal weight as a body mass index (BMI) between 18.5 and 25. However, many medical professionals recommend a BMI of 21 to 23 as a healthy weight.

Although intense exercise increases the risk of Achilles tendinopathy, exercise is by no means off-limits as long as you are healthy and show no signs of illness. On the contrary: sufficient physical activity is essential for a healthy lifestyle. When exercising, however, be sure to maintain proper posture and avoid overexertion.

If in doubt, have an experienced trainer correct your form until you’ve mastered the movements confidently. As a beginner, start slowly to give your body a chance to adjust to the new physical demands.

Warm up thoroughly before you start your workout, and incorporate stretching exercises into your exercise routine. A cool-down phase after exercise is also an essential part of every training session. Be sure to use appropriate equipment as well—for example, good running shoes when jogging.

© Dmytro Panchenko / Fotolia

If you experience persistent, severe, or recurring discomfort, it’s best to see a doctor. If a doctor, physical therapist, or other qualified professional advises against exercising, follow their recommendation.

The tendon that attaches to the heel was, for good reason, the undoing of the mythological hero Achilles. This unassuming tissue is prone to numerous injuries. Many conditions affecting the Achilles heel contribute to one another. Minor tendon tears can lead to achillodynia over time—and conversely, achillodynia increases the likelihood of …

• Inflammation
• Tendon tear
• Achilles tendon irritation
• Nerve damage
• Degeneration of the tendon

Athletes, in particular, are therefore well advised to take preventive measures seriously. Acute Achilles tendinopathy can usually be treated effectively. The most important step is to rest the foot.

In the meantime, pain relievers can help alleviate discomfort if necessary. Do not use pain relievers to continue putting weight on your foot despite the pain! Doing so increases the likelihood of complications.

What are the typical signs of Achilles tendinitis?

The main symptom is pain in the Achilles tendon, which is particularly noticeable in the morning as “start-up pain” and improves after a few steps. When the Achilles tendon is stressed—such as during jogging—the pain returns. Often, a spindle-shaped thickening of the tendon can be felt, which is painful when pressed. In advanced stages, pain occurs even at rest, and the skin over the inflamed area may be reddened and warm. Other symptoms include limited mobility of the foot and a crunching sound during movement.

What causes Achilles tendinitis?

Inflammation of the Achilles tendon is usually caused by an imbalance between the load placed on the tendon and its capacity to withstand that load. Common triggers include a sudden increase in training intensity, running on hard surfaces, or wearing unsuitable footwear that puts pressure on the heel. Biomechanical factors such as a flat foot or tight calf muscles also increase the tension on the tendon. This chronic irritation leads to microtears in the tissue, causing the tendon to wear down and become inflamed.

How is Achilles tendinopathy treated?

If treatment is started early, the chances of recovery are good. The foundation of treatment is the RICE principle (Rest, Ice, Compression, Elevation) and relieving pressure on the tendon. Conservative therapy includes physical therapy, in which targeted exercises stretch and strengthen the tendon. Medications can help relieve acute inflammation. For chronic symptoms, shockwave therapy has proven effective in promoting blood flow and stimulating metabolism in the tendon tissue.

Do orthotics help with Achilles tendinitis?

Yes, orthopedic insoles are an important aid. They can correct misalignments and, by slightly elevating the heel, relieve tension in the calf muscles. This helps relieve pressure on the Achilles tendon and reduce the pull on its attachment to the heel bone. A special support with silicone pads can also distribute pressure evenly, reduce swelling, and relieve pain in the Achilles tendon.

What is eccentric training?

Eccentric training is considered the gold standard in physical therapy for Achilles tendinopathy. It involves loading the calf muscles while they are stretched. For example, stand with the balls of your feet on a stair step, lift yourself up using your healthy leg, and slowly and carefully lower the heel of the affected leg below the level of the step. These stretching and strengthening exercises stimulate the regeneration of collagen fibers and strengthen the tendon over the long term.

When is surgery necessary?

Surgical treatment is usually considered only if consistent conservative therapy over six months fails to bring about improvement or if the tendon is severely damaged. Surgery is also often necessary in the case of an Achilles tendon rupture to reattach the tendon ends. In cases of chronic inflammation, surgery can be performed to remove inflamed tissue or to shave down bony spurs on the heel bone (Haglund’s deformity).

How long does Achilles tendinitis last?

The course of Achilles tendinitis varies greatly. Acute irritation can subside within a few weeks with immediate rest. Chronic Achilles tendinitis, on the other hand, is often protracted and can last from months to over a year. It is important to increase activity only gradually and to continue the exercises even after the pain has subsided to prevent a relapse.

Can Achilles tendinitis be prevented?

To prevent Achilles tendonitis, good footwear with cushioning is essential. Athletes should gradually increase their training volume and ensure adequate recovery periods. Regular stretching of the calf muscles keeps the tendon supple. In addition, foot misalignments should be treated early with orthotic insoles to prevent overloading of the tendon.