Achilles pain: what you are dealing with
Tendons do not behave like muscles. Knowing how this one is built tells you why resting it backfires, and why the exercise that helps one kind makes the other worse.
Get the one-page sheetWhy resting it disappoints you
A torn muscle heals with time off. A tendon does not work that way. A tendon that is not loaded loses its capacity to take load, so six weeks of rest makes the first run back hurt more than the one that stopped you.
That is the trap. Rest feels right for a fortnight, the problem comes back worse, and you conclude it must be something serious. What has happened is that the tendon has become less able to cope while you waited.
You are allowed to load a painful tendon. The test is not whether it hurts while you do it, it is what it does the next morning.
What the pattern tells you
Pain at its worst for the first few minutes of a run, easing as you warm up, then aching that evening or the next morning. Stiffness in the first few steps out of bed is the other giveaway.
This is one of the few problems that can be diagnosed from the history and the examination. A scan that shows tendon change does not tell us how much load you can handle. Testing that is more use than imaging it.
Two types, two different plans
Pain at the bone and pain further up the tendon are not the same problem, even though they feel much the same. Mid-portion pain sits two to six centimetres above the heel bone, often on the inner side. Insertional pain sits at the bone, on the back of the heel.
When the ankle bends upwards, the deep surface of the tendon is pressed against the heel bone as well as being stretched. The further it bends, the harder the squeeze. That is why heel drops off a step are the classic exercise for mid-portion pain, and why insertional pain is better worked on the floor at first.
When the same heel drop programme was given to both groups, 89 per cent of mid-portion tendons did well and 32 per cent of insertional ones did. When the same exercise was repeated for insertional pain without letting the heel drop below the floor, two thirds did well.
The rule that matters
Pain up to about four or five out of ten during the exercise is fine, as long as it has settled back to your normal within 24 hours and is not creeping up week on week.
Still worse the next morning means that dose was too much. Drop it and build again from there. This turns every session into information rather than a gamble.
Worth knowing that this rule is what we use in clinic and what the research programmes used. It has been shown to be safe to work to.
Try this first
- Find out which type you have before choosing an exercise
- Isometric calf holds, 30 to 45 seconds, five times, once a day
- Judge the dose by how it feels next morning, not during
- Keep walking. Take out the hills and the speed rather than stopping
Get it looked at if
- A sudden snap or blow to the back of the ankle and you cannot push off, same day
- Swelling and pain around the tendon with no change in training to explain it
- Pain that is there at rest and at night rather than with loading
- Six weeks of sensible loading and nothing has shifted
- You have recently taken a quinolone antibiotic such as ciprofloxacin
What we would do
We work out which type you have, because that decides whether the standard exercise is the right one or the wrong one for you. Then we test the calf rather than guess at it, and build the programme around that number and around your week.
Want this as a one-page sheet?
The version we hand out in clinic. Print it, stick it on the fridge, work through it.
Related: Ankle and Achilles pain treatment · All patient guides · Our blog
This guide is general information about a common problem, not a diagnosis of yours. If something is not settling, or it does not match what is written here, come and get it looked at.