Achilles Pain

Your Achilles tendon is the strongest and largest tendon in your body. It is connected to your calf muscles and attaches to the back of the heel bone. Your Achilles tendon is crucial for your ability to walk and run - taking on forces of up to twelve times your body weight during jumping. As such, the Achilles tendon and the structures around it can be injured when it is overloaded and strained during physical activity. This can make exercise and even simple daily tasks like walking up the stairs or standing on your tip-toes painful and, in severe cases, unmanageable.

What many people don’t know about the Achilles tendon is that compared to other tendons, it is notably slower and more difficult to heal as it has fewer vessels to bring blood to the area, and a good blood supply brings oxygen and nutrients for optimal repair. This is one of the reasons that we see so many longstanding Achilles injuries in our clinic, paired with not taking (and often not knowing) the right steps to best care for the tendon.

[The term Achilles tendinopathy is often used interchangeably with Achilles tendinitis and Achilles tendinosis to mean Achilles pain, although if we’re getting technical:

• Tendinitis: this refers to the Achilles tendon exhibiting an inflammatory response and becoming swollen, tender and warm, this is often observed in the initial stages of an Achilles injury.
• Tendinosis: this denotes that there is a chronic injury to the Achilles tendon with degeneration at the cellular level and no inflammation present. We often see this when the Achilles tendon is exposed to repetitive strain injuries without having adequate time to heal between exposure.

Tendinopathy: this is the most commonly used term, generally used to describe a tendon injury or problem without offering any insight about the cause behind it. The term “pathy” is derived from Greek denoting a disease or disorder. This is why many class tendinitis and tendinosis as a tendinopathy.]

Most cases of Achilles pain that our podiatrists see and treat come from either an overuse injury, or the degeneration of the tendon over time. Specifically, when the Achilles tendon is subjected to large amounts of force and strain beyond what it can safely physically handle, damage and micro-tears in the tendon can occur. In more serious cases, partial tendon tears or even complete ruptures may result. 

Common activities that overload the Achilles tendon include:

• Running, especially at higher speeds or longer distances than what your body is used to
• Changing the intensity of your training in sports or at the gym without adequate preparation
• Having tight calf muscles that place greater compressive forces on the tendon
• Wearing unsupportive footwear, especially if it has low-set heels
• Having foot biomechanics that add excess strain on the tendon
• Participating in jumping sports such as basketball and volleyball

In many cases we see, a patient may experience dull aches or niggles at the back of the heel and ignore these early signs in the hopes that the pain will resolve on its own. Unfortunately, without changing whatever is causing the overloading, the damage will progress and significant pain and injury will eventually begin.

Achilles pain may be caused by either the tendon or the structures close to the insertion of the tendon. Namely, four common diagnostic causes of Achilles pain that our podiatrists see and treat include:

1. Insertional Achilles Tendinopathy

Insertional Achilles tendinopathy describes damage to the Achilles tendon anywhere within 20mm of the point that the tendon attaches to the back of the heel bone. In the development of insertional Achilles tendinopathy, compression is often a key factor, occurring through movements like when the foot moves up (dorsiflexes) and pulls on and compresses the tendon.

Insertional Achilles tendinopathy tends to come with pain and tenderness directly at the back of the heel that is felt by pressing on the area of the bone where the Achilles attaches to. It is also common for bone spurs to form immediately above this insertion point and contribute to the pain. Achilles pain tends to increase with running or jumping sports and may also be associated with bursitis (see below) at the back of the heel.

2. Mid Portion Achilles Tendinopathy

Midportion Achilles tendinopathy means that the Achilles tendon has been damaged in the area above its insertion at the back of the heel, anywhere from 20mm to 60mm above this point. This is where the pain will be felt, and it may be elicited by pinching the cord-like tendon.

Unlike insertional Achilles pain which is related to compression, mid portion pain is often thought of as a tensile loading problem. Studies have also observed notable tendon degeneration when evaluating the mid portion of the tendon, suggesting that many cases of mid portion Achilles pain may be chronic with degeneration occurring over time.

3. Bursitis

Bursitis simply means the inflammation of a bursa - a small, fluid filled sac that sits between structures in the body to help prevent painful friction and rubbing, while promoting lubrication and healthy movement. When the bursa is overloaded, like from excess pressure from tendons (like the Achilles tendon) or other structures, they can become swollen and painful. This is known as bursitis. We have bursae all around our body, and there are two that sit at the back of the heel that can produce pain: 

• The retrocalcaneal bursa: this bursa sits between the Achilles tendon and the heel bone (calcaneus). Compressing the bursa from the movement of the Achilles tendon will irritate the bursa and produce Achilles pain. This is known as retrocalcaneal bursitis. 
• The superficial calcaneal bursa: this bursa sits just beneath the skin, at the back of the heel where the Achilles tendon attaches to the bone. Damage to this bursa can produce pain that can be reproduced by pinching the skin over the back of the heel bone, and may be aggravated by firm heel counters at the back of the shoes that add pressure to the area.
  

4. Haglund’s Deformity

A Haglund’s deformity is a bony enlargement (bump) that develops at the back of the heel bone. The bony enlargement itself is actually asymptomatic and painless - when symptoms present, they come from the surrounding structures like the Achilles tendon or the bursa at the back of the heel. The symptoms occur because the Haglund’s deformity can interfere with the natural movement or positioning of structures in the heel, leading to irritation.

The specific causes for a Haglund’s deformity is poorly understood, research on the topic does not present a clear cause or understanding as to why the particular bony section of the back of the heel becomes enlarged. It is often considered idiopathic, meaning that it can occur spontaneously. 

Caring for your Achilles pain at home is focused around managing your symptoms to give you relief until you can book in with your podiatrist. You may be able to try:

• Applying ice to the back of the heel for 15 minutes at a time, taking a break between icing sessions. Be careful not to apply the ice directly to the skin, instead wrap it in a tea towel or other protective layer. Alternatively you can place your foot in an ice bath for the same time, doing so a few times per day.
• To help with pain, you may use non-steroidal anti-inflammatories (NSAIDs) to help give you some relief
• If your pain levels allow, try to incorporate some gentle walking into your day. You will likely need some rest days first. We call this progressive loading, and it can help prevent the atrophy that can occur when a muscle or tendon is left unused. Never push yourself to the point of pain - this can indicate that more damage is occurring.
• Keep your feet supported in good shoes both inside and outside of the house. Ideally, opt for shoes that have a slight heel (not “high heels”) as this will help ease some tension from your Achilles tendon as you walk.
• If you already have orthotics at home, wear them, and continue to do so if they are helping you get relief from your symptoms

If you’re experiencing Achilles pain your appointment will start with a comprehensive assessment to understand which structures at the back of the heel have been injured, and how and why this has occurred. Once we know this, our podiatrists will put together an evidence-based management plan that supports you in getting the best outcome for your pain and injury, while helping reduce the likelihood of the problem recurring in the future. This may involve:

• Using in-shoe heel lifts to reduce the strain on the Achilles tendon while keeping you mobile
• Custom foot orthotics: your orthotics will be custom designed to reflect your symptoms together with your foot characteristics to help optimise the way the feet are positioned and how they move. This can address biomechanical factors that may be placing excess strain on your Achilles
• Stretching and strengthening program: tight calf muscles are one of the major contributors to Achilles tendon pain, so having a stretching program that addresses this issue (if present) as well as other muscle tightness, weakness or imbalance will help you both manage your current symptoms and help prevent the problem from recurring in the future. This is where a professional progressive loading plan will also come in, allowing you to apply a safe, gradual load to the tendon without going overboard and causing more damage. This will result in gradual and safe strengthening, and a return to healthy tendon function.
• Footwear advice or modifications: we’ll review your footwear to ensure it is supporting your recovery and keeping you pain-free, instead of adding further strain on the Achilles tendon.

In severe cases where your assessment indicated a significant tear or rupture of your Achilles (we would confirm this with ultrasound), we may need to immobilise the foot using a moon boot or CAM walker for the initial stages of your recovery.