Achilles Tendinopathy and Heel Cord Pain: Causes, Symptoms and What May Help

The Achilles tends to present its pain immediately when you put a foot to the floor in the morning. The tendon at the back of the heel feels short and sore and the stairs are descended in a sideways stance. It eases as you move and most people conclude it is nothing much and it will pass. If you’re a runner then you find it feels fine for the first mile but it tightens up again by the evening.

That warm-up-and-return pattern is the signature pattern of Achilles tendinopathy and it is not confined to runners. Roughly two-thirds of cases diagnosed in GP practice have nothing to do with sport.[5]

This page covers the achilles tendon itself and the back of the heel. Pain underneath the heel belongs on my plantar fasciitis and heel pain page, ankle joint problems on the ankle and foot pain page and all other lower limb conditions are covered in detail on my leg, knee, ankle and foot pain guide page.

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What is Achilles tendinopathy?

The Achilles is the thick cord running from the calf muscles to the back of the heel bone and is the strongest tendon in the body. Tendinopathy is the pain felt and the loss of function in that tendon, usually with some thickening of the tissue. The older name of tendonitis is not used for the condition so much any more because the changes found in longstanding cases look more like disorganisation of the tendon fibres than active inflammation. Practically, that it explains why rest and anti-inflammatories tend to not work on this foot and ankle condition.

Two locations of the conditon behave quite differently. Mid-portion tendinopathy sits a few centimetres above the heel bone and is by far the more common. Insertional tendinopathy sits where the tendon attaches to the bone, is more stubborn and does not tolerate the same exercises because dropping the heel below level compresses the tendon against the bone.[5] A bursa sits just in front of that attachment and can be irritated alongside it. These things need distinguishing.

What causes an Achilles problem

Almost always, achilles tendinopathy is caused by load rising faster than the tolernace of the tendon. The usual histories of cause are an increase in weekly running distance, added hill or speed work, a return to running after months off, a new job on hard floors or a holiday of long walks in flat sandals. Tendons do adapt well but are slow to adapt and they object to sudden changes much more than just working hard.

Several things lower the threshold or contribute to developing this painful condition. Calf muscles that are weak or stiff transfer more strain to the tendon, as does a stiff ankle that will not let the shin travel forward over the foot. Most cases come about between ages thirty-five and sixty. Carrying extra body weight and diabetes may also be an associated cause of tendon problems. Alongside this, certain medications such as fluoroquinolone antibiotics and corticosteroids are recognised risks worth mentioning to me at your consultation if you take either.[1]

Explore our leg, knee, ankle and foot guides

Leg, knee, ankle or foot pain: the main guide

Heel, ankle and foot

Plantar fasciitis and heel pain: pain under the heel
Achilles tendinopathy: pain behind the heel, heel cord pain and tight calves (you are here)
Ankle pain and referred foot pain: rolled ankles and ligament injuries

Knee, thigh and calf

Related guides

When leg pain starts in the back

When leg pain starts in the hip or pelvis

Staying active

anatomical image showing the location of the muscles in the calf and heel and where the achilles tendon is and how Achilles tendenopathy has a pain pattern in the heel

The anatomy of the heel and ankle and the location of the Achilles tendon and where the pain is felt with Achilles Tendinopathy in the heel

Symptoms of Achilles tendinopathy

Pain and stiffness at the back of the ankle or heel are the main symptoms, it feels at its worst during the first few steps of the morning and at the start of exercise, easing as things warm through and the pain returns a few hours after you stop. Squeezing the tendon between finger and thumb reproduces the symptoms and there is often a thickened, tender section palpable. Rising up onto tiptoe or hopping is usually uncomfortable. Many people report it as stiffness rather than pain, particularly when the condition is in its early stages.

Insertional problems are felt lower at the bony point and are provoked by uphill walking, by dropping the heel over a step and elongating the back of the ankle and also aggravated by stiff-backed shoes. Swelling in the soft hollow just in front of the tendon suggests the bursa is involved.

a patient holding their painful leg in the area affected by achilles tendinopathy

Pain and stiffness at the back of the ankle or heel are symptoms of Achilles tendinopathy

Conditions your heel and foot pain could be instead:

A few things are not the same as Achilles tendinopathy: pain underneath the heel is a different problem. Sudden severe pain deep in the calf during activity, as though someone kicked you, is a muscle tear rather than a tendinopathy. Pins and needles do not come from a tendon and point towards a nerve, most often referred from the lower back. Diagnosis following an examination are key to pinpointing the condition.

How chiropractic may help

As a chiropractor I conduct an assessment first to distinguish between mid-portion and insertional problems so you are not given the same exercises for both because they are different. Then soft tissue work to the calf, mobilisation of the ankle and midfoot where the ankle will not bend far enough, advice on footwear and temporary heel raises and a loading programme starting at a level suitable to you. I also look at the knee, hip and lower back, because a limp changes everything that is below it and referred pain comes into the diagnostic picture. People who run the same route every day often need nothing more complicated than a change in that route while the tendon catches up rather than stopping exercise. I advise adaptations and compensations.

Achilles tendinopathy is a loading problem and progressive calf loading will help the condition. Hands-on treatment may help with symptoms and with the stiffness that limits how you move but it is not the only solution that rebuilds tolerance in the tendon, a progressive, calf-muscle exercise programme helps most alongside addressing the associated symptoms.

The best available overview compared 29 trials and found large uncertainty, with no trial at low risk of bias, while still concluding that a calf-muscle exercise programme is the sensible place to start.[2] The heel-drop protocol most programmes descend from returned all fifteen participants to running within twelve weeks.[3] More usefully, continuing to run within a pain-monitoring model produced outcomes no worse than resting from sport during rehabilitation.[4]

To see an improvement or change, most possibly, expect months rather than weeks to see progress or recovery. Three to six weeks is typical for a settled tendon and insertional cases recover more slowly.[5] I review at six weeks and if nothing has changed by then we alter the plan or I refer you on for further investigation or a scan.

If your Achilles pain in your foot is getting in the way of things you would rather be doing, come and talk it through. I offer a free 15-minute consultation, you can come in for a short no-obligation chat with no examination or treatment.

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red flags

The main red flag is diagnosing a rupture. A complete tear usually happens during a push-off, feels like a sudden blow or kick to the back of the ankle, sometimes with an audible snap and leaves you unable to push off or rise onto tiptoe on that leg. There may be a palpable gap you can feel in the ankle tendon. Confusingly, some people can still walk afterwards, which is exactly why ruptures get missed. If that describes what happened, go to A&E rather than waiting to see whether it settles.

If Achilles pain develops while you are taking a fluoroquinolone antibiotic, stop exercising and contact the GP, since these drugs are associated with tendon rupture.[1] Tendon pain in both heels in a younger person, alongside morning back stiffness or other painful joints, can point to inflammatory arthritis and you need to see your GP.

Your first visit to Bournemouth Chiropractic

At your first visit I take a full history covering when your ankle and heel pain started, what changed in your training or walking beforehand, any medication that matters and how the tendon behaves through a day. Then I examine the tendon, locate the painful section precisely, test your calf strength and single-leg heel raises, measure ankle movement and watch you walk. I will tell you what I believe is happening biomechanicaly, whether chiropractic care is likely to help and what the loading plan that I prescribe looks like.

Frequently Asked Questions

Can a chiropractor help with Achilles tendinopathy?

Hands-on treatment may help with pain of Achilles tendinopathy and with the ankle and calf stiffness that prevents loading the tendon properly. The loading programme is what does the long term work and my role is to prescribe and progress it as well as to treat the area. If the tendon is not responding or a rupture is suspected, you need a different plan and I will say so.

Should I stop running because I have achilles tendinopathy?

Achilles tendinopathy should not stop you running, usually not completely. Continuing to run within a pain-monitoring model, keeping symptoms below an agreed level and settled by the next morning, produced results as good as stopping.[4] What normally changes is what you do within that run, the volume, the hills and the speed work rather than the running itself.

How long does Achilles tendinopathy take to settle?

Achilles tendinopathy take longer to settle than most people want to hear. Three to six months is a realistic range for a tendon that has been sore for a while and insertional cases at the bone are slower still.[5] The tendon usually feels better long before it is robust, which is why so many people relapse by returning to full training too early.

Do I need a scan for achilles tendinopathy?

Achilles tendinopathy is mainly diagnosed from the history and examination rather than a scan and scan findings may correlate poorly with symptoms.[1] Imaging is useful where a rupture or a partial tear is suspected or when a tendon is not behaving as expected despite proper loading.

When should I go to A&E rather than book an appointment?

Go to A&E the same day if you felt a sudden blow, snap or kick at the back of the ankle and cannot push off or rise onto tiptoe on that leg, even if you can still walk. A hot, red, swollen tendon with a fever also needs urgent medical attention rather than a chiropractic appointment.

Whatever is behind your Achilles, heel or calf pain, come and find out

Achilles problems have a way of dragging on. The pain warms up after ten minutes of walking, which makes it easy to keep going and then stiffens up again the next morning slightly worse than the day before. By the time most people seek help they have been quietly managing it for months. At a first appointment I will take a full medical history, examine the tendon and the calf and look at how much load you have been putting through it and how quickly that changed.

Tight, aching calves and sore Achilles tendons are a regular presentation here at my clinic in Bournemouth, particularly among people who have recently increased their walking or gone back to running after a break.

Tendons respond to loading and a properly graded programme is what the evidence supports most strongly for the Achilles, so that is where the emphasis goes. Hands-on care for the calf and the surrounding joints alongside that is a well-tolerated option worth considering and where a minor sports injury or muscle cramp is part of the picture I can adapt the treatment. Tendon work is slow and I will be honest with you about the timescales rather than promise a quick fix. If I suspect a partial tear or anything that needs imaging or a specialist opinion, I will tell you and help you get to the right person.

Book an appointment online and you can choose what suits you: a first appointment, which is the full thing with a detailed history, examination and treatment where appropriate, or a free 15 minute consultation, which is simply a no-obligation chat about your problem with no examination and no treatment. If you are not sure which you need, call the clinic on 01202 937568 and we will work it out together.

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