Printed on: June 28th, 2025

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Pain in the Achilles region

Pain in the Achilles region

There are several possible causes of pain in the Achilles region, including (Clinical Sports Medicine, Brukner, Khan 4^th Ed.):

• Achilles tendon rupture.
• Achilles tendinopathy (mid-portion or insertional, including that seen in the spondyloarthritides).
• Retrocalcaneal bursitis.
• Haglund’s disease.
• Posterior impingement.
• Sever’s disease.
• Referred pain from sciatica.

This article was updated in June 2025.

Although uncommon, we will start with an important ‘diagnosis not to miss’: Achilles tendon rupture.

An Easily Missed review in the BMJ looked at the diagnosis of acute Achilles tendon rupture, and reminds us that 20% of these are missed. They are a common cause of medicolegal claims. It is a common misconception that patients cannot walk after an Achilles tendon rupture (Mayo Clin Proc 2006;81:818). Here’s a reminder of how to spot them (BMJ 2015;351:h4722).

The injury usually occurs during repetitive jumping motion or bursts of sudden activity; it is rare during normal walking. Patients often describe either feeling a blow to the heel as if they had been hit by something or even hearing an audible snap.

Risk factors include:

• Increasing age.
• History of tendinopathy (although the absolute risk of Achilles rupture after diagnosis of tendinopathy is only 4% (JAMA 2023;330:2285)).
• Steroid injection into or around Achilles tendon.
• Drugs: oral corticosteroids and quinolone antibiotics.

Most will not have had any symptoms in the affected tendon until the acute injury occurs.

The diagnosis is clinical, and can nearly always be made in the acute setting without imaging.

Make the diagnosis using ‘Simmonds’ triad’ (you can watch a video of this at the link in the useful resources box below). This triad has a sensitivity of 96% and specificity of 93%.

Bruising and swelling may be present, but can be mild, and patients may still be able to stand on their tiptoes and actively plantarflex because other ankle tendons are intact.

The diagnosis should be made clinically – in an acute and subacute setting, do not delay referral to await imaging.

When Achilles tendon rupture is suspected, refer to the orthopaedic or sports injury team the same day. They will assess the injury and decide whether surgical or non-surgical treatment is required.

All patients will be offered supervised physiotherapy for several months.

• Often involves casting, boot and physiotherapy. The tendon heals naturally, but casting is important to prevent it from healing at a different length from the non-injured side, making it more susceptible to injury in the future.
• Usually considered for older, less active patients and those with comorbidities.

• Usually considered for young people, athletes and those with high activity levels.
• It ensures correct apposition of the tendon ends and has a lower re-rupture rate.
• There are increased risks of wound infection and non-healing.

A meta-analysis pooling RCTs and observational studies considered this issue and reported that, in comparison with non-operative treatment, operative treatment (BMJ 2019;364:k5120):

• Reduces the risk of re-rupture, though the absolute difference was small (2.3% vs. 3.9%). While statistically significant, this is of debatable clinical significance.
• Had a significantly higher complication rate, mostly of infection.

The accompanying editorial comments that other important outcomes, e.g. the ability to return to physical activity and confidence in the tendon, were not considered, and that observational studies suggest that surgery may be superior for these outcomes (BMJ 2019;364:k5344).

A well-designed RCT comparing non-operative management with both open and minimally-invasive operative treatment also showed no difference in patient- or clinician-observed outcomes at 1 year across all three groups. There was a higher re-rupture rate in the non-operative group and a higher risk of nerve injury in both operative groups (more significant for minimally-invasive surgery) (NEJM 2022;386:1409-20). The accompanying editorial concluded that “none of the standard treatments for Achilles tendon rupture is clearly superior for unselected patients, and choice of treatment should be a shared decision” (NEJM 2022;386:1465). This is clearly one for secondary care to decide!

There is some association between acute Achilles tendon rupture and thromboembolism so prophylaxis may be offered.

No.

Platelet-rich plasma injections are increasingly used in musculoskeletal medicine with a mixed evidence base. In lab conditions, they improve cellular and physiological tendon healing and so have been considered as an adjunctive treatment for acute Achilles tendon rupture.

A UK-wide placebo-controlled RCT compared platelet-rich plasma injection with placebo injection in 230 adults with acute Achilles tendon rupture. There was no difference in objective or subjective measures of function or quality of life. They do not appear to offer any patient benefit (BMJ 2019;367:l6132).

Early treatment offers a good prognosis, on average:

• 12w to normal walking and stair climbing.
• 9m to return to normal sporting activities.

More detailed descriptions of the pathophysiology of ‘tendinopathy’ can be found in our article Tendinopathy.

• The Achilles tendon, the largest tendon in the body, is prone to tendinopathy due to overuse. Runners have a 30 times greater risk of Achilles tendinopathy than sedentary controls (Clinical Sports Medicine, Brukner, Khan 4th Ed.).
• Midportion Achilles tendinopathy causes pain 2–6cm proximal to the insertion. It is easier to treat than insertional tendinopathy (JAMA 2023;330:2285).

There’s more about this in our article Tendinopathy, but, most commonly, repetitive overloading of the tendon causes a response involving disorganisation of the collagen fibres and some microvascular changes.

Despite years of research, in terms of the tissues and nociception, the exact cause of the pain is poorly understood. Several mechanisms have been proposed, including a neuropathic pain component (BMJ Open Sport & Exercise Medicine 2022;8:e001297).

Overuse is the commonest cause in older age groups, with running being the key causative activity (JAMA 2023;330:2285).

Fluoroquinolones can also cause Achilles tendinopathy. You can read more about that in our article Quinolones (the -floxacins): the risks.

Glucocorticoids also increase the risk of Achilles tendinopathy, and the combination of glucocorticoid plus quinolone further increases risk (Am J Med 2012;125:1223).

The typical features include (JAMA 2023;330;2285):

• Pain in the mid-Achilles, often severe on starting activity and then improving, only to return if activity is protracted or intense.
• Tenderness to palpation.
• Palpable thickening.
• Painful arc sign (the swollen area moves with dorsi/plantarflexion of the ankle).

The risk of rupture of the tendon following diagnosis of tendinopathy is around 4%, usually after an acute injury. We should suspect this in anyone with an acute ankle injury and pain in this area, and seek the relevant physical signs (calf squeeze test, gap in the tendon).

Treatment usually consists of a combination of activity modification and physiotherapy (JAMA 2023;330:2285).

Activity modification (possibly with a sports coach or occupational health doctor) aims to decrease tendon loading by altering volume and/or intensity of activity, improving technique and optimising equipment, e.g. footwear.

Physiotherapy is based around Alfredson’s eccentric heel-drop exercise programme for 6–12 weeks. This is described below and may be something you can teach your patients while they wait for formal physiotherapy. This should be offered to all patients with Achilles tendinopathy.

There is an array of other treatment options. We must remember that for most MSK conditions with dozens of proposed treatments, it is likely that none of them work particularly well.

If the heel-drops fail to resolve the issue, other options include GTN patch, laser, electrotherapy, injections (sclerosant, platelet-rich plasma), shockwave therapy, night splint or AirHeel brace (a type of ankle support). Trials have not shown significant benefit over eccentric exercise alone.

Surgery may be considered as a last resort, but conservative treatment is generally successful. Surgery is associated with a significant complication rate, needs a protracted rehabilitation programme and has poorer outcomes for sedentary people. It can take years to regain strength and function after surgery.

We consider these conditions together because they often have shared pathophysiology. At the point of insertion, the distal Achilles tendon, the retrocalcaneal bursa and the bone of the calcaneum are very closely related (Cureus 2016;8:e820, Clinical Sports Medicine, Brukner, Khan 4th Ed).

A prominence in the calcaneum may irritate the distal Achilles and the bursa (which lies between the tendon and the bone), especially when the ankle is in dorsiflexion, a position which brings the structures closer.

A posterolateral calcaneal bony prominence is sometimes called a ‘Haglund calcaneus’, ‘retrocalcaneal exostosis’ or a ‘pump bump’. If asymptomatic (as most are), it is not a problem and doesn’t warrant treatment. ‘Haglund’s disease’ refers to the clinical syndrome of pain and swelling in this area associated with the Haglund-type calcaneum. Treatment can be challenging and involves the physio and wider musculoskeletal teams. A simple first step is increasing the heel height of the footwear.

Insertional Achilles tendinopathy (or, more accurately, enthesitis) may be a feature of a seronegative spondyloarthropathy (Arthritis Research & Therapy 2023;25:8). Our suspicions of an underlying rheumatological disease may be raised by other features such as inflammatory-sounding back pain or repeated episodes of other tendon-related pain such as plantar fasciitis or tennis elbow.

Posterior ankle impingement is characterised by posterior ankle pain which occurs in forced plantarflexion. It is commonly felt during end-range ‘tip-toe’ position and in push-off activities.

Anatomically, it may be caused by ‘catching’ of the posterior talus on the posterior tibia.

It can be caused by trauma or overuse. It is most commonly seen in ballet dancers, gymnasts, footballers and downhill runners.

Diagnosis is usually clinical: pain may be reproduced on passive plantarflexion and the area may be tender.

Treatment is generally with physiotherapy. Corticosteroid injection may have a role (NOT into the tendon). Surgery is uncommonly required (J AM Acad Orthop Surg 2005;13:365).

Sever’s disease is an insertional enthesopathy at the ankle. It is one of the most common causes of heel pain in growing children. We can think of this as ‘Osgood-Schlatter’s of the ankle’.

Pain is felt underneath the heel, which may be tender on examination. Running and jumping may exacerbate symptoms. Treatment involves reducing activity, heel pads, shoes with a slightly elevated heel and exercises (through physiotherapy) (American Academy of Orthopaedic Surgeons, accessed Jan 2025).

Pain in the Achilles region Consider Achilles tendon rupture in your differential of acute ankle pain. Remember: patients with tendon rupture may still be able to walk! Mid-portion Achilles tendinopathy is a common cause of posterior heel pain in middle-aged runners, and is best managed with activity modification and physiotherapy. Do not infiltrate corticosteroid in or around the Achilles tendon in primary care. An asymptomatic Haglund deformity (pump bump) needs no treatment. Posterior ankle impingement causes pain on extreme plantarflexion. Sever’s disease is a common cause of heel pain in growing children.

Useful resources: Videos (all resources are hyperlinked for ease of use in Red Whale Knowledge) YouTube – Simmonds’ triad of tests for a suspected Achilles tendon rupture YouTube – flexed knee heel-drop (soleus) YouTube – straight knee heel drop (gastrocnemius)