Achilles tendinitis: symptoms, treatment and how long it takes to heal

What is Achilles tendinitis?

The Achilles tendon is the thick cord at the back of your ankle. It connects your calf muscles to your heel bone and lets you push off when you walk, run, jump and rise onto your toes.

Achilles tendinitis is pain and stiffness in that tendon, usually because it has been asked to do more than it’s used to. In most long-lasting cases the problem is wear and overload in the tendon fibers rather than true inflammation, so doctors often call it Achilles tendinopathy. For you, the two names mean the same thing, and the treatment is the same.

It’s common in runners and in people who play sports with jumping or sprinting, especially from their 30s onward. It also affects people who aren’t very active, particularly at the point where the tendon attaches to the heel bone.

Not sure the pain is in your Achilles? Pain under the heel is more often plantar fasciitis (see heel pain in the morning). Pain in the arch, top or side of the foot may be a pulled muscle in the foot.

Insertional vs mid-portion Achilles tendinitis

There are two types, and they’re treated a little differently:

Symptoms of Achilles tendinitis

• pain and stiffness at the back of the heel or just above it
• stiffness that’s worst with your first steps in the morning or after sitting
• pain at the start of exercise that eases as you warm up, then comes back worse afterward or the next day
• a tendon that’s tender to squeeze, thickened or swollen
• pain going up stairs or hills, or rising onto your toes
• sometimes a creaking feeling when you move the ankle

The pain usually builds over weeks. Because it often eases once you warm up, it’s easy to keep training through it and make it worse.

Tendinitis or a torn Achilles?

A torn (ruptured) Achilles tendon is different. It happens suddenly, often when you push off, sprint or land from a jump, and it can happen in a tendon that was already sore. Signs include:

• a pop or snap at the back of the heel
• a feeling of being kicked or hit in the back of the heel or calf
• trouble pushing off, walking normally or standing on tiptoe on that leg
• sometimes a gap you can feel in the tendon

Some people can still walk flat-footed after a tear, so it’s easy to mistake for a strain. Get seen the same day, at urgent care or an emergency room if your podiatrist can’t see you, and keep weight off the leg until then. Treatment works best when it starts within days.

What causes Achilles tendinitis?

Most cases come from load building up faster than the tendon can adapt:

• Doing too much too soon, such as a jump in running distance, more hills or speed work, a new sport or a return after time off.
• Tight or weak calf muscles, which leave the tendon doing more of the work.
• Shoe changes, such as switching quickly to flat or minimal shoes, running in worn-out shoes, or stiff heel backs that rub.
• Foot shape, such as flat feet that roll in or very high arches.
• Age, because tendons become less springy from middle age.
• Health conditions, including diabetes, high cholesterol, higher body weight and some types of inflammatory arthritis.

Medicines that can harm the tendon

• Fluoroquinolone antibiotics, such as ciprofloxacin (Cipro), levofloxacin and moxifloxacin, can cause tendinitis and tendon tears, most often in the Achilles. It can start within hours of the first dose or up to several months after finishing. The risk is higher if you’re over 60, take steroid medicine or have had a kidney, heart or lung transplant. If your heel or calf starts to hurt while taking one, rest the leg and call your prescriber right away. They can usually switch you to a different antibiotic.
• Steroids. Long-term steroid tablets raise the risk of tendon problems, and steroid injections into or around the Achilles are generally avoided because they can weaken the tendon.

If you’ve had Achilles problems before, mention it whenever a doctor prescribes an antibiotic.

How Achilles tendinitis is diagnosed

A podiatrist or physical therapist can usually diagnose it from your symptoms and an exam. They’ll find exactly where the tendon hurts, feel for thickening or a gap, test your calf strength with heel raises, and squeeze your calf to check that the tendon is intact.

Imaging helps in some cases:

• X-ray shows bone spurs, a bony bump on the heel or calcium in the tendon, which is common with insertional pain. Evolve Health podiatrists have digital X-ray on site.
• Ultrasound or MRI can show how damaged the tendon is and find partial or full tears. They’re used when a tear is suspected, when pain isn’t improving with treatment, or before surgery.

Achilles tendinitis treatment

Most people get better without surgery. Treatment works best when it starts early and you stick with it for at least 3 months.

Ease back, but keep moving

Complete rest weakens the tendon and the calf. Instead:

• cut back on whatever hurts, such as running, jumping, hills and speed work
• keep fit with cycling, swimming or other low-impact exercise
• if you keep running, go shorter, slower and flatter, and only if the pain stays mild during the run (around 3 out of 10 or less), settles by the next morning and isn’t getting worse week to week

Calf-strengthening exercises: the main treatment

Slow, heavy heel raises have the best evidence of any treatment for Achilles tendinitis. They help the tendon rebuild and handle load again. A typical progression:

1. Both legs: stand holding a counter, rise onto your toes on both feet, then lower slowly over about 3 seconds.
2. Up on two, down on one: rise on both feet, then lower slowly on the sore leg only.
3. One leg: rise and lower on the sore leg.
4. Bent knee: repeat each stage with your knee slightly bent, which works the deeper calf muscle.
5. Add weight when 3 sets of 15 feel easy, for example with a backpack.

Typical programs use 3 sets of 15 slow heel raises once or twice a day, or fewer, heavier heel raises every other day. Both approaches work. Keep going for at least 12 weeks, even once the pain eases.

For mid-portion pain, you can do the lowering part off the edge of a step so your heel drops below the step. For insertional pain, stay on a flat floor.

Mild to moderate discomfort during the exercises is expected and OK, as long as it settles by the next morning and your morning stiffness isn’t getting worse from week to week. A physical therapist can tailor the program, check your technique and plan your return to running or sport. Evolve Health offers sports and orthopedic injury rehab at select offices in Florida.

Heel lifts and shoes

• A heel lift raises your heel slightly, so the tendon doesn’t stretch as far with each step. Put one in both shoes so you stay level. It’s especially helpful for insertional pain.
• Shoes with a slightly raised heel and good cushioning ease the strain. Avoid flat shoes, flip-flops and going barefoot while the tendon is sore.
• Soft or open heel backs, or a gel heel sleeve, stop shoes rubbing on a sore or bumpy heel.

Our recommended products include a heel lift cushion and a gel Achilles sleeve. Orthotics can help if your feet roll in a lot, and our guide to orthotics explains when they’re worth it.

Ice and pain relievers

Ice wrapped in a towel for 15 minutes after activity can ease pain. Over-the-counter pain relievers such as ibuprofen (Advil, Motrin) or naproxen (Aleve), or an anti-inflammatory gel such as diclofenac (Voltaren), can help for a short time if they’re safe for you. They ease pain but don’t heal the tendon. Check with your doctor first if you have kidney disease, stomach ulcers or heart disease, or take a blood thinner.

A walking boot for bad flare-ups

If walking is very painful, your podiatrist may suggest a walking boot, often with a heel wedge, for a short time. It isn’t a long-term fix, because the tendon needs to be loaded to heal.

Shockwave therapy

If pain hasn’t improved after 3 to 6 months of a good exercise program, shockwave therapy may be considered. It sends pressure waves into the tendon to stimulate healing, usually over a few sessions about a week apart. Studies suggest it can reduce pain for both types, especially alongside exercise, but it doesn’t work for everyone. Evolve Health offers radial shockwave therapy at some offices.

Injections

• Steroid injections are generally avoided in or around the Achilles, because they can weaken the tendon and have been linked to tears.
• Platelet-rich plasma (PRP) uses a concentrate from your own blood. The evidence is mixed: a large, well-run trial found PRP worked no better than a placebo injection for pain in the middle of the tendon. Ask your podiatrist about the pros and cons for your situation.

Surgery

Surgery is considered only when pain continues after about 6 months of well-done treatment without surgery. It may involve removing damaged tendon tissue, removing a bone spur or bump at the back of the heel, or, rarely, moving a nearby tendon to reinforce the Achilles. Recovery takes several months of rehab.

How long does Achilles tendinitis take to heal?

Recovery isn’t a straight line. Good and bad weeks are normal. What matters is that the overall trend is improving.

How to prevent Achilles tendinitis

• Build up gradually. Increase running distance, speed and hills a little at a time. A common rule of thumb is no more than about 10% more a week, although there’s little research behind the exact number.
• Keep your calves strong. Heel raises two or three times a week help protect the tendon, even when it isn’t sore.
• Change shoes gradually, especially when moving to flatter or lighter shoes, and replace running shoes every 300 to 500 miles.
• Warm up with a few minutes of easy walking or jogging before faster running or jumping.
• Act on early warning signs. Morning stiffness at the back of the heel is a signal to ease off for a while, not to push through.

Our guide for athletes with foot injuries covers returning to sport safely.

When to see a podiatrist

Get seen the same day if:

• you felt a pop or snap, or a kick at the back of the heel
• you can’t push off, walk normally or stand on tiptoe on that leg
• sudden, severe pain came on during activity

Call your prescriber right away if heel or calf pain starts while you’re taking, or soon after finishing, a fluoroquinolone antibiotic.

Book a visit if:

• the pain lasts more than 2 to 3 weeks despite easing off
• it keeps coming back, or makes you limp
• the tendon is swollen, thickened or has a lump
• you have diabetes or inflammatory arthritis
• you’ve done calf exercises for 6 weeks without any improvement

A podiatrist will examine the tendon, check it isn’t torn, take an X-ray if needed and build a plan with you, often alongside physical therapy. You can find a podiatrist near you and book online.