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The Achilles tendon joins the calf muscles to the heel, and it takes several times your body weight with every stride. It can be overloaded, worn where it meets the bone, or torn outright — and a torn one is surprisingly easy to miss.
Achilles tendon pain comes in three quite different forms. Two build up over weeks and are treated with patience and the right exercise. The third happens in a moment and needs seeing within days, because what can be done for it depends partly on how soon.
| In the tendon mid-portion tendinopathy | At the heel bone insertional tendinopathy | Torn rupture | |
|---|---|---|---|
| Where it hurts | A few centimetres above the heel, where the tendon may feel thickened | Where the tendon joins the back of the heel, often over a bony bump | Sudden pain at the back of the ankle or low calf |
| How it began | Gradually, often after running more, new shoes or harder surfaces | Gradually; worse on hills, stairs and in stiff-backed shoes | Suddenly — a pop, or a feeling of being kicked |
| First steps in the morning | Stiff and sore, easing as you move | Stiff and sore, sometimes slower to ease | Weak rather than stiff |
| Rising onto tiptoe on that leg | Possible, but sore | Possible, but sore | Weak or impossible |
| The calf squeeze test | Normal | Normal | The foot does not move |
| How soon to be seen | Within a few weeks | Within a few weeks | Within days |
If it went with a pop, do not wait to see whether it settles. A torn Achilles tendon often still lets you walk, and even point the foot, because other muscles take over part of the job. That is why so many are missed at first. Call the clinic and come in within the next few days, keeping the foot pointed down in the meantime — the options for a rupture are best when it is seen early.
The Achilles is the largest tendon in the body. It gathers the two calf muscles into a single cord that attaches to the back of the heel bone, and it is what lets you push off, climb, and rise onto your toes.
What a picture cannot show is why an overloaded tendon hurts. The old name, tendonitis, implies inflammation, but a painful Achilles is mostly a tendon whose structure has been loaded faster than it could adapt. That is why rest on its own tends to help only while you are resting, and why the treatment that works is a gradual, deliberate increase in load rather than avoiding it.
The tendon also has a stretch with a relatively poor blood supply a few centimetres above the heel. It is where most mid-portion pain sits, and where most ruptures happen.
Being able to walk is not reassurance. People with a complete rupture regularly walk into clinic, and some can still point the foot downward using the muscles behind the ankle. The squeeze test does not depend on any of that, which is why it matters more than how well you are moving.
For tendon pain, the aim is not complete rest but the right load, which is where lasting Achilles pain relief comes from. For a rupture, the choice is between surgery and treatment in a boot, and both can work well.
Cutting back what provokes it — running distance, hills, speed work — rather than stopping everything. A small heel lift in the shoe takes strain off the tendon for a while. Keeping active in ways that do not hurt matters, because a tendon that is not loaded at all gets weaker, not better.
Slow, heavy calf exercises, built up over weeks, are the best-supported treatment for tendinopathy. They take about twelve weeks to work, and some discomfort during them is expected. For pain at the heel bone the programme is adjusted so the heel is not dropped below a step, because that position presses the tendon against the bone.
For tendinopathy that has not settled with a proper exercise programme, shockwave therapy has reasonable evidence behind it and is offered here. It works alongside the exercise rather than replacing it.
A rupture can be treated in a walking boot with the foot pointed down, with weight-bearing started early, or repaired surgically. For many people the results are comparable. Surgery may suit someone returning to high-level sport, or a tear that was not treated in the first days. Either way, recovery is measured in months, and the rehabilitation that follows matters as much as the choice itself.
Achilles tendon injuries here are seen by Dr Jeffrey Tan Gek Meng, a Senior Consultant Orthopaedic Surgeon whose subspecialty is foot and ankle. He is a Fellow of the Royal College of Surgeons of Edinburgh, completed his subspecialty fellowship in foot and ankle surgery at Toronto Western Hospital, and consults in English, Mandarin, Malay, Hokkien and Hainanese.
The usual story is a sudden pop or the feeling of being kicked in the calf, often while pushing off in sport, followed by weakness rising onto the toes. Being able to walk does not rule it out. The calf squeeze test settles it, and ultrasound confirms it.
No. Easing off what provokes the pain helps, but a tendon that is not loaded gets weaker. The treatment that works is a gradual build-up of load, which is why complete rest tends to help only for as long as it lasts.
Not necessarily. Treatment in a walking boot with early weight-bearing gives results comparable to surgery for many people. Surgery may suit high-level athletes or a tear that was not treated early. The decision is made with you, not in advance.
Usually months rather than weeks. A loading programme takes around twelve weeks to show its effect, and pain that has been there a long time can take longer. It improves most reliably when the exercise is kept up.
Often yes, at a reduced level, as long as the pain stays mild and has settled by the next morning. Pain that is worse the day after is the signal that the load is too much and needs cutting back.
No. Bring any ultrasound or MRI reports, and be ready to describe how it started — particularly whether there was a single moment with a pop.
Be ready to say how it started, and whether there was a moment with a pop. That one answer decides how soon you need to be seen.
