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Health condition · Clinically reviewed

Achilles tendinitis, loading, footwear and why steroids stay away from this tendon.

Acute inflammation, not the chronic degenerative disease it’s often confused with. Managed well early, most people return to sport within 12 weeks.

Jump to treatment
A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE CKS, BOFAS and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK guidance including eccentric loading, shockwave therapy and the avoidance of intratendinous corticosteroids.

Key facts

Achilles tendinitis at a glance.

The essentials, in plain English - what it is, where it hurts, and how it’s treated in the UK today.

  • What it is

    Acute inflammation of the Achilles tendon or its surrounding structures - distinct from chronic degenerative tendinopathy.

  • Anatomy

    Mid-portion (2-6cm above insertion), insertional (at the calcaneus) and retrocalcaneal bursitis (Haglund deformity) behave and respond differently.

  • Typical trigger

    A sudden overload - a new runner, a return to sport after a break, or calf tightness in a middle-aged athlete.

  • Drug link

    Fluoroquinolone antibiotics (ciprofloxacin, levofloxacin) and long-term steroids are known tendon toxicities - report symptoms early.

  • First-line care

    Relative rest, ice, NSAIDs short-term, a heel lift and structured physiotherapy - the Alfredson eccentric protocol is the backbone.

  • The steroid rule

    Never inject corticosteroid into the tendon itself - it dramatically raises the risk of rupture. Peritendinous injection is controversial.

Why this guide matters

Load it right, don’t rest it wrong.

Acute Achilles tendinitis is common, treatable and usually settles within 12 weeks. The three points below shape everything else on this page.

  • Acute inflammation is not degeneration

    Tendinitis and chronic tendinopathy look similar but behave differently - ultrasound helps tell them apart and the rehab focus differs.

  • Loading is the treatment

    The best-evidenced intervention is a structured eccentric loading programme, not rest or a boot. The tendon needs work to heal.

  • Steroids belong away from this tendon

    Intratendinous corticosteroid injection is contraindicated - the rupture risk is significant. First-line care is rehab, footwear and time.

How the diagnosis is made

From first twinge to a clear plan.

The steps a UK GP, physiotherapist or foot and ankle surgeon will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    History and mechanism

    Sudden onset after a change in load, new footwear, a hill session or a return to sport - often with morning stiffness.

  2. 02

    Assessing

    Clinical examination

    Tenderness, swelling and warmth over the tendon - the Simmonds-Thompson (calf squeeze) test rules out a rupture.

  3. 03

    Assessing

    Locate the pain

    Mid-portion, insertional or posterior heel (bursitis) - each has a different pathway and prognosis.

  4. 04

    Confirming

    Ultrasound assessment

    The workhorse test - shows tendon thickening, peritendinous fluid and hyperaemia on Doppler. Differentiates acute inflammation from chronic tendinopathy.

  5. 05

    Confirming

    MRI when needed

    Reserved for equivocal cases, suspected partial tear or pre-surgical planning - shows tendon signal change, bursitis and bone-marrow oedema.

  6. 06

    Confirming

    Weight-bearing X-ray

    Useful for insertional disease - shows calcific enthesophytes and a Haglund deformity (prominent posterior-superior calcaneus).

  7. 07

    Preparing

    Drug and medical review

    Ask about fluoroquinolones, oral or injected steroids, statins and any inflammatory-arthritis features - all can drive tendon disease.

Typical timeline: a first visit to a working rehab plan in days, not weeks.

Symptoms

What Achilles tendinitis actually feels like.

The classic pattern of morning stiffness, posterior heel pain and swelling - and the features that mean it’s time to escalate.

  • Posterior heel pain

    Sharp or aching pain 2-6cm above the heel, or at the insertion itself - worse first thing and after activity.

  • Morning stiffness

    A stiff, painful first few steps that ease with gentle movement - a classic tendon-injury pattern.

  • Swelling and warmth

    A visibly thickened or fusiform tendon, sometimes with local warmth in the acute phase.

  • Crepitus on movement

    A creaking sensation as the tendon glides - suggests paratenonitis (inflammation of the surrounding sheath).

  • Posterior heel bump

    A hard bump at the back of the heel - Haglund deformity - often rubbing against the shoe counter.

  • Pain climbing stairs

    Aggravated by push-off, hills, stairs and hopping - anything that loads the tendon eccentrically.

  • Middle-aged onset

    Peak incidence in 30-55 year olds returning to sport or increasing training load quickly.

  • Red flag - sudden pop

    A snapping sensation with immediate weakness may be a rupture - urgent assessment and Simmonds-Thompson test needed.

Treatment

How Achilles tendinitis is treated in the UK.

Load management and physiotherapy first, footwear and shockwave next - and surgery only for the few who need it.

  • Relative rest and load management

    Not immobilisation - a stepped reduction in aggravating activity while keeping the tendon moving. The single most important early intervention.

  • Ice and short-course NSAIDs

    Useful in the first 7-14 days for pain and swelling - long-term NSAID use is not helpful and may impair tendon healing.

  • Heel lift or orthotic

    A 6-12mm heel raise unloads the tendon during walking - a simple, evidence-supported first step, especially for insertional disease.

  • Physiotherapy and eccentric loading

    The Alfredson protocol - twice daily eccentric heel drops for 12 weeks. The best-evidenced conservative treatment for mid-portion disease.

  • Isometric loading (insertional)

    For insertional disease, eccentric drops off a step can worsen symptoms - isometric holds and heavy slow resistance are preferred.

  • Shockwave therapy (ESWT)

    Extracorporeal shockwave for symptoms not settling by 3-6 months - reasonable evidence for both mid-portion and insertional disease.

  • PRP and injectables

    Platelet-rich plasma has mixed evidence. High-volume image-guided injections around (not into) the tendon are used in specialist centres.

  • Surgical debridement or repair

    For refractory cases at 6-12 months - debridement, Haglund resection or FHL tendon transfer, always after exhausting rehab.

What this guide is based on

The sources behind every claim on this page.

UK national guidance, specialist society standards and the primary research trials that shaped modern loading rehab.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP, physiotherapist or foot and ankle surgeon knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • NICE Clinical Knowledge Summary. Achilles tendinopathy.

  • British Orthopaedic Foot and Ankle Society (BOFAS). Patient information on Achilles disorders.

  • Alfredson H et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis.

  • MHRA Drug Safety Update. Fluoroquinolone antibiotics: reminder of tendon disorders and other serious side effects.

Red flags

When Achilles pain needs urgent attention.

Most Achilles tendinitis is manageable in primary care and physiotherapy. These are the situations that aren’t.

  • Suspected rupture

    A sudden pop, immediate weakness, inability to stand on tip-toes, or a positive Simmonds-Thompson test - urgent orthopaedic assessment within 48 hours.

  • Fluoroquinolone exposure

    New Achilles pain within days-to-weeks of ciprofloxacin, levofloxacin or a related antibiotic - stop the drug and seek review promptly.

  • Systemic inflammatory features

    Bilateral Achilles pain with morning stiffness elsewhere, uveitis, psoriasis or IBD - consider a spondyloarthropathy screen.

  • Recent corticosteroid injection

    Any Achilles pain after a peritendinous or intratendinous steroid injection needs urgent review - rupture risk is significantly increased.

  • Sepsis or joint infection features

    Fever, cellulitis, an overlying wound or a rapidly worsening red, hot heel - rule out infection before assuming tendinitis.

  • Progressive weakness

    Ongoing loss of push-off strength despite rehab may signal a partial tear needing MRI and surgical opinion.

  • Persistent night pain

    Rest and night pain unresponsive to conservative care warrants imaging to exclude other causes of posterior ankle pain.

  • Bilateral spontaneous disease

    Bilateral onset without a training trigger raises the suspicion of drug-induced tendinopathy or a systemic cause.

  • Failed 3-month rehab

    No improvement after 12 weeks of appropriate loading deserves specialist review and imaging.

Living with it

A treatable condition, with a clear ladder.

Four things that make the biggest difference week to week - managing load, sticking with rehab, choosing supportive footwear and knowing when to step up.

A quiet reminder

Consistency beats intensity, every time.

Twice-daily heel drops for three months look boring on paper. They also work better than any injection, brace or hero week of rest.

  1. 01 Load

    Manage load, don’t rest completely

    Total rest weakens the tendon. Reduce aggravating activity, keep gentle loading and progress it slowly.

  2. 02 Patience

    Give rehab 12 weeks

    Eccentric loading is not a quick fix - twice daily for three months is the evidence base. Judge progress in weeks, not days.

  3. 03 Footwear

    Small changes add up

    A heel raise, a supportive trainer and avoiding stiff-heeled shoes can meaningfully offload the tendon.

  4. 04 Escalate

    Know when to seek more

    If pain persists past 12 weeks of good rehab, ask about shockwave, imaging and a specialist opinion - don’t settle for chronic disease.

Frequently asked

Everything we get asked about Achilles tendinitis.

Quick answers on rehab, running, steroid injections and when surgery is the right call.

  • What is Achilles tendinitis?

    True Achilles tendinitis is acute inflammation of the tendon or its surrounding paratenon, usually after a sudden change in load. It’s distinct from Achilles tendinopathy, which is a chronic degenerative condition of the tendon substance with little true inflammation.

  • How is it different from Achilles tendinopathy?

    Tendinitis is acute and inflammatory, with swelling, warmth and pain that has developed over days to weeks. Tendinopathy is chronic degeneration - months of pain with a thickened, sometimes nodular tendon and no true inflammatory infiltrate on biopsy. Ultrasound helps tell them apart and the treatment focus shifts from anti-inflammatory measures to structured loading.

  • Can I still run with Achilles pain?

    Often yes, but at reduced volume and intensity. Modern guidance is relative rest, not total rest - the tendon needs load to heal. Stop hill sessions, speed work and long runs, and rebuild gradually alongside a loading programme.

  • Are steroid injections used for Achilles tendinitis?

    Intratendinous corticosteroid should never be given - the rupture risk is significant. Peritendinous injections are controversial and only performed in specialist centres under ultrasound guidance. First-line treatment is loading, footwear modification and time.

  • What is the Alfredson protocol?

    A twice-daily eccentric heel-drop programme performed for 12 weeks - three sets of 15 repetitions of both bent-knee and straight-knee drops off a step. It remains the best-evidenced conservative treatment for mid-portion Achilles tendinopathy and often follows acute tendinitis into the rehab phase.

  • When is surgery needed?

    Surgery is reserved for refractory cases at 6-12 months, or for Haglund deformity that keeps rubbing on the shoe counter. Options include debridement, calcaneal osteotomy or FHL tendon transfer. It is always a last step after exhausting loading, footwear changes and shockwave therapy.

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