Achilles tendinitis: symptoms, treatment and recovery

NICE Clinical Knowledge Summaries (CKS) says that, once a rupture has been ruled out, management starts with self-care. This means applying cold or heat packs after an acute injury, short-term pain relief such as paracetamol or a short course of anti-inflammatory tablets where suitable, and changing activity. CKS says to avoid complete rest, to continue activities if pain is tolerated and to restart exercise when pain is controlled.

The NHS tendonitis page gives general advice for tendon injuries: rest for 2 to 3 days, ice wrapped in a tea towel for up to 20 minutes every 2 to 3 hours, support with a snug bandage, and moving the area gently as soon as pain allows. It adds that a pharmacist can recommend the best painkiller and an ibuprofen gel.

CKS says to consider referral to physiotherapy if there is no improvement in 7 to 10 days with self-care, and to consider a heel X-ray and/or ultrasound scan if symptoms persist for more than six weeks. The physiotherapy team may advise about progressive tendon loading exercises, stretches and other treatments.

Specialist treatment described by CKS includes a progressive tendon loading exercise programme 2 to 3 times a week, increasing intensity according to pain tolerance, and extracorporeal shock-wave therapy (ESWT), which may stimulate tissue healing and provide pain relief. Heel lifts can be considered to reduce load during activity for non-insertional tendinopathy.

CKS advises against injecting corticosteroid into or around the tendon. It says surgery may be indicated for persistent symptoms after at least six months of conservative treatment, and referral to a sports physician or orthopaedics if there is diagnostic uncertainty, a delayed response or ongoing symptoms after six months.

The NHS heel pain page lists pain in the back of the heel, and in the ankle and calf, as the pattern for Achilles tendonitis. NICE CKS describes a gradual onset of localised pain and swelling at the back of the heel, in and around the tendon, with stiffness and reduced function. Symptoms are typically worse at night, at rest or when restarting activity, and are provoked by walking, running and jumping.

CKS describes two patterns. Non-insertional tendinopathy affects an area of the tendon approximately 2 to 6 cm above where it attaches to the heel bone, and is the most common site. Insertional tendinopathy affects the attachment itself, with tenderness over the lowest 2 cm of the tendon and possible redness, swelling and nodularity.

The NHS says the main symptoms of tendonitis in general are pain in a tendon that gets worse when you move, difficulty moving the joint, a grating or crackling sensation when you move the tendon, and swelling, sometimes with heat or redness.

CKS says the exact cause is not known, but it is thought that excessive, repetitive and/or abnormal loading during physical activity disrupts the tendon's repair mechanisms and contributes to degenerative changes. The NHS says tendonitis is usually caused by sudden, sharp movements or repetitive exercise such as running, jumping or throwing.

CKS lists intrinsic risk factors such as biomechanical abnormalities, systemic conditions and increasing age, and extrinsic factors such as running and jumping activities (particularly increased or changed training schedules), mechanical injury, inappropriate footwear and drugs such as fluoroquinolone antibiotics. It says that any potentially causative medicines, such as fluoroquinolone antibiotics, should be stopped immediately and specialist advice sought.

A complete tear needs urgent assessment. The NHS heel pain page lists sudden sharp pain in the heel, swelling, a popping or snapping sound during the injury and difficulty walking as signs of a heel fracture or ruptured Achilles tendon. It says to contact NHS 111 if you have severe heel pain after an injury, have heard a snap, grinding or popping noise at the time of injury, are not able to walk, are not able to walk on your tiptoes or up the stairs, or have swelling and bruising in your calf and ankle.

CKS says that if rupture is suspected, emergency admission or same-day orthopaedic referral should be arranged depending on local pathways. It lists rupture as a possible complication of Achilles tendinopathy.

NICE CKS says full recovery from Achilles tendinopathy can take a year or longer and that re-injury is common. This is longer than for an ordinary tendon strain, for which the NHS says a mild tendon injury should feel better within 2 to 3 weeks. The difference reflects the overuse and degenerative changes involved in Achilles tendinopathy.

CKS advises educating people to recognise future symptoms early and to adjust tendon load and activity early, in order to reduce the risk of re-injury and reduce recovery time.

The NHS says you cannot always prevent tendonitis, but there are things that reduce the chance of a tendon injury, and CKS lists modifiable factors to address.

• Warm up before exercising and gently stretch afterwards (NHS).

• Wear supportive shoes or insoles for exercise (NHS), and get footwear advice (CKS).

• Take regular breaks from repetitive exercises, and do not overexercise tired muscles (NHS).

• Change training loads gradually; CKS notes increased or changed training schedules are a risk factor.

• Manage weight where relevant (CKS).

• Tell your doctor if you are prescribed a fluoroquinolone antibiotic and develop tendon pain (CKS).

The NHS says to see a GP if heel pain is severe or stopping you doing normal activities, is getting worse or keeps coming back, has not improved after 2 weeks of home treatment, or if you have tingling, loss of sensation or diabetes. It says in many areas you can get physiotherapy from NHS community musculoskeletal (MSK) services without a GP referral.

Some people choose to see a private physiotherapist or sports medicine doctor, particularly for a loading programme or shockwave therapy. In general terms the same steps apply: a clinical assessment to rule out rupture, imaging if symptoms persist, and a graded exercise programme. Ask how progress will be reviewed and what happens if there is no improvement after 3 to 6 months.