Achilles Tendonitis

Dr Chong Xue Ling
Dr Chong Xue Ling
Senior Consultant Orthopaedic Surgeon

Achilles tendonitis is an overuse injury affecting the Achilles tendon, which connects the calf muscles to the heel bone. Repeated stress on the tendon leads to inflammation, causing pain and stiffness in the lower leg near the heel. The condition can develop gradually and affect individuals of all activity levels, from athletes to those with a sedentary lifestyle. Symptoms can range from mild discomfort to significant pain that interferes with movement and daily activities.

Symptoms of Achilles Tendonitis

Symptoms of Achilles tendonitis vary in severity and may develop gradually or worsen over time. Common signs include:

Pain and stiffness along the Achilles tendon

Discomfort is often worse in the morning or after rest and may ease with movement. However, prolonged activity can aggravate the pain.

Swelling or thickening of the tendon

The affected area may appear enlarged compared to the unaffected leg, indicating inflammation or early tendon degeneration.

Reduced strength and flexibility

Difficulty pointing the toes downward or standing on tiptoes due to pain and changes in tendon structure.

A crackling sensation during movement

A grating or crackling sound (crepitus) may occur as the inflamed tendon moves against its surrounding sheath, indicating friction.

Tenderness and warmth

The area over the tendon may feel warm to the touch, and applying pressure often triggers sharp, localised pain.

Causes and Risk Factors

Achilles tendonitis develops when excessive strain on the tendon leads to microscopic tears and inflammation. Several factors contribute to its onset:

A rapid increase in exercise intensity or duration places excessive stress on the tendon, which may not adapt quickly enough, leading to tissue damage.

Shoes lacking proper support or cushioning fail to absorb impact forces effectively, increasing strain on the Achilles tendon.

Flat feet, high arches, or irregular foot mechanics can alter weight distribution, creating added tension on the tendon.

As tendons lose elasticity with age, they become less resilient to stress and more susceptible to injury.

Running or exercising on hard or uneven surfaces increases impact forces on the tendon, heightening the risk of irritation and injury.

Conditions such as rheumatoid arthritis, psoriasis, and high blood pressure can affect tendon health by altering blood flow and tissue composition.

Diagnostic Methods

Physical examination

The doctor inspects the foot and ankle for tenderness, swelling, and movement restrictions. The Achilles tendon is palpated along its length to identify painful areas, and the patient may be asked to perform specific movements, such as standing on tiptoes, to assess function and discomfort.

Thompson test

This test helps differentiate tendonitis from a full tendon rupture. While the patient lies face down, the calf muscle is squeezed. If the foot moves normally, the tendon remains intact. A lack of movement may indicate a rupture, requiring further evaluation.

Ultrasound imaging

A non-invasive test that uses sound waves to create detailed images of the tendon. It can reveal inflammation, thickening, or small tears and allows real-time assessment of the tendon’s movement and structure.

MRI scan

Used when further detail is needed, particularly if there are concerns about severe tendon degeneration, partial tears, or chronic inflammation. MRI scans provide high-resolution images of both the tendon and surrounding tissues.

X-rays

Although they do not show soft tissues like tendons, X-rays can detect bone spurs or calcifications at the tendon’s attachment site, which are common in insertional Achilles tendonitis. They can also help rule out fractures or arthritis in the nearby joints.

Treatment Options

Achilles tendonitis is managed with a step-by-step approach, starting with non-surgical treatments. If symptoms persist despite conservative care, surgical options may be considered.

Non-Surgical Treatment

  • Activity modification: Reducing or avoiding activities that put excessive strain on the Achilles tendon allows it to heal. High-impact exercises like running or jumping should be temporarily replaced with low-impact activities such as swimming or cycling, which maintain fitness without overstressing the tendon.
  • Ice therapy: Applying ice for 15–20 minutes several times a day can help manage pain and inflammation. Cold therapy constricts blood vessels, reducing swelling and discomfort. Ice should always be wrapped in a cloth or towel to prevent skin irritation or frostbite.
  • Non-steroidal anti-inflammatory drugs (NSAIDs): Over-the-counter medications such as ibuprofen or naproxen can help relieve pain and inflammation. These should be used as directed and are most effective during the early stages of tendonitis when inflammation is most pronounced.
  • Physical therapy: A structured rehabilitation programme, including stretching and strengthening exercises, can improve flexibility and tendon resilience. Eccentric exercises, where the muscle lengthens while under tension, have been shown to be particularly effective in promoting tendon healing and reducing symptoms.

Surgical Treatment

  • Tendon debridement and repair: This procedure involves removing damaged or degenerated tendon tissue while preserving as much healthy tendon as possible. If the remaining tendon is strong enough, it is repaired with sutures to restore function. In more severe cases, additional reinforcement may be needed using nearby tendons.
  • Removal of bone spurs (if present): In cases of insertional Achilles tendonitis, bone spurs that have formed at the heel can cause persistent irritation. Surgery removes these spurs, and if necessary, the tendon is partially detached and later reattached to allow proper healing.
  • Gastrocnemius recession: If tight calf muscles contribute to excessive strain on the Achilles tendon, a surgical lengthening of the gastrocnemius muscle can reduce tension and improve flexibility. This can help prevent further tendon irritation and reduce the likelihood of recurrence.

Prevention and Management

Preventing Achilles tendonitis involves gradually increasing activity levels, warming up before exercise, and wearing supportive footwear to reduce strain. Regular stretching and strengthening exercises improve tendon flexibility and resilience, while cross-training with low-impact activities helps prevent overuse injuries. Addressing foot alignment issues with proper footwear or orthotics can also reduce stress on the tendon. For those recovering from Achilles tendonitis, maintaining these practices helps prevent recurrence and supports long-term tendon health.

Dr Chong Xue Ling

Dr Chong Xue Ling

Senior Consultant Orthopaedic Surgeon

Dr Chong Xue Ling is a Swiss fellowship-trained orthopaedic surgeon specialising in foot and ankle, as well as shoulder and elbow surgery.

She is a member of the European Group for the Study and Research of Minimally Invasive Surgery of the Foot and Ankle. For shoulder and elbow surgery, she completed her fellowship at La Tour Hospital, an accredited Swiss Olympic Medical Centre and learnt innovative techniques in arthroplasty for earlier return to activity as well as the stabilising techniques, developed to have greater strength without extensive fixation.

  • MBBS (S’pore)
  • MRCS (Ireland)
  • MMed Orthopaedic (S’pore)
  • FRCS Orthopaedic (Edinburgh)

Through active involvement in research, she aims to constantly improve existing treatment in the pursuit of quality care for her patients.

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    Achilles Tendonitis

    Frequently Asked
    Questions

    How long does recovery take?

    Mild cases may improve within 2–4 weeks, while more severe or chronic cases can take 3–6 months. A gradual return to activity is necessary to prevent recurrence.

    Can I still exercise with Achilles tendonitis?

    Yes, but activities should be modified. Low-impact exercises like swimming or cycling help maintain fitness while reducing strain. Avoid movements that cause pain.

    Can Achilles tendonitis return after treatment?

    Yes, recurrence is possible if risk factors such as overuse, poor footwear, or biomechanical issues are not addressed. Ongoing management and preventive measures help reduce the risk.