Achilles Tendinitis (Tendinopathy)

Achilles tendinopathy is pain, stiffness and swelling of the Achilles tendon, usually from overuse. NICE CKS describes it as persistent Achilles tendon pain and loss of function related to mechanical loading. Most people improve with activity changes and a structured calf-loading programme; surgery is kept for those who do not settle after a full course of non-surgical care.

The Achilles tendon joins the calf muscles to the heel bone. Problems fall into two groups: non-insertional (mid-portion) tendinopathy, which affects the tendon about 2–6 cm above the heel, and insertional tendinopathy, at the point where the tendon attaches to the bone. Mid-portion disease is often seen in runners and people with heavy physical work, and about 30% of people with it are not sports-active.

What are the symptoms?

• Pain and stiffness at the back of the heel or lower calf, often worse first thing in the morning or after rest
• Tenderness along the tendon, sometimes with swelling or thickening
• Pain that worsens with walking, running or climbing stairs
• For insertional disease, pain right at the back of the heel, sometimes with a bony bump

NICE CKS notes that symptoms are typically worse at night, at rest, or when restarting activity, and are provoked by walking, running and jumping.

What causes it?

The exact cause is not fully known. Intrinsic factors (foot shape, age, systemic conditions) and extrinsic factors (sudden increases in training, poor footwear, quinolone antibiotics, steroids) both play a part. Histology tends to show degenerative change rather than simple inflammation, which is why "tendinopathy" is often preferred to "tendinitis".

How is it diagnosed?

Diagnosis is usually clinical. Examination looks for tenderness in the mid-portion or at the insertion, thickening, and pain with loading tests such as a single heel raise. Imaging is used when the picture is unclear or symptoms persist. NICE CKS advises considering heel X-ray and/or ultrasound if symptoms persist for more than six weeks. Ultrasound (including Doppler for new vessels) and MRI may also be used; both can give false positives and negatives, so clinical correlation is essential.

A suspected rupture needs urgent assessment: a sudden snap, a gap in the tendon, or inability to push off.

What are the non-surgical options?

• Relative rest and activity modification (reducing aggravating load while staying active in other ways)
• Supportive footwear; a small heel raise may reduce tendon strain
• Short-term pain relief and ice for flares
• A progressive calf-loading exercise programme with a physiotherapist (eccentric or heavy slow resistance programmes are the mainstay)
• Extracorporeal shockwave therapy (ESWT) for longer-lasting symptoms

Guy's and St Thomas' NHS guidance states that most people need 6 to 9 months of rehabilitation before they can return to full activities without pain, and that shockwave therapy may be considered if symptoms have not improved after an appropriate exercise programme. Eccentric strengthening (for example Alfredson's regime) is the mainstay of loading programmes. Evidence for extracorporeal shockwave therapy is limited, and evidence for high-volume injection is mixed. Steroid injection into the Achilles is controversial because of reported cases of rupture.

For mid-portion (non-insertional) tendinopathy that has not settled, Mr Hester can also offer high-volume paratenon injections, as stated on his live Achilles tendinitis page.

When is surgery considered?

Surgery for non-insertional Achilles tendinopathy may be recommended after more than 12 months of conservative measures with no improvement. Options on Mr Hester's live page include:

• Debridement of degenerated tendon tissue
• Removal of inflamed bursae or calcific spurs (insertional disease)
• Tendon reinforcement or transfer if a large amount of tissue has to be removed
• A proximal medial gastrocnemius recession to reduce tension on the tendon

Risks include infection, delayed wound healing, nerve injury, stiffness, blood clots and further surgery. These are discussed individually before an operation.

What is recovery like after surgery?

This is a typical pathway from Mr Hester's live page; your plan is confirmed at each review.

• 0–2 weeks: rest; bulky dressing or back slab; non-weight-bearing
• 2 weeks: wound review; transition to a boot
• 2–6 weeks: gradual weight-bearing in the boot; gentle movement
• 6–12 weeks: physiotherapy begins; wean out of the boot
• 3–6 months: progressive return to full activity and sport-specific rehab
• 6–12 months: return to impact activity for many people

How Mr Hester can help

Mr Hester is a dual fellowship-trained foot and ankle surgeon (FRCS Tr&Orth), trained at Guy's and St Thomas' and in Toronto and Calgary, and a member of EFAS. He sees patients privately at The London Clinic, Cromwell Hospital, King Edward VII's Hospital and HCA The Shard. His NHS practice is at King's College Hospital.

Insured patients need a GP referral and an authorisation code from their insurer. Self-pay patients are welcome. To book, call 020 7046 8004.

Frequently Asked Questions

Sources

1. Achilles tendinopathy. NICE Clinical Knowledge Summaries. https://cks.nice.org.uk/topics/achilles-tendinopathy/
2. Achilles tendinopathy. Guy's and St Thomas' NHS Foundation Trust. https://www.guysandstthomas.nhs.uk/health-information/achilles-tendinopathy
3. A Patient's Guide to Achilles Tendinopathy. Royal National Orthopaedic Hospital. https://www.rnoh.nhs.uk/patients-and-visitors/patient-information-guides/achilles-tendinopathy