Achilles Tendon Pain and Rupture
Achilles tendon pain, tears and rupture
The Achilles tendon connects the calf muscles to the heel bone and transmits force during walking, running and jumping. Achilles symptoms can come from long-standing tendon overload, insertional disease or a sudden partial or complete rupture. These are different problems with different treatment pathways.
Main types of Achilles tendon disorder
Midportion tendinopathy
This usually affects the tendon about 2–6 cm above the heel attachment. Typical symptoms are load-related pain, morning stiffness and sometimes tendon thickening. Although ‘Achilles tendonitis’ is a common search term, most chronic tendinopathy is not simply an inflamed tendon.
Insertional tendinopathy
This causes symptoms at the attachment to the heel and may coexist with calcification, a prominent posterosuperior calcaneus or retrocalcaneal bursitis. Treatment exercises need to take compression at the insertion into account.
Partial and complete rupture
Rupture may occur during a sudden push-off, acceleration or jump. Patients sometimes describe a pop or feeling of being kicked. They may have difficulty pushing off or rising onto tiptoe. A complete rupture deserves prompt assessment even if the patient can still walk. Many people can still walk after a complete rupture, which is one reason it is sometimes missed at first.
How the diagnosis is made
Examination assesses tenderness, tendon contour, resting tension, calf strength and the calf-squeeze (Thompson) test where appropriate. Ultrasound or MRI may clarify an uncertain rupture, partial tear, complex insertional disease or an operation plan, but imaging is not always needed for straightforward tendinopathy.
Tendinopathy treatment without surgery
Progressive exercise-based loading is the cornerstone of treatment. Rehabilitation includes calf strengthening tailored to the site of disease, gradual reintroduction of running or sport, and modification of aggravating activities. A heel lift or footwear change can be helpful for some patients. For insertional disease, exercising deep into dorsiflexion over a step can be poorly tolerated and may need modification. Shockwave therapy is sometimes considered after a suitable rehabilitation trial, but evidence and availability vary. Injections around the tendon require caution; corticosteroid injection into the tendon itself is generally avoided because of rupture risk. A large randomised trial found that a platelet-rich plasma (PRP) injection was no better than a sham injection. Tendinopathy treatment is commonly measured in months, not days.
When might surgery help tendinopathy?
Surgery is considered for selected patients whose symptoms remain disabling after adequate non-surgical treatment. Operations may include debridement, removal of associated bony prominence or calcification, calf (gastrocnemius) lengthening in selected patients, and tendon reattachment or reconstruction in more advanced disease. The chosen technique depends on site and extent of pathology and must be weighed against wound, nerve and healing risks.
Achilles rupture: surgery or boot treatment?
Both contemporary non-operative functional rehabilitation and surgical repair are established treatments for acute complete rupture. A boot with heel wedges and a closely managed progressive rehabilitation programme can achieve good outcomes in suitable patients. Surgical repair brings the tendon ends together through open or minimally invasive incisions. In a large 2022 randomised trial of 554 patients, patient-reported outcomes at 12 months were similar across groups. Rerupture occurred in about 6% after non-operative care compared with under 1% after surgery, whereas nerve injuries were more frequent after surgery, particularly minimally invasive repair (about 5%). These trade-offs should be discussed rather than assuming surgery is always best. Time from injury, tendon gap/apposition, occupation, sporting goals and access to supervised rehabilitation matter. Non-operative treatment works best when it starts soon after the injury, so early assessment is important.
Chronic or missed rupture
With delayed presentation, tendon retraction and scar tissue can make direct repair difficult. Reconstruction, tendon transfer or graft augmentation may be required. Management differs from a recent rupture and should be assessed individually.
Rehabilitation and risk
Whether treated with surgery or functional bracing, rupture recovery requires protection followed by progressive loading. As a general guide, a boot with heel wedges is commonly worn for about 8–10 weeks; running often resumes at around 4–6 months and higher-demand sport at 9–12 months. Most people can drive again at about 8–12 weeks. Full strength can take a year or more, and some calf weakness may persist. Risks include rerupture, elongation, blood clots (more common after Achilles rupture than after many other ankle injuries, so blood-thinning medication may be advised), stiffness, reduced push-off strength and, after surgery, infection, wound problems or sural nerve injury. Contact the rooms promptly if you develop a fever, increasing wound redness or discharge, severe worsening pain or calf swelling after surgery; call 111 for chest pain or breathlessness.
Common questions
Can I keep exercising with Achilles tendinopathy?
Often yes, but load should be tailored to symptoms and recovery, rather than pushing through severe pain.
Is a painful thick tendon about to rupture?
Not necessarily. Chronic tendinopathy and acute rupture are different conditions.
Does every complete rupture need an operation?
No. Functional non-operative treatment is a well-established option for suitable patients.
I felt a pop and now cannot push off properly. What should I do?
Seek timely medical assessment for possible rupture.
Seeking specialist advice
Persistent Achilles pain or suspected rupture warrants diagnosis-specific guidance. This page does not replace a supervised rupture rehabilitation protocol. An Achilles rupture is an injury, so it is usually covered by ACC once your claim is accepted; see the ACC questions on our Your appointment page.
Related pages: Ankle fracture, Driving after surgery.
Reviewed by Mr Suren Senthi, MBChB, FRACS (Orth), orthopaedic foot and ankle surgeon in Auckland, fellowship trained in foot and ankle surgery and paediatric orthopaedics. About Mr Senthi.