The Achilles tendon is the thick strong tendon at the back of the ankle. Pain in the Achilles tendon is a common complaint amongst runners and sports people, even those who do not participate in exercise.

Generally Achilles pain can be divided into sudden or gradual onset pain. Sudden pain is usually the result of a tear or rupture of the tendon. Whilst this is not rare, gradual onset pain is more frequent. Pain which develops slowly and gradually gets worse is most often caused by a group of injuries, known as tendinopathies. These are degenerative conditions of the tendon or the surrounding paratenon, also often known as tendonitis, although this suggests the presence of inflammatory cells which biopsies have not demonstrated.

Other causes of gradual onset pain could be Achilles bursitis or severs disease, although these are less frequent.

Achilles tendonitis can occur in either the mid-portion of the tendon, or at the insertion or attachment point to the heel bone. In mid-portion tendonitis the pain is located approximately 2inches above the heel bone. In insertional cases, it is at the attachment point.

Other symptoms include:

• Stiffness in the tendon, especially after periods of rest.

• The tendon may appear thicker and red compared to the other side.

• It is tender to touch the tendon.

• Pain tends to ease as the tendon warms-up and then hurts more after exercise.

• You may feel small lumps in the tendon (nodules).

• The tendon may ‘creak’ on movement.

Treatment of Achilles pain caused by a tendinopathy should initially involve rest and the application of cold therapy to ease pain and encourage blood flow. When ice is applied initially there is a decrease in blood flow, however when removed after 10-15 minutes there is a massive influx of blood to the area. This is important in Achilles injuries, as the tendon has a notoriously low blood flow which can make healing slow.

Other treatment methods should include gentle stretching of the calf muscle complex, sports massage to the calf muscles and frictions to the tendon. Ultrasound or laser therapy may also be effective. Heel raises can be placed in the shoes on a temporary basis to help take the strain off the tendon. However, wearing these long-term can lead to shortening of the tendon.

Once initial pain has decreased, an eccentric strengthening programme can be implemented. Eccentric exercises involve contracting the muscle whilst it lengthens (as opposed to concentric – where it shortens!). This type of exercise has been shown to be most effective in treating Achilles tendinopathies. The heel drop exercise is the gold standard here, performed on a step, starting on the tip toes and lowering the heels down slowly, under complete control until the heel is below the level of the step.

As pain decreases, a gradual return to sport can be implemented, although to is important to ensure that any factors which may have contributed towards the development of the injury are corrected before returning. Common causative factors include tight or weak calf muscles, overpronation, sudden increases in activity, hill running and wearing high heels regularly.