Achilles Tendon Pain That Won’t Settle (Achilles Tendinopathy): Causes, Treatment and When Surgery Is Considered

What is long-standing Achilles tendon pain (Achilles tendinopathy)?

Guidelines call long-standing Achilles tendon pain Achilles tendinopathy, and they describe it by where the symptoms are: in the middle part of the tendon, or where it attaches to the heel bone ^[1]. The Dutch multidisciplinary guideline describes the midportion form as symptoms 2 to 7 cm above the tendon’s attachment to the heel bone, and the insertional form as symptoms within 2 cm of that attachment ^[1]. Not every guideline draws the line in the same place: the 2024 American physical therapy guideline describes midportion pain as more than 2 cm above the attachment, and insertional pain as lower down, near the attachment ^[2]. Where the pain is felt is one part of the assessment, not a diagnosis on its own ^[2].

A partial tear (partial Achilles tendon tear) is a partial break in the continuity of the tendon ^[3]. There is no universally accepted way of grading partial tears ^[3]. How a partial tear tends to show itself is described under Sore tendon or a tear? ^[3].

Pain where the tendon meets the heel (insertional Achilles tendinopathy)

In my practice, long-standing pain at the back of the heel is mostly at the Achilles insertion, where the tendon joins the heel bone, and at that point there may be wear and tear, a tear, or inflammation. This is a practice observation, not a measured figure.

Several of the guideline recommendations further down this page are stated for the midportion form only, and are not established for pain at the heel end ^[2].

Pain at the back of the heel is not always the tendon. I treat bursitis at the back of the heel (retrocalcaneal bursitis), Achilles tendon inflammation or wear, an Achilles rupture and pinching at the back of the ankle (posterior ankle impingement) as separate conditions, because telling them apart is what makes the right treatment possible. Pinching at the back of the ankle is covered on my hindfoot endoscopy page.

Why does it happen?

In my experience, the cause is almost always a very tight calf muscle, or a lack of flexibility.

As part of preventing Achilles tendinopathy, the Dutch guideline recommends building up training gradually ^[1]. It also advises considering avoiding a group of antibiotics called fluoroquinolones, when a suitable alternative is available and the clinical situation allows ^[1].

The commonest mistake I see in runners and regular walkers is rehabilitation that is too short, followed by an early return to running or walking. In my experience, a tendon that has not had time to recover from the inflammation and the wear is more likely to flare up again, sooner and at shorter distances. Inadequate rehabilitation brings people back to me again and again.

Sore tendon or a tear? When to see a doctor quickly

In my experience, Achilles pain without weakness and without a pop is more likely to be a partial tear, inflammation or simple wear of the tendon, and it is usually treated with good physiotherapy and is less likely to need surgery.

A published review describes a partial tear differently: it usually starts suddenly, and people often have pain when they load the tendon and a feeling of weakness, while usually still able to train, though not at full effort ^[3]. That description is not the same as mine above, and both are given here ^[3].

A complete tear of the Achilles comes with pain, and often with a sound or a sudden feeling at the heel. Weakness in pushing off is a sign of a complete tear, and it should be seen by a specialist at the earliest. If you think you may have torn your Achilles suddenly, my Achilles tendon rupture page explains what to do, and the operation for a sudden rupture is described on its own page, keyhole-assisted (arthroscopic) repair of a torn Achilles tendon.

If you have sudden difficulty breathing, go to the nearest hospital emergency department straight away. To contact us: Dr. Kini, +91 99208 61187, or the clinic, +91 98207 89797.

How it is diagnosed

For the midportion form, the Dutch guideline bases the diagnosis on four findings, all of which should be present: symptoms 2 to 7 cm above the attachment, pain when the tendon is loaded, local thickening of the tendon, and pain when it is pressed ^[1]. The thickening may be absent when the symptoms have been present for only a short time ^[1]. The guideline gives a separate list of four findings for the insertional form ^[1].

The guideline recommends considering a scan or X-ray when the symptoms do not fit all four findings, when the problem does not follow the expected course, or when surgery is being considered ^[1]. The possible tests include an ultrasound of the tendon, an MRI of the ankle and an X-ray of the heel bone, though not every test is needed for every person ^[1]. Ultrasound is preferred, and for pain at the heel end, the guideline lists a side-view X-ray of the heel bone, to look for a bony abnormality ^[1].

When I look at an MRI for a partial tear, I judge it by how much of the tendon’s circumference is torn.

What is tried first: rest, stretching and exercise

In my experience, with long-standing pain at the back of the heel, rest alone does not help, and it can even make the pain worse. For the midportion form, the American guideline says complete rest is not indicated, and that people should carry on with activities within their pain tolerance; this is not established for pain at the heel end ^[2].

For people with midportion tendinopathy whose tendon is not thought to be structurally frail, the same guideline recommends tendon-loading exercise, with loads as high as can be tolerated, as a first-line treatment to improve function and reduce pain (a grade A recommendation) ^[2]. This recommendation is for midportion tendinopathy, diagnosed as described under How it is diagnosed ^{[1] [2]}. It is not extended to pain at the heel end, and it is not a recommendation about partial tears, which are described separately above ^{[2] [3]}.

In my practice, the focus is a stretching and flexibility programme, done regularly, for a minimum of 4 to 6 weeks before judging the result. People who do not keep up the exercises are more likely to have incomplete treatment, or for the problem to come back, and keeping them up is the hardest part of the treatment.

The Dutch guideline recommends progressive calf-strengthening exercises for at least 12 weeks, as part of the first active treatment for both the midportion and the insertional forms ^[1]. It also advises telling people with long-standing Achilles tendinopathy that simply waiting is expected to bring no, or only limited, improvement in the short term ^[1].

These timings are for different kinds of exercise, so they are not directly comparable: in my practice, a stretching programme is judged after a minimum of 4 to 6 weeks, while the Dutch guideline recommends progressive strengthening for at least 12 weeks as part of the first active treatment ^[1]. The emphasis differs too, with stretching in my practice and strengthening (loading) exercise in the guidelines ^{[1] [2]}.

If you are clinically stable and are asking for an operation, you may not need one; I explain why, and I offer exercise, changes to footwear and a trial of rehabilitation. I explain that an operation can be done at any time once we both agree, but it cannot be reversed, so the decision to operate is the most important one. The commonest footwear mistake I see is unsupported, slipper-type footwear with a thin, soft sole. Where physiotherapy is needed I will say so, because without it you are less likely to get better.

For the midportion form, the American guideline advises against night splints and against low-level laser therapy to improve symptoms ^[2]. Separately, it advises against therapeutic ultrasound used on its own to treat Achilles tendinopathy ^[2]. For orthoses (shoe inserts) in the midportion form, it makes no recommendation either way, because the evidence is contradictory ^[2].

For pain at the heel end, one randomised trial of 50 people with long-standing insertional tendinopathy that had not settled with treatment compared low-energy shockwave therapy (extracorporeal shock wave therapy) with an eccentric-loading programme in which the heel was lowered below step level ^[4]. At four months, 16 of 25 people (64%) in the shockwave group and 7 of 25 (28%) in the exercise group were completely recovered or much improved (p < 0.020) ^[4]. This is one trial, and it does not show that shockwave is better than every eccentric-exercise programme ^[4]. Five people had missing four-month outcome data, and because people could switch treatment after four months, there is no clean longer-term comparison ^[4].

Injections: PRP and steroid

If patients ask me about injections, in my practice PRP (platelet-rich plasma) injections can be tried in small, partial tears of a worn tendon.

The trials of PRP described here studied long-standing midportion tendinopathy, not partial tears ^{[5] [6]}. In a double-blind randomised trial of 54 people with long-standing midportion Achilles tendinopathy (27 in each group, with complete follow-up), a PRP injection combined with eccentric exercises did not produce a significantly greater improvement in a symptom-and-function questionnaire score at 24 weeks than a saline (salt-water) injection with the same exercises ^[5]. This does not show that the two are equivalent, and it is not about partial tears or about pain at the heel end ^[5].

A 2024 systematic review and meta-analysis of six randomised trials (422 patients) with long-standing midportion Achilles tendinopathy found no statistically significant difference between PRP and control injections in questionnaire scores or tendon thickness at 3, 6 or 12 months ^[6]. This, too, does not establish that they are equivalent ^[6]. The trials had a mixed risk of bias, and the review includes the trial above, so it is not an independent confirmation of it ^[6]. Its findings do not apply to pain at the heel end ^[6].

In my experience, steroid (corticosteroid) injections are very commonly given; they bring the pain down, but they can cause degeneration of the tendon and lead to a full tear.

A 1996 review found that no rigorous published studies had measured the risk of Achilles tendon rupture with or without a local steroid injection, so the risks and benefits could not be weighed from the evidence then available ^[7]. That is a 1996 statement, not proof that no such evidence exists today ^[7]. The same 1996 review reported that the two studies it judged rigorous, one randomised trial and one cohort study, showed no benefit of steroid injection over placebo ^[7].

When is surgery considered?

In my practice, if pain persists despite a good six weeks of rehabilitation, I ask for an MRI scan to look for a tear. If the MRI shows a full tear, or a partial tear of more than 30% of the tendon’s circumference, it is more likely to need surgery. A partial tear of up to 30% can be rehabilitated and made stronger with an exercise programme, and is less likely to need surgery. The 30% figure is the rule I use in my practice, not a figure from the studies on this page; as noted above, there is no universally accepted way of grading partial tears ^[3]. For a tear of that kind, the operation I suggest is a repair of the torn tendon (tendo-Achilles repair). A sudden complete rupture is a different situation, covered on my Achilles tendon rupture page.

The Dutch guideline recommends considering surgery only when someone has not recovered after at least six months of active treatment, for both the midportion and the insertional forms ^[1]. It also recommends discussing how effective surgery is expected to be compared with continuing active non-surgical treatment, and its possible complications ^[1]. These timings differ: my six weeks is the point at which I look for a tear on an MRI scan, while the guideline’s six months concerns tendinopathy that has not recovered with active treatment ^[1].

Other operations appear in the research ^{[8] [9]}. A systematic review found that releasing a tight calf muscle (isolated gastrocnemius release) was associated with less pain and better foot and ankle function, with a possible reduction in ankle strength (strength fell in four studies, but not in three) ^[8]. That evidence is low in quality, small and non-randomised (ten studies: one prospective case–control study, one cohort study and eight case series) ^[8]. It does not prove that the operation caused the improvement, and it could not separate heel-end from midportion pain ^[8].

For pain at the heel end, a 2025 systematic review compared keyhole (endoscopic) surgery with open surgery ^[9]. It found no statistically significant difference between them in improvement on a foot-and-ankle function score (AOFAS), which does not mean they are equivalent ^[9]. The review reported an earlier return to daily activities and to sport after keyhole surgery, based on six and ten studies respectively ^[9]. All 39 studies in the review were observational and mostly of low or very low quality, and the function-score analysis used 22 of them, without stating the number of patients ^[9].

Recovery after surgery

When I recommend an Achilles tendon repair, I tell patients to plan for usually one night in hospital. In my practice, in the early stage after the operation, only toe-touch weight-bearing is allowed (touching the toes down), as far as pain permits. I ask patients to use a walker for 2 to 3 weeks, and to do rehabilitation for a minimum of 6 to 8 weeks after the operation. After that, they can move on to gym-based strength and conditioning.

If a repair does not hold

Before an Achilles tendon repair, I discuss the degree of wear (degeneration) in the tendon and the size of the gap, because these can make a repair fail.

Reconstruction, by a tendon transfer or a synthetic augment, is a different operation from the original repair.

Getting back to running and walking

Without surgery, the Dutch guideline advises spending enough time on active treatment, at least a few months, before returning to full, symptom-free sports loading ^[1]. Returning to sport within days is associated with a greater likelihood of the problem coming back ^[1]. The guideline gives no exact number of months and no recurrence rate ^[1].

Going back too soon after too short a rehabilitation is the commonest mistake I see, as described under Why does it happen?.

Questions about your own Achilles pain

Many people have already seen a physiotherapist or another doctor, or read about their condition online, before they see me. If your Achilles pain has not settled, or you have weakness when pushing off, see a qualified foot and ankle specialist, and take your previous scans, tests and notes with you, so that the specialist can see what has already been tried.

Common questions