Achilles Tendonitis

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A Patient's Guide  ·  Mr Matthew Welck — Consultant Foot & Ankle Surgeon, RNOH Stanmore & UCL

Achilles Tendonitis

The Achilles is the strongest tendon in the body, but also one of the most commonly injured. “Achilles tendonitis” describes pain, swelling and inflammation in the tendon. There are two distinct types — and knowing which one you have is the key to the right treatment.

01

What Is Achilles Tendonitis?

The Achilles tendon connects your calf muscles to the back of your heel. When it becomes painful, swollen or thickened, this is broadly called Achilles tendonitis (more accurately tendinopathy, because it usually reflects wear-and-tear rather than pure inflammation). It comes in two forms:

Non-Insertional

The problem sits in the middle portion of the tendon, roughly 4–6 cm above the heel. The tendon often feels thickened, with tender lumps to squeeze. This is the more common type, especially in runners and active middle-aged adults.

Insertional

The problem sits right where the tendon attaches to the heel bone. There is often a bony lump (a Haglund's deformity) that rubs against shoes. This type is more common in less active people, women, and those who wear stiff-backed shoes.

02

How Common Is It?

Achilles problems affect around 2 in every 100 adults at some point, and the figures are higher in runners and recreational athletes.

Non-Insertional

Makes up roughly two-thirds of cases. Most people are aged 30–50. It is the classic “runner's” tendon problem.

Insertional

Accounts for the remaining third. More common after age 50 and in people who are less active or have very tight calves.

03

What Causes It?

Both types share a common theme: the tendon is asked to do more than it can repair, or not given enough time to repair. Risk factors include sudden increases in activity, tight calves, age-related tendon changes, certain antibiotics, diabetes and high cholesterol.

Non-Insertional

Most often a “training error” — ramping up running mileage too quickly, hill work, or returning to sport after time off, failure to stretch or inadequate footwear.

Insertional

More often mechanical irritation. A prominent heel bone, stiff shoes (work boots, court shoes) and tight calves all squeeze and rub the tendon on the bone where it inserts.

04

What Are the Symptoms?

Both types share morning stiffness, pain after exercise, and a tendon that feels worse at the start of activity, eases briefly, then flares afterwards.

Non-Insertional

Pain and a tender, sometimes thickened lump 4–6 cm above the heel. It is sore to squeeze in this area. Pain is usually worst at the start of a run and after stopping.

Insertional

Pain right at the back of the heel where the tendon meets bone. A visible bony bump is common. Shoes with hard backs cause direct pressure — many people switch to backless slippers at home.

05

What Investigations Might You Need?

A careful history and examination diagnose most cases. Imaging confirms the type and severity.

Non-Insertional

Ultrasound is excellent for showing tendon thickening, abnormal blood vessels and small tears in the mid-tendon. MRI is often reserved for severe or pre-surgical cases.

Insertional

A weight-bearing X-ray is essential to look for bony spurs and the prominent heel bump. MRI shows how much of the tendon is damaged at its attachment, which guides surgical planning.

06

Non-Surgical Treatment Options

Most patients improve without surgery. The cornerstone is a structured exercise programme, but the treatment differs between the two types.

Non-Insertional

The gold-standard treatment is heel-stretch exercises (lowering the heel off a step), done daily for 12 weeks. Around 80–90% of patients improve. Shockwave therapy, activity modification and a small heel raise, and orthotics can also help. Injections are seldom indicated. Mr Welck has a stepwise algorithm he takes his patients through.

Insertional

Eccentric exercises are done flat on the floor, not over a step — dipping below the step squashes the tendon onto the heel bone and worsens pain, therefore stretching has to be more careful. Stretching and other non-surgical treatments such as shockwave therapy are less useful. A higher percentage of patients with this condition come to needing surgery.

07

Surgical Options

Surgery is considered when 6–12 months of dedicated non-surgical treatment fails.

Non-Insertional

The most common procedure is a gastrocnemius recession (a small release of the tight calf muscle), often combined with tendon debridement (cleaning out damaged tissue), sometimes minimally invasively.

Insertional

Surgery typically involves removing the prominent heel-bone bump (Haglund's), debriding the damaged tendon and re-anchoring it to the heel using bone anchors. If more than half the tendon is damaged, an FHL tendon transfer (using the big-toe tendon) reinforces the repair. Recovery is longer.

08

Why Choose Mr Welck?

Mr Matthew Welck is a Consultant Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH) Stanmore and Honorary Associate Clinical Professor at UCL. With double fellowship training and over 50 peer-reviewed publications, he treats the full spectrum of Achilles tendon problems — both insertional and non-insertional, NHS and private.

09

Frequently Asked Questions

Will I need surgery?

Around 80% of patients avoid surgery with the right exercise programme.

How long does recovery take?

For non-insertional, expect 3–6 months of rehab; for insertional, often longer because of the bony component.

Can I keep running?

In non-insertional cases, modified running is often safe. In insertional cases, a temporary break or a switch to cycling is usually advised.

Will it come back?

Both types can recur, but maintaining calf strength and gradual training progression dramatically reduces the risk.

10

Book a Consultation

To arrange a consultation with Mr Welck for assessment of your Achilles tendon, please get in touch:

This page is for information only. It does not replace personalised medical advice. Always consult a qualified clinician for diagnosis and treatment.

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