My Achilles hurts so much? What shall I do?

After a sudden change in activity (load) or direct trauma, an Achilles tendon may become very painful, so much so that exercise and sometimes even walking can be very sore and difficult to do. In this article, we explore why this might be the case, what the pain means, and what you can do about it.

In this article:

1. Why the sudden Achilles pain?

2. What does having this amount of pain mean?

3. What can I do to help my Achilles tendon to recover?

Why the sudden Achilles pain?

Sometimes, when an Achilles tendon has experienced a sudden change in activity (load) or suffered a direct blow/trauma, it can react and cause very acute and intense pain. This is known as a reactive tendinopathy.

A healthy tendon is made up of lots of collagen fibres parallel to each other. These fibres are organized in bundles. There are many such bundles in a tendon. It is this parallel-and-bundle arrangement that makes a tendon so strong.

If you were to look at a reactive tendinopathy under a microscope, you would see minimal changes to the collagen fibres and bundles. The main change would be an increase in fluid among the fibres. This is thought to be a reversible process.

If you have a longstanding Achilles problem or indeed changes to the fibres of your tendon, you can still get a reactive tendinopathy in a part of your tendon. This can therefore create an acute reaction (reactive tendinopathy) on top of an old injury.

What does having this amount of pain mean?

The amount of pain and symptoms you have doesn't tell you anything about the severity of the injury. Pain is part of your body's alarm system, and what you feel depends on how sensitive your alarm system is.

When you stop training and rest an injury, it just calms the alarm system down - it doesn’t rehabilitate or make your tendon more robust to withstand the load (amount of activity) you want to do.

So, pain does NOT equal harm or damage.

What can I do to help my Achilles tendon to recover?

In a nutshell: The treatment consists of activity/load management, exercise, and possibly anti-inflammatory drugs.

Activity/load management

This is where knowledge about your job, your sport, and activities of your day-to-day life is important, as well as information on how much, how often, and how intense you do them.

When they are healthy, our tendons can handle the forces of our normal activities. This includes the load we put through them when we walk, run, jump, dance, or whatever activity we choose to do that contracts our calf muscles or resists a stretching force to the calf muscles. This is known as tensile load.

When you have a reactive tendinopathy, reducing this tensile load is important – for example decreasing how fast you run, or for how long you do an activity. This is not the same as resting your tendon completely – tendons do not get more robust to handle the activity you want to do by resting. We refer to this approach as relative rest.

This means that modifying your activity is paramount. Pain can settle quite quickly when you decrease activity (in as little as 5-10 days) but if you then increase the activity again before the tendon is robust enough to handle it, it can increase the symptoms again.

A general guide to help with this is that you should first be comfortable at rest and with normal walking before restarting your sporting activity. Then, you should monitor your symptoms for 24 hours after you have done something. Tendons are typically more sore later that day or the next day than they are at the time of exercising. It’s usually OK if you experience a niggle level of pain (0-3/10) over the next 24 hours. If it goes above this level, it may mean that the activity was too intense for what your tendon currently wants.

You can keep your fitness levels up by cross-training. This means choosing an exercise, such as swimming or cycling, that does not flare your pain up. If you are unsure or can’t get this fine balance right with the demands of your day-to-day life / sport and training, please get advice. This is something that we can also help you with.

Strengthening exercises

Strengthening exercises help to increase the robustness of the tendon, but there is no one-size-fits-all. What strength training exercise programme will work for you depends on you, your fitness levels, pain levels and training – it’s really worth seeking guidance from a professional.

Traditionally, isometric exercises (a contraction without movement) have been advocated for reactive tendinopathies. An example of an isometric exercise for your gluteal muscles is to clench your buttock muscles while you are sitting. These types of exercises for your calf muscles can be a useful starting point for people who cannot, because of pain, start with exercises with movement, e.g. calf raises.

Reactive tendinopathies may not like a compressive force either, e.g. stretching your foot over the side of a step – this position brings your Achilles tendon closer to the heel bone, causing it to compress there. This is not a problem for healthy tendons but can irritate your tendon when it is injured. Therefore, avoiding calf stretches may be a good idea in the short term. Stretching can be resumed, with advice, once things settle.

Medication

Inflammation has not been shown to occur in a reactive tendinopathy. Despite this, anti-inflammatory medication is thought to be helpful – the theory being that it inhibits the production of proteins responsible for tendon swelling. Please remember always speak to a GP or pharmacist before taking any medication.

The solution to getting rid of a really painful tendon lies in combining all the advice above in a treatment plan that is individualised to you. That’s why we always start our online treatment process by doing a thorough assessment of you to find your ideal starting point. For example: what you can do without flaring any symptoms, what you would like to be able to do in the future and how strong you are right now. Based on your current strength and capability, we then design a rehabilitation and load management programme that suits you and your lifestyle.

How we can help

Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

About the Author:

Alison Gould is a chartered physiotherapist and holds an MSc in Sports and Exercise Medicine. You can follow her on LinkedIn, Facebook, Instagram, and Twitter.

References

1. Cook, J.L. and Purdam, C.R., 2009. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), pp.409-416.

2. Cook, J.L. and Purdam, C., 2012. Is compressive load a factor in the development of tendinopathy?. Br J Sports Med, 46(3), pp.163-168.

3. Cook JL, Rio E, Purdam CR, et al. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? British Journal of Sports Medicine 2016;50:1187-1191.