Achilles tendonitis

Anatomy: What does the Achilles tendon do?

The Achilles tendon connects the calf muscles (gastrocnemius and soleus) with the heel bone (calcaneus). It transmits high forces when walking, running and jumping. The middle tendon zone (“midportion”) lies 2–6 cm above the heel bone and has less blood supply. This explains the tendency to irritation and slower healing processes.

• Midportion: typical location of tendinitis/tendinopathy
• Insertion (attachment to the heel bone): more likely to be enthesopathy, often with bone spurs or bursa involvement
• Paratenon: thin layer of sliding tissue around the tendon, can become separately inflamed (paratendinitis)

What is Achilles tendinitis?

Achilles tendonitis is a painful irritation of the tendon, usually in the midportion area. Tendinopathy is often the cause: an irritable condition with structural changes triggered by overload, insufficient regeneration or biomechanical factors. Acute signs of inflammation can be present, but stress-dependent pain symptoms are dominant.

• Those affected are those who do sports (e.g. runners), but also those who do a lot of standing/walking for work
• Symptoms develop gradually or after a sudden burst of stress
• Early management improves the course

Typical symptoms

• Pain and tenderness 2-6 cm above the heel
• Morning stiffness, starting or starting pain, later pain on exertion
• Swelling or thickening of the tendon
• Pain when climbing stairs, running uphill, sprinting
• Occasional rubbing noises or crunching in paratendinitis

Causes and risk factors

The tendon is often overwhelmed by a sudden increase in training or monotonous repetitive stress. Technology, footwear and individual factors also play a role.

• Stress: rapid increase in volume or intensity, lots of mountain runs/sprints
• Calf muscle imbalance, limited dorsiflexion (shortened calf muscles)
• Foot axis/misalignments (e.g. overpronation), leg length differences
• Inappropriate or worn footwear, hard surfaces
• Systemic factors: obesity, diabetes, dyslipidemia
• Medications: Fluoroquinolones, rarely statins (check with a doctor)
• Previous injuries and inadequate regeneration

Diagnostics: this is how we proceed

At the beginning there is a discussion about complaints, stress and goals. This is followed by a physical examination with functional and provocation tests.

• Inspection and palpation: pain point, thickening, warming
• Function: toe stand, calf strength, single leg lifting test
• Flexibility: Dorsiflexion, Silfverskiöld test (gastrocnemius vs. soleus)
• Exclusion of tendon rupture: e.g. B. Thompson test for acute trauma
• Ultrasound: tendon thickness, fiber structure, lubrication; optional Doppler (neovascularization)
• MRI: if the diagnosis is unclear, there is no response or a partial tear is suspected
• X-ray: v. a. if attachment problems are suspected (bone spurs, Haglund configuration)

Differential diagnoses

• Achilles tendon insertion irritation/enthesopathy (insertion) – different location, often with retrocalcaneal bursa
• Paratendinitis (inflammation of the sliding tissue)
• Partial or complete tear of the Achilles tendon
• Retrocalcaneal bursitis, Haglund exostosis
• Plantar fascia irritation in the hindfoot area
• Referred pain/neuropathic causes, rarely spondyloarthropathies

Conservative therapy: structured step-by-step plan

Most Achilles tendonitis can be treated well with conservative measures. Adapted load control and progressive strength training are crucial. We plan therapies individually – based on activity level and goals.

Phase 1: Acute management (1–3 weeks)

• Relative rest instead of complete immobilization: avoid pain provocation, continue everyday activities in a measured manner
• Cool after exercise, observe pain level
• Short-term use of NSAIDs can relieve pain (consult a doctor, not a long-term solution)
• Temporary heel wedge (5-10mm) to reduce load for 1-2 weeks
• Tape/bandages for relief, soft heel cap
• Isometric calf exercises (e.g. 5×45–60 s hold, moderate pain intensity tolerable)

Phase 2: Build-up (4-12 weeks)

• Eccentric training or heavy load training (HSR): 3x15 repetitions eccentric twice a day or HSR 3x/week, progressively increasing
• Stretching of the calf muscles in a measured manner, without severe pain
• Physiotherapy: manual therapy, gliding improvement, technique training
• Insoles/shoe advice for overpronation or axis abnormalities
• Activity modification: cycling/swimming instead of sprinting/mountain running

Phase 3: Return to Running/Sport (from weeks 8-12)

• Gradual running programs (walk-run interval), pain during/after exercise ≤ 3–4/10
• Jumping and plyometric elements only when everyday activities and running have little symptoms
• Continuation of strength training 2–3 times/week to prevent recurrences

Pain is a leading signal: slight discomfort is tolerable as it builds up, a significant increase after 24-48 hours indicates overload and requires adjustments.

Regenerative and complementary processes – when does it make sense?

If structured basic therapy over several weeks does not have sufficient effect, additional procedures can be considered. We carefully explain the benefits, risks and evidence.

• Extracorporeal shock wave therapy (ESWT): can reduce pain and stimulate healing, especially a. in persistent midportion tendinopathy
• Autologous conditioned plasma (ACP/PRP): studies mixed; Option for treatment-resistant symptoms
• Infiltrations: Cortisone is not injected into the tendon (increased risk of rupture). Paratendinous, ultrasound-targeted measures are considered individually.
• Dry needling/peeling techniques are only used in selected cases

Orthoses, bandages and footwear

• Temporary heel wedges and Achilles tendon supports can reduce the peak load
• Stable, well-cushioned running shoes; Pronation control if necessary
• Insoles for axial deviations or functional overpronation
• Barefoot or minimal shoe concepts only gradually and after building up stability

Exercises for home

Exercises should be challenging but controlled. Pain up to about 3/10 is tolerable, persistent after-effects require adjustment.

Prevention and stress control

• Increase the load slowly (e.g. 10% rule), plan recovery days
• Regular calf and hip strength training
• Technique and step training, variation in training (surface, speed)
• Warm up before intensive sessions, cool down afterwards
• change shoes on time; Check deposits
• React early at the first warning signs

Course and prognosis

With consistent conservative therapy, symptoms often improve within 6-12 weeks. Complete normalization of the load can take 3-6 months, longer in chronic cases. Consistency and a structured strength program are crucial to avoid relapses.

Safely back to sport and everyday life

• Low pain in everyday life, one-legged toe stand can be performed painlessly
• Running interval program with no clear reaction the following day
• Plyometrics only when jumping tests (two-legged/one-legged) are possible without subsequent problems
• Maintain strength training, gradually increase volumes

When should you seek medical advice?

• Acute, whip-crack-like pain with sudden weakness – suspected tear
• Increasing pain at rest, significant swelling/overheating
• Complaints > 4–6 weeks despite adjusting the load
• Concomitant systemic diseases or medication issues (e.g. fluoroquinolones)

Surgical options – rarely necessary

Surgery is an option if there is insufficient improvement after 6-12 months of consistent conservative therapy or if there is significant structural damage. Procedures include, but are not limited to: Debridement of degenerative parts, paratenolysis or gastrocnemius recession in the case of functional shortening. The indication is given cautiously and individually.

After surgery, structured follow-up treatment, moderate stress and long-term strength training are important. We will explain the risks, possible complications and the realistic benefits in a personal conversation.

Your treatment in Hamburg-Winterhude

Our practice at Dorotheenstraße 48, 22301 Hamburg, specializes in conservative orthopedics and joint-preserving therapies. We combine precise diagnostics with a clear rehabilitation schedule tailored to your everyday life or sport. Appointments can be requested flexibly via Doctolib or by email.