What Causes Achilles Pain?

One of the biggest misconceptions about Achilles pain is that it always begins with a dramatic injury. In reality, most patients cannot recall a single event. Instead, the tendon is gradually overloaded until it can no longer keep up with the demands placed upon it.

Think of the Achilles tendon like a rope. Every run, jump, or step places stress on it. Normally, the tendon repairs those microscopic areas of damage. However, when the workload consistently exceeds the tendon’s ability to heal, degeneration begins to develop.

Common risk factors include:

• Sudden increases in running or walking mileage

• Starting a new exercise program

• Soccer, basketball, tennis, and pickleball

• Hill running or sprint training

• Tight calf muscles

• Weak calf muscles

• Flat feet or high arches

• Poorly fitting or worn-out shoes

• Previous ankle injuries

• Obesity

• Diabetes

• Smoking

• Certain antibiotics, such as fluoroquinolones

• Age-related tendon degeneration

Often it is several of these factors—not just one—that lead to persistent Achilles pain.

What Are the Symptoms?

Symptoms often begin subtly before becoming more noticeable over time.

The most common symptoms include:

• Pain in the back of the heel or lower calf

• Morning stiffness that improves after a few minutes of walking

• Pain when climbing stairs

• Pain while pushing off during walking or running

• Tenderness when squeezing the tendon

• Thickening of the tendon

• Swelling

• Decreased athletic performance

• Pain after exercise that may be worse later that evening or the following morning

Many runners describe a classic pattern: the tendon hurts during the first mile, feels better after warming up, and then becomes significantly more painful after the run. This is a common presentation of chronic Achilles tendinopathy.

When Should You See a Foot & Ankle Specialist?

Not every episode of Achilles pain requires immediate evaluation. Mild soreness after an unusually strenuous workout often resolves with temporary activity modification.

However, I recommend being evaluated if:

• Your pain lasts longer than two to four weeks.

• You have persistent swelling.

• Walking becomes painful.

• You cannot participate in your normal activities.

• You notice increasing weakness.

• You develop a lump within the tendon.

• You hear or feel a sudden “pop.”

A sudden pop associated with difficulty pushing off or standing on your toes raises concern for an Achilles tendon rupture, which should be evaluated promptly.

How Is Achilles Tendinopathy Diagnosed?

The diagnosis begins with listening carefully to your history. Understanding when the pain started, how it has progressed, and what activities make it worse often provides important clues.

During the physical examination, I evaluate:

• The exact location of your pain

• Areas of tendon thickening

• Calf flexibility

• Strength of the calf muscles

• Foot alignment

• Walking mechanics

• Balance

• Whether there are signs of a partial tendon tear

• Whether another condition could be causing your symptoms

Many cases can be diagnosed with a careful history and physical examination alone.

Do You Need X-Rays or an MRI?

X-rays are frequently obtained during the initial evaluation. Although they do not show the tendon itself, they help identify bone spurs, calcification, arthritis, fractures, and a Haglund’s deformity that may be contributing to your symptoms.

MRI is not necessary for every patient.

I generally recommend MRI when:

• Symptoms fail to improve despite appropriate treatment.

• I suspect a partial tendon tear.

• Surgery is being considered.

• Another diagnosis remains possible.

MRI provides detailed information regarding the quality of the tendon, the extent of degeneration, and whether there is associated inflammation or tearing.

Diagnostic ultrasound can also be an excellent tool in experienced hands and offers the advantage of evaluating the tendon dynamically during movement.

My Treatment Philosophy

One of the questions patients ask most often is:

“What’s the fastest way to get rid of this?”

The honest answer is that tendon healing cannot be rushed.

There are treatments that improve the healing environment, reduce pain, and restore strength, but there is no injection, medication, or operation that instantly creates a healthy tendon.

My philosophy is straightforward:

First, identify why the tendon became overloaded. Then correct the problem—not just the pain.

That may mean improving calf strength, modifying training, changing footwear, addressing foot alignment, or temporarily decreasing activity while the tendon heals.

The goal is not simply getting you through next weekend.

The goal is helping you return to the activities you enjoy without the pain coming back.

Conservative Treatment

The overwhelming majority of my patients improve without surgery.

Treatment is individualized but commonly includes:

Activity Modification

Activity modification does not necessarily mean complete rest.

Instead, we temporarily reduce activities that continue to overload the tendon while maintaining overall fitness whenever possible. Cycling, swimming, elliptical training, and other lower-impact exercises often allow patients to stay active while their Achilles recovers.

Physical Therapy

Physical therapy remains the single most important component of treatment for most patients.

A structured rehabilitation program focuses on:

• Progressive strengthening

• Eccentric loading exercises

• Calf flexibility

• Balance and proprioception

• Hip and core strengthening

• Correction of abnormal movement patterns

• Gradual return to sport

The goal is not only to reduce pain but also to improve the tendon’s ability to tolerate force.

Clinical Pearl from Dr. Sarang Desai

Patients often ask me whether they should completely stop exercising.

Usually, the answer is no.

The key is choosing activities that allow the tendon to recover rather than repeatedly irritating it. In many cases, we can keep patients active while still allowing the Achilles to heal.

That approach tends to produce happier patients—and better long-term results.

Advanced Non-Surgical Treatment

Most patients who come to my office have already tried something. They have stretched, changed shoes, rested for a week, bought inserts online, or taken anti-inflammatory medication. Sometimes these measures help, but persistent Achilles pain usually requires a more structured approach.

The key is understanding that chronic Achilles tendinopathy is not simply an inflammatory condition. It is a problem of tendon health and tendon loading. Successful treatment focuses on restoring the tendon’s ability to tolerate stress rather than simply masking pain.

Eccentric Strengthening

One of the most thoroughly studied treatments for chronic Achilles tendinopathy is eccentric strengthening.

These exercises involve slowly lowering the heel while the calf muscle contracts. Although they may seem simple, they stimulate tendon remodeling and encourage healthier collagen formation over time.

Patients are often surprised that these exercises may produce mild discomfort during rehabilitation. That does not necessarily mean the exercises are harmful. A properly supervised physical therapy program helps determine the appropriate amount of loading while avoiding overload.

Recovery requires consistency. Missing several weeks of therapy or stopping exercises as soon as the pain improves often leads to recurrence.

Footwear Matters More Than Most People Think

Your shoes directly influence the amount of stress placed on the Achilles tendon.

I commonly recommend:

• Supportive athletic shoes

• Replacing worn running shoes regularly

• Avoiding excessively worn heels

• Avoiding sudden transitions into minimalist footwear when symptoms are present

For runners, rotating shoes and ensuring they match your foot type can also reduce repetitive stress on the tendon.

Do Heel Lifts Help?

In many patients, yes.

A temporary heel lift decreases tension on the Achilles tendon by placing it in a slightly shortened position. This can be especially beneficial during the early stages of treatment or for patients with insertional Achilles tendinopathy.

Heel lifts are generally a temporary measure. As pain improves and strength returns, they are gradually discontinued.

Are Orthotics Worth It?

Not every patient needs orthotics.

However, patients with significant flatfoot, abnormal mechanics, or excessive pronation may benefit from custom or well-designed over-the-counter orthotics that improve alignment and reduce abnormal loading across the tendon.

Orthotics are rarely a cure by themselves, but they can be an important part of a comprehensive treatment plan.

Shockwave Therapy

Extracorporeal Shockwave Therapy (ESWT) has become an increasingly popular treatment for chronic Achilles tendinopathy.

Shockwave therapy uses mechanical energy to stimulate the body’s healing response within the damaged tendon.

Current research suggests that some patients—particularly those with chronic symptoms who have failed traditional rehabilitation—may benefit from ESWT when it is combined with an appropriate physical therapy program.

It is not a miracle treatment, but in carefully selected patients it can provide meaningful improvement while avoiding surgery.

What About PRP?

Platelet-Rich Plasma (PRP) receives a great deal of attention, particularly among athletes.

PRP involves concentrating platelets from your own blood and injecting them into the area of tendon degeneration in an effort to stimulate healing.

Patients often ask whether PRP “works.”

The honest answer is that the scientific evidence is mixed.

Some studies have shown improvement, while others have demonstrated little difference compared with a structured rehabilitation program alone.

For that reason, I do not routinely recommend PRP for every patient. Instead, I individualize the decision based on the patient’s age, MRI findings, activity level, duration of symptoms, previous treatments, and goals.

When used appropriately, PRP may be a useful adjunct, but it should never replace a comprehensive rehabilitation program.

Why I Generally Avoid Cortisone Injections

This is one of the most important discussions I have with patients.

Although cortisone injections can reduce inflammation in many areas of the body, they are generally not recommended within or around the Achilles tendon because they may weaken the tendon and increase the risk of rupture.

For that reason, I rarely recommend cortisone injections for Achilles tendinopathy.

Whenever possible, I prefer treatments that improve tendon health rather than simply decreasing pain for a short period of time.

Can You Continue Exercising?

In many cases, yes.

One of the biggest misconceptions is that every patient with Achilles pain must completely stop exercising.

Instead, I usually recommend modifying activities while maintaining overall fitness.

Depending on the severity of symptoms, patients are often able to continue:

• Cycling

• Swimming

• Deep-water running

• Upper-body strength training

• Certain lower-impact gym exercises

The goal is to reduce repetitive overload on the tendon while keeping the rest of the body healthy and active.

When Should Surgery Be Considered?

Fortunately, surgery is necessary for only a small percentage of patients.

I generally begin discussing surgery when:

• Symptoms have persisted for six months or longer despite appropriate treatment.

• A dedicated rehabilitation program has failed.

• MRI demonstrates significant tendon degeneration or partial tearing.

• There is a large Haglund’s deformity causing ongoing mechanical irritation.

• Pain continues to interfere with work, exercise, or everyday life.

The decision to proceed with surgery is never based solely on an MRI.

I treat patients—not imaging studies.

Some patients have significant degeneration on MRI with very little pain, while others have debilitating symptoms despite relatively modest imaging findings.

The decision is always based on the combination of your symptoms, physical examination, activity level, imaging, and personal goals.

Clinical Pearl from Dr. Sarang Desai

One of the most rewarding conversations I have is telling a patient they don’t need surgery.

Many people arrive assuming an operation is inevitable because their pain has lasted for months.

In reality, the majority of patients improve with the right rehabilitation program. Surgery is an excellent option when conservative treatment truly fails, but my goal is always to help patients recover without an operation whenever possible.

Surgical Treatment

When patients hear the word “surgery,” they often imagine that the Achilles tendon is simply sewn back together.

In reality, Achilles surgery is highly individualized. The procedure depends on where the tendon is damaged, how much of the tendon has degenerated, and whether other problems—such as a Haglund’s deformity or bone spurs—are contributing to the pain.

My goal is always to preserve as much healthy tendon as possible while removing only the diseased tissue that is preventing healing.

Surgery for Insertional Achilles Tendinopathy

Insertional Achilles tendinopathy often involves more than just the tendon itself.

Many patients also have:

• Chronic tendon degeneration

• Bone spurs

• Calcium deposits within the tendon

• A Haglund’s deformity

• Inflamed bursae around the tendon

When these problems are present, surgery may involve several components:

• Removal of diseased tendon tissue

• Removal of bone spurs

• Excision of inflamed bursa

• Resection of the Haglund’s deformity

• Repair of the remaining healthy tendon back to the heel using modern suture anchor fixation

The exact procedure depends on your MRI findings and the quality of the tendon at the time of surgery.

What Is a Haglund’s Deformity?

A Haglund’s deformity is an enlargement of the upper back portion of the heel bone.

Many patients refer to it as a “pump bump.”

As the Achilles tendon repeatedly rubs against this prominence, irritation develops.

If the bone remains uncorrected, simply treating the tendon may not completely resolve symptoms.

For patients with significant bony prominence, removing the Haglund’s deformity is often an important part of successful treatment.

When Is an FHL Tendon Transfer Needed?

Patients often become nervous after reading online about FHL tendon transfers.

Fortunately, most Achilles surgeries do not require one.

The Flexor Hallucis Longus (FHL) tendon helps flex the big toe.

In patients with severe tendon degeneration—particularly when a large portion of the Achilles must be removed—the FHL tendon can be transferred to reinforce the repair and improve strength.

Because other muscles continue to flex the big toe, most patients notice very little functional loss after this procedure.

It is an excellent option when the native Achilles tendon is too damaged to provide a durable repair by itself.

Gastrocnemius Recession

Some patients have an extremely tight calf muscle despite months of stretching.

Persistent calf tightness places increased stress on the Achilles tendon every time you walk.

For carefully selected patients, lengthening the gastrocnemius muscle through a small incision can decrease tension across the Achilles and improve long-term function.

Not every patient needs this procedure, but when calf tightness is a major contributor to symptoms, it can significantly improve outcomes.

Recovery After Surgery

Recovery depends on the exact procedure performed and the quality of the tendon.

Although every patient heals differently, a typical recovery follows this general progression.

Weeks 0–2

Your ankle is protected in a splint or boot.

Elevation is extremely important during this period to minimize swelling and protect the incision.

Depending on the procedure, you may remain non-weight bearing.

Weeks 2–6

The incision is evaluated and sutures are removed.

Patients typically transition into a walking boot and begin gentle range-of-motion exercises under the guidance of physical therapy.

Weight-bearing progresses based on healing and the type of repair performed.

Weeks 6–12

Patients gradually transition into supportive athletic shoes.

Physical therapy becomes more aggressive, focusing on restoring motion, rebuilding strength, improving balance, and normalizing gait.

Many patients begin feeling substantially better during this phase, although the tendon is still healing.

Three to Six Months

Strength and endurance continue to improve.

Many patients return to:

• Golf

• Cycling

• Hiking

• Swimming

• Lower-impact fitness activities

Running is generally introduced only after adequate strength and function have returned.

Six to Twelve Months

Although many patients feel well before six months, tendon remodeling continues for up to one year.

The strongest repairs are built through patience and consistent rehabilitation.

Returning to Sports

One of the most rewarding aspects of my practice is helping athletes return to the sports they love.

Return to sport is not based on the calendar alone.

Before returning to unrestricted activity, I want patients to demonstrate:

• Full ankle motion

• Excellent calf strength

• Ability to perform repeated single-leg heel raises

• Good balance and proprioception

• Minimal swelling

• Minimal pain

Only then do we begin sport-specific progression.

Whether your goal is returning to competitive soccer, running a marathon, playing pickleball, or simply enjoying long walks without pain, rehabilitation is tailored to your individual goals.

From My Practice

Patients often ask me:

“Doctor, when will I be 100%?”

The honest answer is that tendon healing continues much longer than most people realize.

Many patients feel dramatically better within a few months, but the tendon continues to remodel for nearly a year.

The patients who do the best are not necessarily the fastest healers.

They are the patients who stay committed to their rehabilitation program long after the incision has healed.

Surgery lasts a few hours.

Rehabilitation determines the final outcome.

Frequently Asked Questions

These are the questions I hear most often from patients in my office.

Will Achilles tendonitis heal on its own?

Sometimes.

Very mild cases may improve with activity modification and time. However, if pain persists for several weeks, the tendon often begins to develop degenerative changes that require a structured rehabilitation program rather than simple rest.

How long does Achilles tendinopathy take to heal?

Every patient heals differently, but as a general guideline:

• Mild cases: 4–8 weeks

• Moderate cases: 2–4 months

• Chronic tendinopathy: 6–12 months

• Surgical recovery: Significant improvement by 4–6 months, with continued remodeling for up to one year

Patience is critical. Tendons heal more slowly than muscles.

Can I still walk?

Most patients can continue walking, although prolonged walking that significantly increases pain should be avoided.

If normal walking becomes painful, temporary use of a walking boot may be appropriate.

Should I stretch?

It depends.

Patients with non-insertional Achilles tendinopathy often benefit from calf stretching.

Patients with insertional Achilles tendinopathy may actually worsen their symptoms with aggressive stretching because it increases compression where the tendon attaches to the heel.

This is one reason why obtaining the correct diagnosis is so important.

Should I stop running?

Not necessarily.

Some runners can continue modified training while others require temporary rest.

The decision depends on:

• Severity of symptoms

• MRI findings

• Training goals

• Running mechanics

• Response to treatment

The goal is not to stop running forever—it is to return to running safely.

Is surgery common?

No.

Fortunately, most patients recover without surgery.

When surgery is necessary, it is usually because months of appropriate conservative treatment have failed or because significant tendon degeneration is present.

Will I return to sports?

In the vast majority of cases, yes.

Return to sport depends on strength, balance, flexibility, healing, and completion of an appropriate rehabilitation program—not simply the passage of time.

Myth vs. Fact

Myth:

“Achilles tendonitis is just inflammation.”

Fact:

Most chronic Achilles pain is actually tendon degeneration (tendinopathy), which requires progressive strengthening rather than simply reducing inflammation.

Myth:

“I should just stretch more.”

Fact:

Stretching is only one component of treatment and may actually worsen insertional Achilles tendinopathy if performed aggressively.

Myth:

“If I can tolerate the pain, I should keep running.”

Fact:

Running through progressively worsening pain often delays healing and increases the risk of further tendon degeneration.

Myth:

“Once the pain is gone, the tendon is healed.”

Fact:

Pain often improves before the tendon has fully recovered. Returning to high-impact activity too quickly is one of the most common reasons symptoms recur.

Preventing Achilles Tendon Problems

Although no injury is completely preventable, several habits significantly reduce your risk.

I recommend:

• Increasing training gradually

• Wearing supportive, well-fitting athletic shoes

• Replacing worn running shoes regularly

• Maintaining calf strength and flexibility

• Addressing abnormal foot mechanics when appropriate

• Cross-training to reduce repetitive overload

• Listening to early warning signs rather than pushing through persistent pain

One of the easiest injuries to treat is the one that never develops.

Why Choose Dr. Sarang Desai?

Choosing the right physician is about more than simply finding someone who performs surgery.

As a fellowship-trained orthopedic foot and ankle surgeon, I specialize in both surgical and non-surgical treatment of Achilles tendon disorders. My goal is always to identify the underlying cause of your pain and create an individualized treatment plan based on your anatomy, activity level, imaging findings, and personal goals.

I care for:

• Runners

• Soccer players

• Pickleball athletes

• Tennis players

• Golfers

• Active adults

• High school and collegiate athletes

• Patients simply hoping to walk without pain again

Whenever possible, I recommend conservative treatment first. When surgery is appropriate, my goal is to restore strength, function, and confidence while helping patients safely return to the activities they enjoy.

I proudly serve patients throughout McKinney, Flower Mound, Frisco, Prosper, Plano, Allen, Celina, and the greater North Texas region.

Final Thoughts

Achilles tendinopathy is one of the most common conditions affecting active adults and athletes, but it is also one of the most misunderstood.

The good news is that the overwhelming majority of patients recover without surgery when the condition is recognized early and treated appropriately. The key is understanding that tendons require progressive rehabilitation—not simply rest or stretching.

If your Achilles pain has persisted despite home treatment, prevents you from enjoying the activities you love, or continues to worsen, an evaluation by a fellowship-trained orthopedic foot and ankle surgeon can help determine the cause and develop an individualized treatment plan.

My philosophy is simple:

Treat the cause—not just the symptoms.

By identifying why the tendon became overloaded and correcting the underlying problem, most patients can return to an active lifestyle with less pain, better function, and a lower risk of recurrence.

References

This article is based on current evidence and clinical guidelines, including publications from:

• American Academy of Orthopaedic Surgeons (AAOS)

• American Orthopaedic Foot & Ankle Society (AOFAS)

• Journal of Bone & Joint Surgery (JBJS)

• Foot & Ankle International

• Journal of Orthopaedic & Sports Physical Therapy (JOSPT)

Author:

Dr. Sarang Desai

Fellowship-Trained Orthopedic Foot & Ankle Surgeon | Sports Medicine Specialist