Achilles Tendon and Heel Pain

Also known as: Achilles tendinopathy, Plantar fasciitis, Heel spur, Sever disease

Most heel pain is a loading problem, not a structural one, and most of it resolves without surgery. The treatment that works is unglamorous: the right exercise, done properly, for longer than most people expect.

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Achilles tendinopathy

Pain and thickening of the tendon, either in its mid-portion two to six centimetres above the heel, or at its insertion into the heel bone. The two behave differently and are treated differently, so distinguishing them matters.

The tendon is not inflamed in the usual sense. The collagen is disorganised and the tendon has failed to adapt to the load being put through it. The treatment follows from that: load it in a controlled way so it remodels.

Progressive loading, eccentric or heavy slow resistance, for at least twelve weeks. This is the treatment with the best evidence and the one most often abandoned too early.
Insertional disease does not tolerate the same exercises. Stretching into dorsiflexion compresses the tendon against the heel bone and makes it worse, so the programme is modified and a heel raise is used.
Shockwave therapy as an adjunct where a proper loading programme has stalled.
No steroid injection into the tendon.
Surgery for the small group that fails all of this: debridement, and at the insertion, removal of the prominent upper corner of the heel bone with reattachment of the tendon.

Plantar fasciitis

Pain under the heel, worst with the first steps in the morning and after sitting. Nine in ten cases settle without an operation, though it commonly takes months.

Calf and plantar fascia stretching, done several times a day
A cushioned, supportive shoe, and an insole or heel cup
Load and weight management
Night splints for persistent morning pain
Shockwave therapy for cases lasting beyond six months
Surgery only in genuinely refractory cases, and the calf is often the more useful target than the fascia itself

Achilles rupture

A sudden sharp pain at the back of the ankle, often with an audible snap, and difficulty pushing off. It is diagnosed clinically with the calf squeeze test.

Both non-operative treatment in a functional boot protocol and surgical repair give good results in the right patient. Re-rupture rates are similar with modern protocols; surgery carries wound and nerve risks, non-operative treatment requires strict adherence to the boot regime. The choice depends on the delay since injury, the gap between the tendon ends, and the demands of the patient.

Typical recovery after surgery

A typical course. Your own plan is set at your visit and depends on the operation.

Weeks 0 to 12Loading programme. Pain during the exercise is expected and acceptable; it should settle within 24 hours.
Months 3 to 6The point at which non-operative treatment can be judged fairly. Most people are better by here.
After surgery, weeks 0 to 6Boot, with weight-bearing according to the procedure performed.
After surgery, months 3 to 9Progressive strengthening. Return to running is late, and calf strength recovers slowly.

Common questions

I was told I have a heel spur. Should it be removed?

Almost never. Spurs are common in people with no pain at all and are a consequence of long-standing traction rather than the cause of symptoms. Treating the plantar fascia and the calf resolves the pain; removing the spur does not.

How long does plantar fasciitis take to get better?

Longer than people are usually told. Around nine in ten cases resolve without surgery, but the average is several months. Calf and plantar fascia stretching plus a supportive shoe are the mainstays.

Are steroid injections a good idea?

Into the plantar fascia they can give short-term relief, at some risk of fat pad atrophy and rupture, so they are used sparingly. Into or around the Achilles tendon they should be avoided, because of the risk of rupture.

My child has heel pain when playing sport.

In a growing child this is usually Sever disease, irritation of the growth plate at the back of the heel. It is self-limiting, it settles once growth finishes, and it is managed with activity modification, calf stretching and a heel cushion. It is not a tendon injury and does not need imaging in a typical case.

Can a ruptured Achilles be treated without surgery?

Yes. With a modern functional rehabilitation protocol in a boot, results for many patients are comparable to surgery, with fewer wound complications. Surgery is favoured for a delayed presentation, a large gap between the tendon ends, and in some high-demand athletes. It is a genuine discussion rather than an automatic decision.

This page is for patient information and does not replace an examination by a doctor.