Overview
The Achilles joins the calf muscles to the heel bone and transmits the force of every push-off. Injuries fall into two groups. Tendinopathy (often called tendinitis) is an overuse problem: the tendon thickens and hurts, either in its mid-portion 2 to 6 cm above the heel or at its insertion onto the bone. A rupture is a sudden, almost always complete tear during a push-off or stumble.
Which group you are in determines the treatment. Tendinopathy is treated with a loading program and very rarely with surgery. A rupture is treated either with an early-motion protocol in a boot or with surgical repair; Dr. O'Donnell recommends repair for athletes and active patients who want the lowest re-rupture risk and the strongest push-off, and manages selected ruptures without surgery when the torn ends sit together on ultrasound.
Common Symptoms
- Tendinopathy: a stiff, sore tendon with the first steps in the morning that loosens with walking and aches again after activity
- A tender thickening above the heel, or pain and a bony bump at the back of the heel in insertional disease
- Rupture: a sudden snap or the sensation of being kicked in the back of the calf, often with an audible pop
- Inability to rise onto the toes of that foot, and a flat-footed, weak push-off
- A gap you can feel in the tendon and bruising tracking toward the heel over the next day or two
Pain under the heel rather than behind it points to plantar fasciitis. A pop during a twist, with swelling over the outside of the ankle, is more likely an ankle sprain or an ankle fracture.
Causes & Risk Factors
The classic rupture patient is a man between 30 and 50 who plays an intermittent sprinting-and-jumping sport: basketball, tennis, pickleball, soccer. The tendon fails during a forceful push-off with the knee straight or on a sudden unexpected dorsiflexion. A recent fluoroquinolone antibiotic and a prior corticosteroid injection into the tendon both weaken it. Tendinopathy is a runner's condition driven by a jump in mileage, tight calves and worn shoes; the insertional form is commoner after 50, often with a prominent heel bone (Haglund deformity).
How It Is Diagnosed
A rupture is a clinical diagnosis. Dr. O'Donnell performs the Thompson test (squeezing the calf with the patient face down; a foot that does not point downward means the tendon is not connected), feels for the gap, and compares the resting angle of both feet with the knees bent to 90°. For tendinopathy the exam localizes the tender segment, tests single-leg heel raises and measures calf tightness with the knee straight and bent.
Ultrasound in the office confirms a rupture and measures whether the torn ends come together with the foot pointed down; that gap decides whether non-operative treatment is safe. MRI is reserved for ruptures that present late, partial tears, and insertional disease when surgery is being considered. Out-of-town patients can send existing imaging through mymedicalimages.com.
Treatment Options
Non-operative care
Mid-portion tendinopathy responds to a 12-week eccentric loading program: slow heel drops off a step, straight-knee and bent-knee, three sets of fifteen twice a day, with a heel lift and reduced rather than stopped running. Insertional tendinopathy uses the same loading only to floor level, because dropping below the step compresses the tendon against the bone. Cases still painful at 3 months are candidates for shockwave or an ultrasound-guided injection around, never into, the tendon.
A rupture treated without surgery goes into a boot with heel wedges, with early protected weight bearing and graded removal of the wedges over 6 weeks. It works when the ends are apposed on ultrasound within two weeks and the boot stays on; the trade-off is a somewhat higher re-rupture rate and less push-off power.
Achilles tendon repair
For athletes, active patients under about 60, ruptures with a gap that does not close in plantarflexion, and injuries more than two weeks old, Dr. O'Donnell performs an Achilles tendon repair, through a small incision that protects the sural nerve and the fragile skin at the back of the ankle. The ends are sutured at their correct length, which is what preserves push-off strength. Surgery for tendinopathy is reserved for failure of at least 6 months of loading.
Recovery & What to Expect
After repair the ankle is held pointed down with heel wedges and brought back to neutral gradually; dorsiflexion past neutral is not allowed for the first 6 weeks, because the risks are re-rupture and a tendon that heals long.
| Phase | Timing | What happens |
|---|---|---|
| Protection | Weeks 0–2 | Splint or boot in plantarflexion; weight bearing per Dr. O'Donnell; toe, knee and hip motion; elevation |
| Protected motion | Weeks 2–6 | Progressive weight bearing in the boot with heel lifts; active motion to neutral only; sub-maximal isometric calf work |
| Motion & strength | Weeks 6–12 | Wean boot to shoe with a heel lift; restore full dorsiflexion gradually; seated then standing calf strengthening; balance; bike |
| Advanced strengthening | Months 3–6 | Resistive calf work and single-leg heel raises; low-impact conditioning; jogging late in this phase if criteria are met |
| Return to sport | Months 6–9 | Running, plyometric and agility progression; cleared on symmetric strength and hop and heel-raise testing |
Desk work resumes within the first week; driving waits until the boot is off and the right calf can brake hard, typically 8 to 10 weeks for a right-sided repair; sport returns at 6 to 9 months. The full protocol is available as a PDF: Achilles tendon repair.
Frequently Asked Questions
Can a torn Achilles heal without surgery?
Yes, if the torn ends touch when the foot is pointed down on ultrasound and the boot-and-wedge protocol is followed strictly from the first two weeks. Healing takes the same 6 to 9 months, with a somewhat higher re-rupture risk, which is why Dr. O'Donnell recommends repair for athletes.
How do I know if my Achilles is torn or just strained?
A rupture is usually obvious: a pop or a feeling of being kicked in the calf, then an inability to rise onto the toes of that foot. Many can still walk flat-footed, which delays the visit. A strain hurts but leaves you able to push off. If you felt a pop, get examined the same week.
How long is recovery after Achilles repair?
The boot comes off at about 6 weeks, walking is normal by 10 to 12 weeks, jogging starts around month 4 to 6 once single-leg heel raises are close to symmetric, and return to sport is typically 6 to 9 months. The repair protocol spells out each phase.
When can I walk after Achilles surgery?
Weight bearing in the boot begins in the first two weeks per Dr. O'Donnell's instructions and progresses to full weight in the boot by week 6. Walking in a shoe with a small heel lift starts between weeks 6 and 12; barefoot walking and any stretch past neutral are avoided early.
Can I get a cortisone shot for Achilles pain?
Not into the tendon. Corticosteroid weakens tendon tissue and is a known cause of Achilles rupture. Dr. O'Donnell will inject around the tendon or its sheath under ultrasound guidance in selected cases, and relies on eccentric loading and shockwave for persistent tendinopathy.
This page is for general education and is not a substitute for a medical evaluation. Treatment recommendations depend on your individual diagnosis and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.