The Achilles is the strongest tendon in the body, connecting the calf muscles to the heel bone. It carries heavy loads every time you walk, run or jump. Pain at the back of the heel or ankle is often linked to this tendon or the structures around it.
Which tendon problems affect the foot and ankle?
- Mid-portion Achilles tendinopathy: thickening and pain a few centimetres above the heel.
- Insertional Achilles tendinopathy: pain where the tendon attaches to the heel, often with a bony bump (Haglund) and calcification.
- Achilles tendon rupture: usually a sudden tear that feels like being kicked in the back of the leg.
- Posterior ankle impingement and os trigonum: a small extra bone behind the talus that can be pinched when you point your foot.
- FHL tendon disorders: irritation of the tendon that bends the big toe as it runs through a groove behind the ankle.
- Peroneal tendon problems: tears or dislocation of the tendons on the outside of the ankle.
What are the symptoms?
- Pain and stiffness at the back of the heel with the first steps in the morning or after sitting
- Swelling or thickening of the tendon
- Pain that worsens with running, hills and stairs
- Pain where the back of the shoe rubs
- With a rupture: sudden pain, inability to rise on tiptoe and a gap in the tendon
- With os trigonum or FHL problems: deep pain behind the ankle when rising onto the toes
What causes them?
Most tendon problems come from repeated overload: increasing training too fast, unsuitable shoes, tight calf muscles, foot alignment problems and age-related weakening of tendon tissue. Ballet, football and running can make posterior impingement more likely.
Assoc. Prof. Tokgöz’s study on how the presence and size of an os trigonum affect FHL tendon lesions was published in Foot and Ankle Surgery, and his research on the role of prenatal hormone balance in the development of os trigonum appeared in Early Human Development.
How are they diagnosed?
The examination checks the tender area, thickening, calf flexibility and tendon continuity; a rupture can usually be diagnosed clinically. Weight-bearing X-rays show heel spurs and calcification. Ultrasound and MRI show the condition of the tendon and the size of any tear.
How are they treated without surgery?
Most tendinopathies are treated without an operation. The core of treatment is a progressive tendon-loading programme, especially eccentric exercises, supported by temporary activity changes, calf stretching, heel raises, suitable footwear and, in some cases, shockwave therapy. Patience is needed: improvement usually takes weeks to months.
For some Achilles ruptures, treatment in a special boot without surgery is a valid option. The choice depends on age, activity level and the nature of the tear, and is made together with you.
When is surgery needed?
Surgery is considered for tendinopathy that has not improved after several months of consistent treatment. In insertional tendinopathy, damaged tendon tissue and the bony bump are removed and the tendon is reattached to the bone. When the tendon is weak, it can be reinforced with an FHL tendon transfer. Assoc. Prof. Tokgöz co-authored a study comparing outcomes of insertional Achilles surgery with and without FHL transfer, published in The Journal of Foot & Ankle Surgery.
Achilles ruptures can be repaired through an open or a small-incision approach. For os trigonum and FHL problems, posterior ankle arthroscopy allows the extra bone to be removed and the tendon released.
Recovery and return to sport
Tendons heal slowly. After surgery, a protective boot with gradual weight-bearing and physiotherapy is usual. Recovery after posterior arthroscopy is usually a matter of weeks, while return to sport after Achilles repair or tendon transfer usually takes several months and varies between patients.
Frequently asked questions
Will Achilles tendinopathy go away on its own?
Mild cases may settle with reduced load, but most people need a structured exercise programme. Training through the pain tends to slow recovery.
Can I have an injection in my Achilles tendon?
Steroid injections into the Achilles tendon are generally avoided because they may increase the risk of rupture. Other injection treatments are considered case by case.
Does everyone with an os trigonum have pain?
No. Many people have one without any symptoms. Problems arise when it gets pinched, typically in activities with repeated pointing of the foot.