The Authoritative Guide to Achilles Tendon Injuries

Achilles Tendon Injuries

One of the most common types of injuries that dedicates runners have to deal with is achilles tendonitis. Defined as a sudden or stabbing pain to the achilles tendon, this particular ailment commonly strikes people who engage in intense physical exertion that is far more intense than their common workout or run. While it may seem like achilles tendon discomfort is difficult to cure, severely hampering a workout routine or daily run regimen, the good news is that there are a number of effective treatments available.

Achilles Tendonitis

In order to arrive at an effective achilles tendonitis treatment, it is essential to understand what causes achilles tendon injuries in the first place. Once you understand the root cause of your achilles tendon injury, it is fairly straightforward to devise an effective course of therapy to reduce and eliminate the pain.

As you may have learned in school, the achilles tendon is the strongest tendon in the entire human body. Connecting your calf muscles to your foot, an achilles tendon rupture occurs when too much stress or pressure is placed on the tendon. During the process of running, the achilles tendon comes into play when you begin each step.

Achilles tendon discomfort can often result when runners increase the intensity of their runs, run uphill, or engage in speed training. It is estimated that as much as 5-10% of all runners suffer from some sort of achilles tendon pain and research has shown that achilles tendinopathy disproportionately affects male runners.

Achilles Tendon Pain

Most people experience an achilles tendon injury in the middle of their run. The pain usually strikes viciously and swiftly, causing a debilitating discomfort that will render you unable to do much more than limp home.

Achilles tendinopathy is usually divided into two categories: pain in the middle of the tendon, the most common form of achilles tendon rupture, and pain at a spot just above the heel, referred to as “insertional” tendonitis. Insertional cases are more persistent because they usually are accompanied by an inflammation of the cell tissues directly behind the tendon.

Causes of Achilles Tendonitis

Research has shown that most cases of achilles tendon pain are the result of excess pressure and stress being placed on the tendon. This can be the result of insufficiently strong calf muscles, poor gait, or problems relating to how the ankle joint is used. Compounded with demanding runs that add to the load on the tendon, it is no wonder why many runners suffer from achilles tendonitis.

Over time, the loads placed on the achilles tendon tend to fray the fibers of the tendon, resulting in inflammation and pain. Thus, the first step in devising an effective achilles tendonitis treatment is to begin by repairing the collagen fibers of the tendon itself.

How to Treat Achilles Tendonitis

For many decades, medical researchers and physical therapy experts attempted to devise a set of metrics to prescribe an effective level of calf muscle strength, pronation, and ankle motion in order to resolve achilles tendonitis by this method. Unfortunately, it was discovered that the fibers of the tendon heal very slowly or not at all despite taking these pro-active steps. It is now believed that a deeper understanding of how to repair the fibers of the tendon is the key to reducing and eliminating pain.

The achilles tendon, like all tendons in the body, is made up of several thick strands of collagen fibers woven together. Overuse of the tendon leads to damage in these collagen fibers, eventually rupturing the cell walls. During the healing process, the body begins to grow new collagen fibers to replace the damaged ones but the process is somewhat haphazard and asymmetrical. Some doctors have described the collagen fibers of the tendon as being much closer in appearance to a plate of spaghetti than the neatly woven fibers used in cable suspension bridges.

Many doctors originally recommended a series of carefully prescribed achilles tendon stretches as a way to reduce inflammation. Unfortunately, it has since been discovered that achilles tendon stretches often result in further damage to the healing collagen fibers that make up the tendon. The technique now recommended by physical therapists is far different. Entitled the eccentric heel drop, it has shown promising results in both speeding up the healing process of damaged achilles tendons as well as reducing and eliminating pain.

What is the Eccentric Heel Drop?

There are two components to the eccentric heel drop. One form of this tendon strengthening exercise is performed with the knee locked in the straight position and the other form has the knee bent.

To get effective relief for achilles tendonitis, it is necessary to perform 15 total eccentric knee drops twice a day for a total course treatment lasting three months. For this exercise you’ll need a small raised platform of some kind to use as a step.

How to perform the eccentric heel drop:

  1. Stand on the step with your heel hanging over the empty space below you.
  2. Now balance on one leg.
  3. Slowly and carefully lower the injured leg down until your heel is below the level of the step.
  4. Use your uninjured leg to lift your injured leg back up so that both heels are back at the starting position.
  5. Lift your uninjured leg and repeat for a total of 15 repetitions.

Alternate between keeping your injured leg held with the knee straight and with the knee bent.

You may notice some considerable discomfort when performing this exercise. A moderate amount of pain is normal when performing this exercise on your injured tendon and the pain is a sign that you are correctly performing the steps. Only discontinue the exercise if the pain becomes absolutely unbearable.

After a while, you should notice that the moderate pain disappears. When your achilles tendon is sufficiently strong, add more weight on the tendon by wearing a backpack when performing the exercise. You can continue to add weight to the backpack as your injured achilles tendon gets stronger.

Note: if you are suffering from achilles tendonitis in both legs, use a handrail or other support to help lift your legs back up to the starting position.

The way these exercises work is actually to cause new damage to the achilles tendon. The initial discomfort is the result of asymmetrical tendon fibers being stripped away. Over time, your body will then begin to create new collagen fibers in a more efficient and symmetrical manner that will add strength and durability to the tendon.

Exercise for Insertional Achilles Tendonitis

If the pain you are experiencing is a sharp sensation immediately above the heel, it is likely that you have insertional achilles tendonitis. These types of injuries are more difficult to treat and so a slight modification of the heel drop is necessary.

To treat insertional tendonitis, the exercise will be performed on a level surface. The injured leg must be held in the straight position.

  1. Standing on level ground, balance on your injured leg.
  2. Slowly and carefully lift your injured leg until you are standing on your toes.
  3. Carefully ease your injured leg back down until it is resting on the ground.
  4. Repeat 15 times.

As with the eccentric heel drop, twice-daily performance of the exercise is essential for a course of three months. Likewise, as the tendon begins to heal, add additional weight to your leg by wearing a backpack.

Other Ways to Heal Achilles Tendinitis

The eccentric heel drops will force your body to remove damaged collagen fibers and begin the process of laying down new layers in a healthier and more symmetrical manner. However, there are other steps you can take to minimize future injuries and help speed the healing process.

  • Foam rolling – it is effective to wrap foam around your achilles tendon to help stretch and loosen the fibers.  It is essential, however, to never apply heat directly to the tendon.
  • Don’t perform too many other stretching exercises for your calves.
  • Avoid rolling or over-flexing your ankles.
  • If it helps relieve the pain, you can apply a bag of warm water to the tendon but be careful not  to overheat the area.
  • Perform shin stretches – after entering a kneeling stance, lean backwards slowly and carefully  to help loosen up the ankles.
  • Upgrade your shoes – if you have been using flat-soled shoes such as “racing flats” or “spikes”,  physical therapists recommend switching to conventional sports shoes with a full-sized heel until  the tendon is completely healed.


Treating pain in the achilles tendon can be done at home for minimal cost. By following these basic steps, you should be on your way to a complete recovery in approximately three months:

  • Perform the heel drops every day, three sets of 15 repetitions every day.  Continue this course of treatment for a full three months, adding weight as your tendon heals.
  • Apply ice to your achilles tendon after every run or workout.
  • Apply mild warmth to your achilles tendon before beginning your run or workout.
  • Use contrast baths – using two basins or buckets, fill one with ice cold water and one with very hot water.  Place your leg up to the knee in the cold bucket and stand for five minutes.  Then immediately put your leg up to the knee in the hot bucket and stand for five minutes.  Repeat this procedure three times. The rapid change in temperature will cause your body to increase  blood flow to the region, speeding the healing process.
  • Avoid taking anti-inflammatory medications such as ibuprofen or Advil. While these medications may reduce pain in the short run, they work against your body’s ability to heal the injury.
  • Don’t engage in strenuous stretching of the calves.
  • Use a foam roller to massage your calves.
  • Wear traditional sports shoes with a full-sized heel during your run.
  • Use a night splint during the night when you’re sleeping.
  • Try ankle-strengthening exercises.

If these exercises fail to offer you relief or the injury to your Achilles tendon is severe, please consult with a medical professional.

About the Author

Dr. Lev Kalika is clinical director of NYDNRehab, located in Manhattan. Lev Kalika is the author of multiple medical publications and research, and an international expert in the field of rehabilitative sonography, ultrasound guided dry needling and sports medicine Dr. Kalika works with athletes, runners, dancers and mainstream clients to relieve pain, rehabilitate injuries, enhance performance and minimize the risk of injuries. His clinic features some of the most technologically advanced equipment in the world, rarely found in a private clinic.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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