Understanding Pain and Stiffness in the Back of the Heel
Achilles tendinopathy is a painful, degenerative condition of the Achilles tendon, which connects the calf muscles to the heel bone. It can affect the middle of the tendon or the point where it attaches to the heel (insertional tendinopathy). It is common in runners and active adults, but also occurs in people who are less active. A structured loading program is the foundation of treatment, and recovery often takes three months or more.
Causes
A sudden increase in running mileage, speed, or hill training.
Tight or weak calf muscles.
Poor footwear or training on hard surfaces.
Age-related tendon changes.
Certain medications, especially fluoroquinolone antibiotics.
Diabetes, high cholesterol, and inflammatory arthritis.
Symptoms
Pain and stiffness in the back of the heel or lower calf, worst in the morning.
Pain at the start of activity that may ease during exercise, then worsen afterward.
Thickening, swelling, or a tender lump in the tendon.
Pain with pushing off, climbing stairs, or rising onto your toes.
Seek prompt medical care if: You feel a sudden pop or a kick-like blow to the back of the ankle and have trouble walking or rising onto your toes. This may be an Achilles rupture, which needs urgent evaluation.
Imaging Studies to Consider
Ultrasound shows tendon thickening, tears, and new blood vessel growth, and can guide injections.
MRI is used for unclear cases or when a partial tear is suspected.
X-rays can show bone spurs or calcification in insertional tendinopathy.
Physical Therapy, Home Exercise & Other Conservative Techniques
Physical Therapy
Progressive calf loading, such as eccentric and heavy slow resistance exercises.
Gradual return-to-running program.
Home Exercise Program
Daily heel drops or calf raises as prescribed by your therapist.
Calf stretching (avoid deep stretching off a step for insertional tendinopathy).
Other Studied Techniques
Temporary heel lifts.
Activity modification rather than complete rest.
Extracorporeal shockwave therapy (ESWT) for persistent symptoms.
Interventional Treatment Options
Platelet-rich plasma (PRP) injection: Results have been inconsistent in randomized trials despite positive case series, so PRP is a second-line option to discuss after a full loading program. When used, it is placed around the tendon rather than into it, under ultrasound guidance. PRP is self-pay.
High-volume image-guided injection: Saline injected around the tendon to disrupt painful new blood vessels and nerves; evidence is limited.
Corticosteroid injection: Generally avoided in or around the Achilles tendon because of rupture risk.
Surgical referral: For persistent symptoms after 6 months of quality rehabilitation, or for tears.
Neuromodulation: Spinal Cord & Peripheral Nerve Stimulation
Neuromodulation is not a standard treatment for Achilles tendinopathy. Peripheral nerve stimulation may be considered for rare cases of chronic nerve-related pain around the heel after surgery.
Evidence Base: Guidelines & Levels of Evidence
Progressive loading exercise: Level I · APTA/AOPT Midportion Achilles Tendinopathy Clinical Practice Guideline (Chimenti et al., J Orthop Sports Phys Ther 2024 revision)
Extracorporeal shockwave therapy: Level II · APTA/JOSPT Clinical Practice Guideline; randomized trials
Platelet-rich plasma (PRP): Level I · Grade C · ASPN 2024 consensus guideline: inconsistent vs. placebo; re-rupture rate unchanged
Corticosteroid injection: Not recommended · Rupture risk
Evidence levels and guideline citations above are summarized for general clinical reference based on the literature and major society guidelines available at the time of writing. Guidelines are periodically updated; please verify current recommendations before relying on this summary for clinical decision-making.
Pain Psychology Techniques
Graded activity pacing for a safe return to running.
Pain neuroscience education: some pain during loading exercise is acceptable and expected.
Acceptance and commitment therapy (ACT) for staying active during a long recovery.
Non-Opioid Medication Options
Anti-inflammatory and analgesic options
NSAIDs for short-term flares; long-term use is not helpful for tendon healing.
Acetaminophen.
Topical treatments
Topical diclofenac gel.
Related Procedures
Related Conditions
Talk With Us About Your Options
Call 650-507-4113 or send us a message to schedule a consultation at our Daly City, Los Altos, or Stockton office. We will review what may be causing your pain and walk through the risks, benefits, and alternatives of each option with you.
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This information is provided for general patient education and does not replace individualized medical advice. Please discuss your specific symptoms, diagnosis, and treatment options with your pain management physician.
