Achilles tendonitis (tendinopathy): heel pain assessment and treatment

If the pain came on suddenly during activity, especially with a “pop” at the back of the calf or heel, this may be a torn Achilles tendon rather than a gradual overuse problem.^[2] A sudden pop with difficulty pushing off is a different problem from gradual overuse pain and should be assessed promptly.^[2]

That pattern is covered on its own page: Achilles tendon rupture.

Diagnosis is primarily clinical. It rests on a gradually developing pain about 2 to 6 cm above the heel, together with tenderness when the middle of the tendon is pressed.^[1]

Two named tests may be used to help confirm that the pain comes from the tendon itself:^[1][3]

• The arc sign. The examiner feels for swelling or a nodule in the tendon while your ankle is moved through its range. The sign is positive when that swelling or nodule moves with the movement, which shows the problem sits within the tendon rather than the tissue around it.^[3]
• The Royal London Hospital test. The examiner finds the most tender point while your ankle is relaxed, then asks you to point your foot up and down. The test is positive when the tenderness clearly reduces or disappears once the tendon is under tension, which is another way of confirming that the pain comes from the tendon itself.^[3]

Assessment also looks at how the tendon performs. This can include heel-raise and hop tests (one-legged checks of how well the calf and tendon are working, such as rising onto the toes or hopping on one leg), and measures such as ankle movement, calf strength and endurance, and tenderness when the tendon is pressed. These are done and interpreted by a clinician, not as self-diagnosis.^[1]

Surgery is the exception, not the expected course. It is considered only if the pain has not improved after a sustained course of non-surgical treatment, commonly cited as 6 months.^[2] Most people improve without it.^[2]

Recovery from Achilles tendonitis takes weeks to months.^[1] It is guided by how the tendon responds to increasing load, not by a calendar date.^[1]

Most people improve, but results vary.^[1] In a large group of runners, the median time to recovery was 82 days, with the quickest at 21 days and the longest at 479.^[1] Even with early treatment, pain may last longer than 3 months.^[2] Symptoms can also return if they are not properly managed early.^[1]

Ask the clinic team for current information about fees, panel status, pre-authorisation and expected payment arrangements. Insurance coverage and out-of-pocket costs depend on the individual policy and the insurer’s decision; no coverage is guaranteed.

A cost estimate for surgery can be given only after a consultation and assessment, once a surgical plan has been developed. Each individual condition is unique — implants used, time taken, and other factors contribute to the overall estimate. The estimate will be provided to you by the clinic should you decide on surgical management, and will also be used to assist in obtaining pre-authorisation from insurance where applicable.

Specific benefits, pre-authorisation, reimbursement and cashless treatment depend on the individual policy and insurer approval and are not guaranteed.

Arrange a consultation: the appointment section is further down this page.

1. Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther. 2018;48(5):A1-A38. doi:10.2519/jospt.2018.0302. PMID 29712543.
2. American Academy of Orthopaedic Surgeons (AAOS). Achilles Tendinitis. OrthoInfo. Available at: https://orthoinfo.aaos.org/en/diseases–conditions/achilles-tendinitis
3. StatPearls [Internet]. Achilles Tendinopathy. Treasure Island (FL): StatPearls Publishing. NBK538149. Available at: https://www.ncbi.nlm.nih.gov/books/NBK538149/

Reading about a problem is a starting point. An assessment brings together the history, an examination where needed and any useful tests, and helps you and your clinician decide what to do next. How much physical examination is needed is a matter of clinical judgement. It may be limited when pain makes an examination unreliable, or when imaging clearly shows a problem that matches the symptoms, such as a fracture seen on an X-ray or an MRI scan that clearly shows an injury consistent with the symptoms. The Singapore Medical Council and the UK General Medical Council both allow remote medical consultations, where a physical examination is not possible, with safeguards: the doctor must be clear about the limits of an opinion formed without an examination, and whether an in-person examination is needed, or referral to other services, is left to the clinical judgement of the attending doctor.

Signs that need urgent help

Some symptoms should not wait for a routine appointment. Each item below says where to go.

After an injury

• The ankle or foot sits at an odd angle, a bone is showing, there is a deep cut, you are in severe pain, or the toes look blue or white or feel numb. Go to an emergency department or call 995.
• You felt a sudden pop or sharp pain at the back of the heel or calf, and pushing off or rising onto your toes is difficult. Arrange an urgent same-day assessment.
• It is very painful or the pain is getting worse, the swelling or bruising is large or spreading, or it hurts to put weight on the ankle or foot. Arrange an urgent same-day assessment.

At any time

• A joint, such as the ankle, is suddenly very painful, hot, red and swollen, especially with a fever or feeling generally unwell. Go to an emergency department or call 995.
• One calf or thigh is newly painful and swollen. Arrange an urgent same-day assessment. If you also feel short of breath or have chest pain, go to an emergency department or call 995.

If you have diabetes

• You have a foot sore and a fever or feel very unwell, or the foot is cold, pale or blue. Or skin on the foot or toes has turned black, or a sore looks deep, or there is pus or redness spreading up the foot. Go to an emergency department or call 995.
• You have a new foot sore, or a foot that is hot, swollen, changed in colour or leaking fluid, without the signs above. Arrange an urgent assessment within 24 hours.

If you are admitted by the doctor at the urgent care centre of one of these private hospitals, the Parkway Pantai hospitals (Mount Elizabeth Orchard, Mount Elizabeth Novena, Gleneagles and Parkway East), Farrer Park Hospital and Thomson Medical Centre, you may ask for Dr Sean Leo to be your attending orthopaedic surgeon. If you are instead discharged and referred for orthopaedic follow-up, you may contact the clinic to arrange an appointment. Both are subject to the hospital’s admission processes and to Dr Leo’s availability.