Evidence-Based Sports Injury Care by Dr. Sean LeoAchilles Tendon Injuries in Athletes: How They Happen and How They Are Treated

Achilles tendon pain typically presents as a dull ache or stiffness at the back of the ankle, most noticeable first thing in the morning or after sitting for long periods. During activity, the pain may feel like a burning sensation that worsens with running, jumping or pushing off the foot. In cases of a more severe achilles tendon injury, the pain is sharp and sudden, often accompanied by a popping sound at the back of the ankle. The location and character of achilles tendon pain helps an achilles tendon specialist distinguish between tendonitis, tendinosis and a partial or complete tear. If the pain does not improve within a few days of rest, early assessment is recommended to prevent progression.

Mild to moderate achilles tendon injuries  including tendonitis and some partial tears, can heal with structured conservative treatment. This typically involves a combination of rest, eccentric strengthening exercises, physiotherapy and gradual return to loading over several weeks. The key to successful non-surgical management is consistency with the rehabilitation programme and avoiding the temptation to return to sport too early. However, complete achilles tendon ruptures and injuries that do not improve with conservative care usually require surgical intervention to restore full tendon function. An achilles tendon specialist can assess the injury and advise on the most appropriate treatment path.

Recovery timelines depend on the type and severity of the Achilles tendon injury. Tendonitis may resolve within four to six weeks with appropriate management, while tendinosis and partial tears typically require three to six months of structured rehabilitation. Complete ruptures, managed surgically or conservatively, generally need six to twelve months before a full return to sport. Current clinical guidelines emphasise that both time-based and criterion-based milestones should guide progression through rehabilitation. Consistency with the rehabilitation programme is the most important factor in lasting recovery from Achilles tendon injuries in athletes.

Reference:

¹ Marrone, W., Andrews, R., Reynolds, A., Vignona, P., Patel, S., & O’Malley, M. (2024). Rehabilitation and return to sports after Achilles tendon repair. International Journal of Sports Physical Therapy, 19(9), 1152–1165. 🔗 https://pmc.ncbi.nlm.nih.gov/articles/PMC11379499/

² Chimenti, R. L., Neville, C., Houck, J., Cuddeford, T., Carreira, D., & Martin, R. L. (2024). Achilles pain, stiffness, and muscle power deficits: midportion Achilles tendinopathy revision 2024. Journal of Orthopaedic & Sports Physical Therapy, 54, 1–32. 🔗 https://doi.org/10.2519/jospt.2024.0302

Sports that involve repetitive jumping, sprinting and sudden changes of direction place the greatest demand on the Achilles tendon. Running, basketball, football, tennis, badminton and volleyball are among the most common sources of achilles tendon injuries in athletes. A meta-analysis found that gymnastics and ball sports had the highest prevalence of Achilles tendinopathy at 17 percent and 6 percent respectively. Weekend warriors who train intensely after periods of inactivity are also at elevated risk, as their tendons have not been conditioned for sudden high loads. The risk of achilles tendon injury increases further when training surfaces, footwear or session frequency change abruptly.

Reference:

¹ Wang, Y., Zhou, H., Nie, Z., & Cui, S. (2022). Prevalence of Achilles tendinopathy in physical exercise: A systematic review and meta-analysis. Sports Medicine and Health Science, 4(3), 152–159. 

🔗 https://pmc.ncbi.nlm.nih.gov/articles/PMC9453689

You should consult an achilles tendon specialist if you experience persistent achilles tendon pain that does not improve with a few days of rest. Other warning signs include a sudden pop or snap at the back of the ankle during activity, difficulty walking or pushing off the affected foot, visible swelling or thickening along the tendon, and pain that worsens rather than improves over time. Early assessment prevents a mild achilles tendon injury from progressing to a more serious condition such as a partial or complete tear. At Orthokinetics, Dr. Sean Leo provides comprehensive evaluation and personalised treatment for achilles tendon injuries in athletes at all levels.

Achilles tendonitis is an acute inflammatory condition caused by sudden overuse, resulting in achilles tendon pain, mild swelling and stiffness that typically settles within a few weeks of appropriate management. Achilles tendinosis, by contrast, is a chronic degenerative condition where the tendon’s collagen fibres become disorganised and weakened over time. Tendinosis develops when early-stage tendonitis is not properly managed and the tendon undergoes structural breakdown rather than healing. The distinction matters because treatment differs — tendonitis responds to rest and anti-inflammatory measures, while tendinosis requires a longer, progressive loading programme to stimulate tendon remodelling.

Reference:

“Achilles Tendinopathy; NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health. StatPearls; Miguel A et al”

🔗https://www.ncbi.nlm.nih.gov/books/NBK538149/

In most cases of tendonitis or mild tendinosis, walking remains possible, although achilles tendon pain may be present during the first few steps after rest. The pain often eases with gentle movement as the tendon warms up, but may return after prolonged activity. With a partial tear, walking may be possible but noticeably uncomfortable, and push-off strength is usually reduced. A complete achilles tendon rupture, however, typically makes it very difficult to walk normally as  the foot feels weak and pushing off is not possible without significant pain. If walking causes increasing achilles tendon pain or if you notice a change in your gait, assessment by an achilles tendon specialist is recommended to determine the extent of the injury.

Preventing achilles tendon injuries in athletes starts with managing training load. Increasing volume and intensity gradually rather than making sudden jumps in activity. A structured warm-up that includes dynamic calf stretching and ankle mobility exercises prepares the tendon for the demands of sport. Eccentric calf strengthening, performed regularly as part of a maintenance programme, has been shown to improve tendon resilience and reduce injury risk. Wearing appropriate footwear that supports the foot and absorbs impact, and replacing shoes before they lose their cushioning, also reduces strain on the Achilles tendon. 

Surgery is not always necessary for a complete achilles tendon rupture, but it is the preferred option for most athletes and active individuals. Surgical repair restores the tendon’s original length and tension, which is important for push-off strength and explosive movements required in sport. Non-surgical management using a structured bracing and rehabilitation protocol can be effective for less active individuals or those who carry higher surgical risk. Evidence on outcomes remains nuanced — some earlier studies suggested surgical repair offered lower re-rupture rates, but a randomised controlled trial by Willits et al. (2010)¹ found no statistically significant differences in re-rupture rates or functional outcomes between surgical and non-surgical groups at two years, when both used an accelerated functional rehabilitation protocol. A systematic review by Ochen et al. (2019)² similarly found no significant difference in re-rupture rates when accelerated functional rehabilitation was applied, though operative treatment did carry a higher complication rate, particularly infection. An achilles tendon specialist can advise on the most suitable approach based on the patient’s activity goals, risk profile, and injury characteristics.

References:

¹ Willits, K., Amendola, A., Bryant, D., Mohtadi, N.G., Giffin, J.R., Fowler, P., Kean, C.O., & Kirkley, A. (2010). Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. Journal of Bone and Joint Surgery, 92(17), 2767–2775. 

🔗 https://pubmed.ncbi.nlm.nih.gov/21037028/

² Ochen, Y., Beks, R.B., van Heijl, M., et al. (2019). Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ, 364, k5120. 

🔗 https://pubmed.ncbi.nlm.nih.gov/30617123/

Leaving an achilles tendon injury untreated allows the condition to progress through increasingly severe stages. Early-stage tendonitis, if not managed, can develop into tendinosis, a degenerative condition where the tendon weakens and loses its normal structure. Over time, a weakened tendon becomes more vulnerable to partial or complete rupture, particularly during sudden movements or high-intensity sport. Chronic untreated achilles tendon pain can also lead to compensatory movement patterns that increase stress on the opposite leg, the knee and the hip. Seeking timely assessment from an achilles tendon specialist helps prevent a manageable condition from becoming a complex and prolonged injury.