Key takeaways
- How it started matters more than how it feels now. Pain that built up over weeks points to tendinopathy. A single moment, often with a snap or the sense of being kicked in the back of the leg, points to rupture.
- Being able to walk does not rule out a rupture. Other muscles take over, so many people limp on a completely torn tendon. This is the main reason ruptures are missed.
- A rupture can hurt less than tendinopathy once the initial shock settles. Low pain is not reassurance.
- Three checks help at home: the calf squeeze, the single-leg heel raise, and the resting angle of the foot. None of them is a diagnosis.
- A suspected rupture is urgent. Go to an emergency department or urgent treatment centre the same day. Tendinopathy is not urgent and is initially managed by a foot & ankle consultant with the help of a physiotherapist.
- It might be neither. Bursitis, a calf tear, a stress fracture and a blood clot can all cause pain at the back of the ankle.
Start with how it began
Most people compare symptoms. The more reliable clue is how the problem started, not how it feels now.
Tendinopathy builds. It usually starts as stiffness or a dull ache, worst for the first few steps in the morning or at the start of a run, and it can grumble on for weeks or months.
A rupture happens. There is a moment. Pushing off in a rally, sprinting for a bus, stepping awkwardly off a curb. Many people describe a loud snap, or turning round to see who kicked them in the back of the leg, only to find nobody there.
If you had a moment, treat it as a possible rupture until a clinician says otherwise. If it built up gradually with no single event, tendinopathy is far more likely. If you are unsure who to see, our guide on whom to see for foot or ankle pain in London explains the options. This article was written by Mr Malagelada, Consultant Trauma and Orthopaedic Surgeon, who specialises exclusively in the foot and ankle and treats Achilles tendon injuries in his central London clinics and at The Royal London Hospital, the UK’s largest trauma centre.
What each injury actually is
The Achilles joins the two calf muscles to the heel bone and carries several times your body weight on every push-off. A stretch roughly 2cm to 6cm above the heel has a relatively poor blood supply, and it is where most tendinopathy and most ruptures happen.
Tendinopathy is a failure of the tendon to keep up with load. The collagen fibres become disorganised, and the tendon thickens. Chronic Achilles problems are mostly degenerative rather than inflammatory, which is why clinicians say tendinopathy rather than tendinitis, and why loading the tendon properly works better than anti-inflammatory approaches alone.
The location matters: mid-portion tendinopathy (in the body of the tendon) usually responds to exercises that lower the heel below step level, while insertional tendinopathy (at the heel bone) is often worse on stairs, and a small heel raise in the shoe helps more than a low heel drop. Calf and ankle flexibility work, covered in our guide to stretches to improve foot and ankle flexibility, supports both patterns alongside strength work.
A rupture is a tear through the tendon, usually a complete one. The classic patient is thirty to fifty and returning to a sport played only occasionally. Partial tears exist but are less common and harder to diagnose.
Three things that mislead almost everyone
- You can often still walk on a completely ruptured tendon. Other muscles in the leg can produce enough movement for a slow, flat-footed limp. What you almost certainly cannot do is rise onto the toes of that leg alone.
- A rupture can hurt less than tendinopathy. The moment itself is sharply painful, but it often settles into a dull ache once the torn tendon stops being pulled on. Judging severity by pain level is not safe here.
- There may be no dramatic swelling or bruising, at least at first. It can take hours to appear, and by then it may have filled and hidden any visible gap.
Recognising the pattern
Tendinopathy: start-up pain that eases after a few minutes, a warm-up effect where pain fades mid-activity then returns worse later, a tender thickened spot, and symptoms that track training changes.
Rupture: a single moment during push-off or a change of direction, a snap or pop, an immediate loss of push-off power, and sometimes a palpable gap before swelling arrives.
Three checks you can do at home
These help you decide how urgently to act. They are not a diagnosis, and a reassuring result does not rule out a tear. Stop if anything is very painful, and ideally have someone else present.
The calf squeeze (Thompson or Simmonds test)
Lie face down with your feet hanging free. Have someone squeeze the fleshy part of your calf. With an intact tendon, the foot points down on its own. If it does not move at all, that suggests the tendon is not connected.
The single-leg heel raise
Standing on the injured leg only, try to rise onto your toes. This is usually possible with tendinopathy, even if painful, but usually impossible with a complete rupture.
Mr Francesc Malagelada
Mr Francesc Malagelada is a highly respected Consultant Trauma and Orthopaedic Surgeon based at the Royal London Hospital, the largest Trauma Centre in the UK. He has a special interest in foot and ankle surgery and treats common conditions such as bunions, sports injuries, ligament damage, tendon issues, as well as complex conditions that require reconstruction surgery. Mr Malagelada takes a patient-centric approach to care and offers both surgical and non-surgical options to adapt to each patient’s lifestyle.
The resting angle (Matles test)
Lying face down with knees bent, an intact Achilles holds the foot slightly toes-down. If one foot hangs noticeably flatter than the other, that asymmetry is suspicious.
Go to an emergency department the same day if
- You felt or heard a snap or pop at the back of your ankle.
- You felt as though you were kicked in the back of the leg and nobody was there.
- You cannot rise onto the toes of that leg alone.
- You can feel a dip or gap above your heel.
- Your calf is hot, swollen and painful with no injury at all, which can indicate a blood clot.
Any single abnormal home check, or a clear moment of injury even if the checks look normal, is also a reason to be seen. Uncertainty is a reason to be assessed, not a reason to wait.
It might be neither
Pain at the back of the ankle has other causes: retrocalcaneal bursitis (deeper, slightly in front of the tendon), Haglund’s deformity (a bony prominence rubbing on shoes), a calf muscle tear (higher up, with a normal calf squeeze test), a calcaneal stress fracture (after a mileage jump, sore when the heel bone is squeezed), a deep vein thrombosis (needs urgent same-day assessment), or, in children, Sever’s disease affecting the growth plate.
Who is at risk
More linked to tendinopathy: a sudden increase in training, running or jumping sports, reduced calf flexibility, higher body weight, diabetes, and inflammatory conditions such as psoriatic arthritis.
More linked to rupture: being thirty to fifty and returning to sport intermittently, sports with sudden direction change (football, badminton, squash, tennis, padel), a previous rupture, and corticosteroid injection near the tendon. Older adults can also rupture the Achilles during ordinary activity, so being outside the classic profile is not a reason to assume your tendon is fine.
Antibiotics and steroids: what UK guidance says
Fluoroquinolone antibiotics (ciprofloxacin, levofloxacin, ofloxacin) are associated with tendon damage and rupture, most often at the Achilles. The MHRA restricted their use in a Drug Safety Update on 22 January 2024, with particular care needed in people over 60 or with reduced kidney function. Problems can start within 48 hours or appear months later, and risk is higher alongside an oral steroid. Contact your prescriber promptly if you develop tendon pain – never stop a prescribed antibiotic without advice.
Does tendinopathy turn into a rupture, and why do ruptures get missed?
The two are related – tendons that rupture usually show degenerative change beforehand – but most people with tendinopathy never rupture, and many who rupture had no symptoms first. Tendinopathy is a reason to load the tendon properly, not to fear your own leg.
Ruptures are commonly missed at first contact for the three reasons above: the person could walk, the pain had settled, and swelling hid the gap. This matters because delay narrows the options – a tendon seen within the first week or two can usually be managed with the full range of treatments, while scarring and calf shortening later make surgery more likely.
First 24 hours and where to go
If you suspect a rupture: avoid weight-bearing on that leg, keep the foot pointed slightly down, elevate and ice it, and take paracetamol if suitable. Do not drive, stretch, or massage the area. Go to an emergency department the same day – you will usually be placed in a boot and referred into a virtual fracture clinic for review.
For suspected tendinopathy, reduce the aggravating activity, keep walking within comfort, and see a GP or self-refer to an orthopaedic consultant within the next week or two. A private assessment is worth considering when the diagnosis is genuinely uncertain, a partial tear is suspected, or tendinopathy has not responded after several months.
How each condition is diagnosed and treated
The examination does most of the diagnostic work: how the injury started, feeling for a gap or thickening, the resting angle, and the calf squeeze test. Ultrasound is the usual first scan, done in real time as the ankle moves. MRI is used when the picture is unclear or surgery is being planned. X-ray does not show tendons and only excludes a bony injury.
Tendinopathy is treated with a structured, progressive loading programme rather than rest, usually calf raises building over weeks under a physiotherapist’s guidance, plus a heel raise in the shoe for insertional cases. Improvement is measured in months, and a twelve-week programme is a fair first test.
Rupture has two established routes. Functional bracing holds the ankle in a boot with the foot pointed down, with angulation gradually changed over roughly eight to ten weeks. Surgical repair stitches the tendon ends together, but carrying its own risks, including wound problems and nerve injury. The gap on ultrasound helps guide the choice: over 10mm generally points towards surgery, a smaller gap towards bracing. Both routes show broadly similar outcomes when paired with early, structured rehabilitation. Our guide on whether an Achilles tendon tear needs surgery explains how that decision is made.
What not to do
- Do not have a steroid injection into the Achilles tendon.
- Do not rest a tendinopathy completely for weeks, since unloaded tendons weaken further.
- Do not push through a sudden new pain or loss of power.
- Do not aggressively stretch a suspected rupture, as this can separate the torn ends.
Whichever condition you’re dealing with, Mr Malagelada’s team can help you decide on the right course. View the full range of foot and ankle treatments or book an appointment to discuss your options.
Recovery timelines, side by side
These are general ranges; recovery varies with age, health and how consistently rehabilitation is followed.
- Tendinopathy: weeks 1–6, starting the loading programme; weeks 6–12, most people notice real improvement; 3–6 months, a good recovery for most.
- Rupture: weeks 0–10, in a boot; weeks 10–16, back into a shoe, rebuilding calf strength; 4–6 months, jogging for many; 9–12 months, return to cutting and jumping sports.
Watch for: re-rupture (usually if activity resumes too early), blood clots, wound or nerve problems after surgery, and persistent calf weakness.
Talk to a foot and ankle specialist about your Achilles
Whether your tendon has been sore for months or gave way on the pitch last week, a specialist consultation aims for a clear diagnosis, an honest explanation, and a plan you can follow. A private appointment usually runs 30 to 45 minutes, with findings explained in plain language, and often includes diagnostic ultrasound at the same visit.
Mr Malagelada sees self-pay and insured patients (Bupa, AXA, Aviva, Vitality, Allianz, WPA and Cigna). You can refer yourself without a GP, though most insurers will still want a referral and authorisation number before funding treatment.
Frequently asked questions
Can you walk with a ruptured Achilles tendon, and does it hurt a lot?
Often yes, which is the main reason ruptures are missed – other muscles can produce enough movement for a slow, flat-footed limp even with a complete tear. What you almost certainly cannot do is rise onto the toes of that leg alone. Pain is also unreliable: the moment of rupture is very painful, but it often settles into a dull ache once the tendon stops being loaded.
How do I know if my Achilles is torn or just strained?
The clearest clue is how it started. A tear usually has a single moment, often with a snap, followed by an immediate loss of push-off power. A strain or tendinopathy builds gradually over weeks. If you have a moment, or cannot do a single-leg heel raise, seek a same-day assessment.
What is the calf squeeze test?
It is the Thompson or Simmonds test. With someone squeezing your calf while you lie face down, an intact tendon makes the foot point down on its own. If it does not move, that suggests a rupture. It is a useful check, not a diagnosis.
Should I go to A&E for a suspected Achilles rupture?
Yes, the same day. Prompt assessment keeps all treatment options open. Suspected tendinopathy does not need emergency care and is better handled by a GP or physiotherapy self-referral.
How long does an Achilles rupture take to heal?
Roughly eight to ten weeks in a boot, three to four months to walk comfortably, four to six months before straight-line jogging, and nine to twelve months before cutting and jumping sports, though timescales vary considerably.
Is surgery always needed for a ruptured Achilles tendon?
No. Many ruptures are treated without surgery using a boot and a structured rehabilitation programme, with broadly similar outcomes to surgery for most patients when paired with early rehabilitation. The choice depends on age, activity level and how the tendon looks on ultrasound.
Do I need a GP referral to see a foot and ankle surgeon privately in London?
Not to book the appointment, since you can refer yourself. If you are claiming on private medical insurance, your policy will usually still want a GP referral and authorisation number before it funds treatment.
What else could pain at the back of my ankle be?
Retrocalcaneal bursitis, a Haglund’s bony prominence, a calf muscle tear, a calcaneal stress fracture, or in children, Sever’s disease. A hot, swollen, painful calf with no injury may indicate a deep vein thrombosis and needs urgent same-day assessment.
References
- NHS inform. (2026). Achilles tendinopathy. Available at: https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/leg-and-foot-problems-and-conditions/achilles-tendinopathy/
- National Institute for Health and Care Excellence. Clinical Knowledge Summaries: Achilles tendinopathy. Available at: https://cks.nice.org.uk/topics/achilles-tendinopathy/
- British Orthopaedic Foot and Ankle Society. Achilles tendon acute rupture. Available at: https://www.bofas.org.uk/hyperbook/trauma/achilles-tendon-acute-rupture
- Medicines and Healthcare products Regulatory Agency. (2024). Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate. Drug Safety Update, 22 January 2024. Available at: https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-must-now-only-be-prescribed-when-other-commonly-recommended-antibiotics-are-inappropriate
NHS. Tendonitis. Available at: https://www.nhs.uk/conditions/tendonitis/
StatPearls (NCBI Bookshelf). Achilles Tendon Rupture. Available at: https://www.ncbi.nlm.nih.gov/books/NBK430844/
- StatPearls (NCBI Bookshelf). Achilles Tendinopathy. Available at: https://www.ncbi.nlm.nih.gov/books/NBK538149/