Key takeaways
- How it started matters more than how it feels now. Pain that built up over weeks points to tendinopathy. Pain that arrived in a single moment, often with a snap or the sense of being kicked in the back of the leg, points to a rupture.
- Being able to walk does not rule out a rupture. Other muscles take over and let many people limp on a completely torn tendon. This is the single biggest reason ruptures get missed.
- A rupture can hurt less than tendinopathy after the first few minutes. Low pain is not reassurance.
- Three checks help at home: the calf squeeze, the single-leg heel raise and the resting angle of your foot when lying face down. None of them is a diagnosis.
- A suspected rupture is an urgent problem. Go to an emergency department or urgent treatment centre the same day. Tendinopathy is not urgent and is usually managed by a GP or physiotherapist.
- It might be neither. Bursitis, a calf muscle tear, a stress fracture and a blood clot can all cause pain at the back of the ankle.
Start with how it began, not how it feels
Most people trying to work this out are sitting with a sore ankle and a search engine, and they start by comparing symptoms. That is the wrong end of the problem. The most reliable single clue is not the pain at all. It is the story of how the injury started.
Achilles tendinopathy builds. It usually starts as stiffness or a dull ache that you notice for the first few steps in the morning, or when you start a run. You can often name the week it began but not the moment. It may have grumbled along for a month or three, better on some days, worse after a hard session. It is one of the commonest reasons for foot or ankle pain after running, and it frequently travels with calf tightness that people have been ignoring for months.
An Achilles rupture happens. There is a moment. Almost everyone can point to it: pushing off in a badminton rally, sprinting for a bus, stepping awkwardly off a kerb. Many describe a loud snap or crack. A very common description is turning round to see who kicked them in the back of the leg, only to find nobody there.
If you have a moment, treat it as a possible rupture until a clinician says otherwise. If you have a gradual build-up over weeks with no single event, tendinopathy is far more likely. The rest of this article explains what to check, what misleads people, and where to go next. If you want the wider picture first, we have separate guides on whom should I see for foot or ankle pain in London, which scan you need for a painful foot, and on whether an Achilles tendon tear needs surgery.
This article was written by Mr Francesc Malagelada, Consultant Trauma and Orthopaedic Surgeon, who specialises exclusively in the foot and ankle and treats acute tendon injuries both in his central London clinics and at The Royal London Hospital, the UK’s largest trauma centre.
What each injury actually is
The Achilles is the thickest and strongest tendon in the body. It joins the two big calf muscles, gastrocnemius and soleus, to the back of the heel bone, and it carries several times your body weight every time you push off. It also has a stretch of relatively poor blood supply roughly 2cm to 6cm above the heel. That stretch is where most tendinopathy and most ruptures happen, and it is not a coincidence. The detailed anatomy of this region is one of Mr Malagelada’s own research interests, and it is the reason keyhole surgery around the back of the ankle has to be planned so carefully.
Achilles tendinopathy
Tendinopathy is a failure of the tendon to keep up with the load being put through it. The tissue changes structurally: the collagen fibres become disorganised, and the tendon thickens. You will still see the word tendinitis used widely, including by some hospital websites, and people search for it constantly. It is worth knowing that the ending ‘itis’ means inflammation, and that decades of tissue studies have shown that chronic Achilles problems are mostly degenerative rather than inflammatory. That is why clinicians now say tendinopathy, and it matters practically, because it explains why anti-inflammatory approaches alone tend to disappoint and why loading the tendon properly is the treatment that works.
Insertional or mid-portion? The distinction changes the advice
This is missing from almost every patient-facing page on the subject, and it changes what you should do.
- Mid-portion tendinopathy sits in the body of the tendon, two to six centimetres above the heel bone. You can usually pinch the sore spot between finger and thumb, and it moves as you flex your ankle. It generally responds well to progressive loading, including exercises that take the heel below the level of the step.
- Insertional tendinopathy sits right where the tendon meets the heel bone. It is often worse going uphill or on stairs, and stiff-backed shoes can rub it. Loading exercises are still the answer, but taking the heel below step level often aggravates it, and a small heel raise in the shoe frequently helps. Getting this wrong is a common reason people feel their rehabilitation is making things worse.
Either way, ankle and calf flexibility is worth working on alongside the strength work. Our guide to stretches to improve foot and ankle flexibility covers the movements most often prescribed, though stretching alone will not resolve a tendinopathy.
Achilles rupture
A rupture is a tear through the tendon, and it is usually a complete one. The classic patient is between thirty and fifty, is male more often than not, and is returning to a sport they used to play regularly rather than one they play every week. That stereotype is useful but incomplete, and later in this article there is a fuller picture of who is actually at risk.
Partial tears exist but are less common than people assume, and they are harder to diagnose. A partial tear can behave a bit like tendinopathy and a bit like a rupture, which is precisely why self-assessment has limits.
Three things that mislead almost everyone
If ruptures were obvious, they would not be missed. They are missed regularly, and these three misconceptions are the reason.
1. You can often still walk on a completely ruptured tendon
This surprises people more than anything else. The Achilles is the main engine for pushing off, but it is not the only muscle that points the foot down. Tibialis posterior, the peroneals and the long toe flexors all contribute, and together they can produce enough movement for a slow, flat-footed limp. So the reasoning of ‘I walked to the car, so it can’t be torn’ is not safe reasoning. What you almost certainly cannot do is rise onto the toes of that leg alone, or push off to run.
2. A rupture can hurt less than tendinopathy
The moment of rupture is usually sharply painful. Then, for a good number of people, it settles into a dull ache that is easier to live with than the tendon pain they had the week before. This makes sense mechanically: a torn tendon is no longer being pulled on, so the pain generator has gone quiet. Judging severity by pain level is unreliable here, and low pain has led plenty of people to wait a week before seeking help.
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.
3. There may be no dramatic swelling or bruising
Swelling and bruising above the heel are useful when present, and a visible dent or gap in the line of the tendon is a strong sign. But swelling can take hours to appear, and it can then fill the gap and hide it. An absence of bruising in the first few hours means very little.
The tendinopathy pattern
Tendinopathy has a rhythm that is quite specific once you know to look for it.
- Start-up pain. The first steps out of bed are the worst of the day. Stiffness and soreness that ease after a few minutes of moving around is close to a signature finding.
- The warm-up effect. Pain is noticeable at the start of a run or a walk, eases in the middle as the tendon warms, then returns later that evening or the next morning, often worse than before. Very few injuries behave like this, and it is a strong pointer.
- A tender, thickened spot. You can usually find the sore area with your fingers, and the tendon may feel fatter than the other side.
- It responds to load. More running, more hills, new shoes, a return after time off. Symptoms track training changes.
Pain that is present at complete rest, at night, or that came with fever or redness is not typical tendinopathy and should be checked promptly.
The rupture pattern
- A single moment, usually during a push-off or a sudden change of direction.
- A snap, crack or pop, sometimes loud enough for other people nearby to hear it.
- The sensation of being struck or kicked in the back of the lower leg.
- Immediate loss of power. You cannot push off. Sprinting, jumping and climbing stairs normally become impossible straight away.
- A gap you can sometimes feel, a few centimetres above the heel, in the first hour or two before swelling arrives.
- Swelling and bruising develop over the following hours, often tracking down towards the heel and ankle.
Three checks you can do at home
These are versions of tests used in clinic. They are useful for deciding how urgently to seek help. They are not a diagnosis, and a reassuring result does not rule out a tear. Do them only if you can do so safely, ideally with someone else present, and stop if anything is very painful.
The calf squeeze (Thompson or Simmonds test)
- Kneel on a chair or lie face down on a bed with your feet hanging freely over the edge.
- Have someone gently squeeze the fleshy part of your calf, about a third of the way down from the back of the knee.
- Watch the foot. With an intact tendon, squeezing the calf makes the foot point downwards on its own.
- If the foot does not move at all when the calf is squeezed, that suggests the tendon is not connected and needs same-day assessment.
Always compare with the uninjured side first, so you know what a normal response looks like on you. This test is well regarded in clinical practice, but it is not infallible: partial tears and swelling can both produce a misleading result.
The single-leg heel raise
Stand near a wall or worktop for balance and put your weight on the injured leg only. Try to rise onto your toes. With tendinopathy, this is usually possible even though it hurts, and you can often repeat it. With a complete rupture, it is usually impossible, no matter how hard you try. Do not attempt this if you have just had a violent injury or if standing on the leg is very painful.
The resting angle (Matles test)
Lie face down with your knees bent to a right angle and your feet relaxed in the air. An intact Achilles holds the foot in a slightly toes-down position. If one foot hangs noticeably flatter or with the toes pointing back towards the shin compared with the other side, that asymmetry is suspicious. Comparing both legs at once is what makes this test useful.
Go to an emergency department or urgent treatment centre 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 or hit in the back of the leg and there was nobody there.
- You cannot rise onto the toes of that leg while standing on it alone.
- You can feel a dip or gap in the tendon above your heel.
- Your calf is hot, swollen and painful without any injury at all, which can indicate a blood clot and needs same-day assessment.
When to stop testing and get seen
- Any single abnormal result on the checks above.
- A clear moment of injury, even if all three checks look normal.
- You cannot bear weight, or you cannot do a single-leg heel raise.
- You are unsure. Uncertainty is a reason to be assessed, not a reason to wait and watch.
It might be neither
Pain at the back of the ankle has more than two possible causes, and this is the part almost every article on this topic leaves out. Worth considering:
- Retrocalcaneal bursitis. A fluid-filled sac between the tendon and the heel bone becomes irritated. Tenderness sits deeper and slightly in front of the tendon rather than in it.
- Haglund’s deformity. A bony prominence at the back of the heel that rubs against shoes and irritates the tendon and bursa. Often worse with stiff heel counters.
- Calf muscle tear. Frequently the inner head of the calf muscle, sometimes called tennis leg. It also arrives with a sudden pop, but the pain sits higher, in the muscle belly rather than the tendon, and the calf squeeze test is usually normal.
- Calcaneal stress fracture. More likely in runners with a recent jump in mileage, or in people with low bone density. Pain is in the heel bone itself and hurts when the heel is squeezed from the sides. It is one of the most common fractures around the foot and ankle, and it is regularly mistaken for a soft tissue problem.
- Deep vein thrombosis. A calf that becomes hot, swollen, tender and red without an injury needs urgent assessment. This is a medical emergency, not a tendon problem.
- Sever’s disease. In active children and teenagers, heel pain is often coming from the growth plate rather than the tendon.
This is exactly why a clinical assessment is worth having rather than settling the question yourself. Six conditions that all present as pain at the back of the ankle cannot reliably be separated from a website, and two of them need same-day care.
Who is at risk, and who gets which
The risk profiles overlap, but they are not the same.
More associated with tendinopathy
- A sudden increase in training volume, intensity or hill work. This is the single commonest trigger we see, and it is covered in more detail in our guide to common causes of foot pain in runners.
- Running and jumping sports, and jobs involving long periods standing or walking on hard floors.
- Reduced ankle flexibility and calf weakness.
- Higher body weight, diabetes, and inflammatory conditions such as psoriatic arthritis and ankylosing spondylitis.
More associated with rupture
- Being between thirty and fifty, and returning to sport intermittently rather than training consistently.
- Sports with sudden acceleration and direction change: football, badminton, squash, basketball, tennis.
- A previous rupture on either side.
- Corticosteroid injection into or immediately around the tendon, which is why this is generally avoided at the Achilles.
Antibiotics and steroids: what UK guidance says
Fluoroquinolone antibiotics, which include ciprofloxacin, levofloxacin and ofloxacin, are associated with tendon damage and rupture, and the Achilles is the tendon most often affected. The MHRA issued a Drug Safety Update on 22 January 2024 restricting their use to situations where other antibiotics are inappropriate. The important practical points for patients are that tendon problems can begin within 48 hours of starting treatment and can also appear months after finishing it, and that the risk is higher when a fluoroquinolone and an oral corticosteroid are taken together. The same update asks prescribers to take particular care in people over 60, and in those with reduced kidney function or a solid organ transplant.
If you develop tendon pain while taking or shortly after taking one of these antibiotics, contact the prescriber promptly for advice. Do not stop a prescribed antibiotic without speaking to a clinician, and do not adjust any other medication based on a web page.
Beyond the weekend footballer
The sporting stereotype hides several groups. Older adults can rupture the Achilles during ordinary activity such as missing a step. People with diabetes, chronic kidney disease or inflammatory arthritis carry higher tendon risk. Anyone with reduced bone and tissue health, including people who have gone through the menopause and athletes with low energy availability, may be more vulnerable than the stereotype suggests. Being outside the classic profile is not a reason to assume your tendon is fine.
Does tendinopathy turn into a rupture?
This is the question people ask once they have decided they probably have tendinopathy, and it deserves a straight answer rather than reassurance or alarm.
Degenerative change in a tendon is commonly found in tendons that go on to rupture, and tissue examined after rupture usually shows changes that were present beforehand. So the two conditions are related. What does not follow is that having tendinopathy means you are heading for a rupture. Many people with a long history of Achilles tendinopathy never rupture. Equally, a large proportion of people who rupture had no symptoms at all beforehand, which tells you that silent degeneration is common and that symptoms are a poor guide to tendon strength.
The useful conclusion is a calm one. Tendinopathy is a reason to load the tendon properly and progressively rather than to rest it into weakness or to push through pain and hope. It is not a reason to be frightened of your own leg.
Why ruptures get missed, and why that matters
A meaningful proportion of acute Achilles ruptures are not identified at the first medical contact. The usual causes are the three misconceptions above: the person walked in, the pain had settled, and swelling had already filled the gap. It is not a rare error, and it is well documented in the clinical literature.
It matters because delay narrows the options. A tendon treated within the first week or two can usually be managed with the full range of approaches, including non-surgical treatment in a boot. Once the gap has begun to fill with scar and the calf muscle has shortened, treatment becomes more complicated, and surgery becomes more likely to be needed. This is the strongest practical reason to get a suspected rupture looked at quickly rather than giving it a fortnight to see how it goes.
If you have already been seen and told it is a strain, but you still cannot rise onto your toes on that leg, it is entirely reasonable to ask for a second opinion or an ultrasound scan.
What to do in the first 24 hours
If you suspect a rupture and are waiting to be assessed:
- Stop weight-bearing on that leg as far as you reasonably can. Do not test it repeatedly to see whether it still hurts.
- Keep the foot pointed slightly downwards rather than pulled up towards you. Lying face down with the foot hanging off the end of the bed, or resting on a cushion so the toes drop, keeps the torn ends closer together.
- Elevate the leg when sitting and apply an ice pack wrapped in a cloth for around fifteen minutes at a time to help with swelling.
- Take simple pain relief such as paracetamol if it is suitable for you, following the packet instructions.
- Do not drive. You cannot safely operate pedals with a suspected Achilles rupture, and you may not be insured.
- Do not stretch the calf, massage the area, or try to walk it off.
For suspected tendinopathy, the first 24 hours are far less critical. Reduce the aggravating activity rather than stopping all movement, keep walking within comfort, and arrange to be assessed in the next week or two if it is not settling.
Where to go first in the UK
This is the practical decision most articles skip, and the routes are genuinely different for the two conditions.
Suspected rupture: same day
Go to an emergency department or an urgent treatment centre. Do not wait for a GP appointment. In many parts of the UK you will be examined, placed in a boot or a plaster with the foot pointed down, and then referred into a virtual fracture clinic. That is a review of your case by an orthopaedic team, often the next working day, without you needing to attend in person. They decide whether you need an in-person clinic appointment, an ultrasound scan, or a change of treatment plan, and someone contacts you with the outcome. It is a normal part of modern NHS orthopaedic care and not a sign that your injury is being taken less seriously.
Suspected tendinopathy: routine
This is not an emergency department problem. Options are to see a GP, or in most areas to self-refer directly to NHS physiotherapy without seeing a GP first, which is usually the faster route. A physiotherapist can diagnose Achilles tendinopathy clinically and start a loading programme in the first appointment. Ask for onward assessment if there has been no improvement after around three months of a properly followed programme.
When a private assessment is worth considering
Privately, the main practical advantage is speed and the availability of same-appointment ultrasound, which is the imaging test of choice for the Achilles because it shows the tendon moving in real time. That is most valuable when the diagnosis is genuinely uncertain, when a partial tear is suspected, or when tendinopathy has not responded to several months of treatment. It is worth saying plainly that if you have a suspected complete rupture, going to an emergency department the same day is the right answer, not booking an appointment for later in the week.
Not sure whether it is a tendinopathy or a tear?
An Achilles that has been grumbling for months, or one that has been called a strain but still will not let you rise onto your toes, is exactly the situation a specialist assessment is designed to settle.
Mr Malagelada is a fellowship-trained Consultant Orthopaedic Surgeon who works exclusively on the foot and ankle, performs more than 250 foot and ankle operations a year, and treats acute tendon injuries as part of his trauma practice at The Royal London Hospital. Appointments are available at short notice at his central London clinics, you can refer yourself without seeing a GP first, and imaging is arranged and reviewed as part of the consultation rather than sent away and waited on.
Book an appointment or speak to the team about an Achilles assessment.
If you think you have ruptured your Achilles today, please go to an emergency department or urgent treatment centre first. Getting the tendon supported quickly keeps every treatment option open.
How each condition is diagnosed in clinic
For both conditions, the examination does most of the work. A clinician takes the history of onset, feels along the tendon for a gap or a thickened area, checks the resting angle of both feet, and performs the calf squeeze test. In many cases, that is enough to be confident.
- Ultrasound is the usual first imaging test. It is quick, involves no radiation, and it can be done dynamically, meaning the sonographer moves your ankle and watches the tendon ends. It shows tendon thickening in tendinopathy and shows a gap and whether the ends come together in a rupture, which directly influences treatment.
- MRI is used when the picture is unclear, when a partial tear is suspected, when a rupture presents late, or when surgery is being planned. It gives more detail of the tendon and surrounding structures but takes longer to arrange.
- X-ray does not show tendons. It is used to exclude a bony injury such as an avulsion fracture, where the tendon has pulled a fragment of bone away, or to check for a Haglund’s prominence or a calcaneal stress fracture.
You do not always need a scan. A confident clinical diagnosis of tendinopathy in a typical presentation is perfectly reasonable, and imaging findings in tendons often do not match symptoms well. If you are unsure what to expect, our guide to which scan you need for a painful foot explains what each test does and does not show.
How each condition is treated
Tendinopathy: progressive loading is the treatment
Tendons adapt to load and weaken without it, so the core of treatment is a structured, progressive strengthening programme rather than rest. This typically means calf raise variations building over weeks from slow, controlled movements to heavier and eventually faster and springier work, guided by a physiotherapist. Pain during the exercises is expected and acceptable within limits, and the usual guidance is that soreness should settle within 24 hours and should not be worse the following morning.
Alongside that, activity is modified rather than stopped, load is reduced temporarily and reintroduced gradually, and footwear is reviewed. A heel raise inside the shoe is often helpful for insertional tendinopathy. Simple pain relief may be used short term. Improvement is measured in months, not weeks, and a properly followed programme of around twelve weeks is a fair first test. Injections, shockwave therapy and surgery exist for cases that do not respond, but they sit well down the list and are decisions for a specialist.
This is the part of the pathway where most Achilles patients actually get better, which is why Mr Malagelada runs a multidisciplinary practice including physiotherapy and podiatry rather than a surgical clinic alone. The vast majority of patients benefit from tailored non-operative treatment, and surgery is only advised when it is genuinely necessary. You can see the full range of foot and ankle treatments offered, operative and otherwise.
Rupture: bracing or surgery
There are two established routes and UK practice uses both.
- Functional bracing. The ankle is held in a boot with the foot pointed downwards, using wedges that are gradually removed over roughly eight to ten weeks to bring the foot back towards neutral as the tendon heals. Early weight-bearing in the boot is now common practice rather than prolonged non-weight-bearing.
- Surgical repair. The tendon ends are stitched together. This avoids the risks of a long period in a boot but introduces the risks of surgery itself, principally wound healing problems and injury to the nearby sural nerve. Infection, blood clots and re-rupture are also recognised risks and should be discussed with you before you consent.
Modern comparisons of the two approaches, when both are combined with an early, structured rehabilitation programme, show broadly similar functional outcomes for most patients. That is why the decision is an individual one, weighing your age, activity level, general health, the position of the tendon ends on ultrasound and how soon after injury you presented. Your surgeon should talk you through both. Whichever route is chosen, rehabilitation does the heavy lifting.
Ultrasound is doing more work in that decision than most people realise. Where the tendon ends sit when the foot is pointed down is a practical threshold: a gap larger than 10mm, and in some cases 5mm, points towards surgical repair, while smaller gaps that close on the scan point towards treatment in a boot. Our article on whether an Achilles tendon tear needs surgery goes through how that judgement is made.
What not to do
- Do not have a steroid injection into the Achilles tendon. Injection into or immediately around it is associated with rupture and is generally avoided.
- Do not rest a tendinopathy completely for weeks. Unloaded tendons get weaker, and the problem usually returns worse when you go back.
- Do not push through a sharp new pain or a sudden loss of power. That is a different event from tendinopathy soreness.
- Do not aggressively stretch a suspected rupture. Pulling the foot up separates the tendon ends.
Recovery timelines, side by side
These are general ranges. Individual recovery varies a great deal with age, general health, the specific injury and how consistently the rehabilitation programme is followed.
Tendinopathy
- Weeks 1 to 6: starting the loading programme, modifying aggravating activity. Early gains are often small.
- Weeks 6 to 12: most people notice meaningful improvement in this window if the programme is being followed properly.
- 3 to 6 months: typical timescale for a good recovery and a return to previous activity. Long-standing cases can take longer, and reviewing the diagnosis and the programme is sensible if there has been no progress by three months.
Rupture
- Weeks 0 to 10: in a boot, with the foot gradually brought up towards neutral. Walking in the boot, often with crutches at first.
- Weeks 10 to 16: out of the boot, back into a shoe, working on walking normally and building calf strength from a low base. The calf will look visibly smaller than the other side.
- 4 to 6 months: jogging in a straight line for many people, if strength targets have been met.
- 9 to 12 months: return to cutting and jumping sports. Some people, particularly at higher levels of sport, take longer or do not fully regain their previous push-off power.
Work, driving and sport
Desk-based work is often possible within a week or two of a rupture if you can get there safely, since the leg can be elevated. Manual, standing or driving work generally means several months off. On driving, the rule of thumb is that you must be out of the boot and able to perform an emergency stop safely and without hesitation. Check with your insurer and your treating clinician before driving again, and note that the requirements differ for automatic and manual vehicles and for which leg was injured.
Complications to be aware of
- Re-rupture, most commonly in the first few months, and typically when someone returns to activity earlier than the programme allows.
- Blood clots. Immobilising a lower limb in a boot or plaster raises the risk of deep vein thrombosis. You should be assessed for this risk and may be offered preventive treatment. Report new calf pain, swelling or breathlessness urgently.
- Wound problems and nerve irritation after surgical repair, mostly minor but occasionally significant.
- Persistent calf weakness, which is common and is best addressed by continuing strength work well beyond the point of feeling recovered.
Being seen privately in London: what to expect
No page ranking for this topic explains this, so here it is plainly.
A private foot and ankle appointment usually runs 30 to 45 minutes. You will be asked about how the problem started, examined with your shoes and socks off, and given the findings in plain language rather than in terms you have to look up afterwards. Many clinics can perform diagnostic ultrasound in the same visit, which is what turns an uncertain assessment into a clear answer on the day. If an MRI is needed, it is normally arranged separately.
At Mr Malagelada’s clinics, consultation fees currently range from £215 to £325, and that figure covers the clinical review, the review of your imaging and a personalised treatment plan rather than the examination alone. Where Achilles surgery is indicated, the self-pay price is published rather than quoted on request, and finance is available through Chrysalis over one to five years at a fixed 14.9% APR, with a minimum loan of £350. Full pricing for consultations and surgery is listed on our patient information page.
On insurance, Mr Malagelada is recognised and fee-assured by all the major insurers including Bupa, AXA, Aviva, Vitality, WPA and Cigna. Two practical points are worth knowing. You do not need a GP referral to book an appointment, because you can refer yourself. Most insurers, however, will still want a referral and an authorisation number before they will fund treatment, so it is worth calling your policy provider before your first visit.
How to choose a clinician
- Check the GMC register for a doctor, or the HCPC register for a physiotherapist or podiatrist. Both registers are publicly searchable online.
- For surgical opinions, look for a consultant on the GMC specialist register in trauma and orthopaedic surgery whose declared practice is foot and ankle rather than general orthopaedics.
- Membership of the British Orthopaedic Foot and Ankle Society (BOFAS) indicates a specialist interest in this area. Mr Malagelada is a BOFAS member, has been on the GMC orthopaedic specialist register since 2013, and co-directs the BOFAS-accredited Barts Health Foot and Ankle Fellowship.
- Ask directly whether ultrasound is available at the same appointment, who performs and reports it, and what the total cost includes.
- Ask what the plan is if the scan is normal. A good answer means the clinician has thought past the obvious diagnoses.
Frequently asked questions
Can you walk with a ruptured Achilles tendon?
Often yes, and this is the main reason ruptures are missed. Other muscles in the leg can produce enough downward foot movement for a slow, flat-footed limp even when the Achilles is completely torn. What almost nobody can do with a complete rupture is rise onto the toes of that leg alone or push off to run. Being able to walk should never be treated as evidence that the tendon is intact.
How do I know if my Achilles is torn or just strained?
The clearest clue is how it started. A tear almost always has a single moment, often with a snap or the feeling of being kicked in the back of the leg, followed by an immediate loss of push-off power. A strain or tendinopathy builds gradually over weeks and is typically worst for the first few steps in the morning. If you had a moment, or you cannot do a single-leg heel raise, seek same-day assessment.
Does a ruptured Achilles always hurt a lot?
No. The moment of rupture is usually very painful, but the pain often settles quickly into a dull ache because the torn tendon is no longer being loaded. Some people describe less pain the day after a rupture than they had from tendinopathy the week before. Pain level is not a reliable measure of how serious the injury is.
Can Achilles tendinopathy turn into a rupture?
The two are related. Tendons that rupture usually show degenerative change that was present beforehand. But most people with tendinopathy never rupture, and many people who rupture had no symptoms at all first. Having tendinopathy is a reason to follow a proper loading programme rather than a reason to expect a rupture.
What is the calf squeeze test and can I do it myself?
It is the Thompson or Simmonds test. Lying face down with the feet hanging free, someone squeezes the calf muscle. With an intact tendon, the foot points downwards on its own. If it does not move, that suggests a rupture. You need another person to do it properly, and you should compare with the uninjured side. It is a useful triage check, not a diagnosis, and it can be misleading with partial tears.
Should I go to A and E for a suspected Achilles rupture?
Yes. Attend an emergency department or urgent treatment centre the same day. Prompt assessment keeps all treatment options open, whereas a delay of a few weeks can make treatment more complicated. Suspected tendinopathy, by contrast, does not need emergency care and is better handled by a GP or by self-referring to physiotherapy.
What is the difference between insertional and mid-portion Achilles tendinopathy?
Mid-portion tendinopathy sits in the body of the tendon roughly two to six centimetres above the heel bone. Insertional tendinopathy sits where the tendon attaches to the heel bone itself. The distinction matters because exercises that drop the heel below step level often help mid-portion tendinopathy but aggravate insertional tendinopathy, where a small heel raise in the shoe is usually more helpful.
Do I need a scan to diagnose an Achilles problem?
Not always. A clinical examination is often enough, particularly for straightforward tendinopathy. Ultrasound is the usual first scan when a tear is suspected or the picture is unclear, because it shows the tendon moving in real time. MRI is reserved for uncertain, partial or late-presenting cases and for surgical planning. X-rays do not show tendons and are used only to check the bone.
Can antibiotics cause an Achilles tendon rupture?
Fluoroquinolone antibiotics such as ciprofloxacin, levofloxacin and ofloxacin are associated with tendon damage and rupture, most often at the Achilles. The MHRA restricted their use in January 2024. Problems can begin within 48 hours of starting treatment or appear months after finishing, and the risk is higher if an oral steroid is taken at the same time. Contact your prescriber promptly if you develop tendon pain, and do not stop a prescribed antibiotic without advice.
How long does an Achilles rupture take to heal?
Roughly eight to ten weeks in a boot, three to four months to walk comfortably in normal shoes, four to six months before straight-line jogging for many people, and nine to twelve months before returning to sports involving cutting and jumping. Timescales vary considerably, and some people do not fully regain their previous push-off power.
Is surgery always needed for a ruptured Achilles tendon?
No. Many ruptures in the UK are treated without surgery, using a boot with wedges and a structured rehabilitation programme. When both routes are paired with early functional rehabilitation, outcomes are broadly similar for most patients. The choice depends on your age, activity level, general health, how the tendon ends look on ultrasound and how quickly you were seen. It is a discussion to have with a foot and ankle specialist.
Do I need a GP referral to see a foot and ankle surgeon privately in London?
Not to book the appointment. You can refer yourself, and you can also be referred by a GP or a physiotherapist. If you are claiming on private medical insurance, your policy will usually still ask for a GP referral and an authorisation number before it will fund your consultation or treatment, so check with your insurer first.
What else could pain at the back of my ankle be?
Several things. Retrocalcaneal bursitis, a Haglund’s bony prominence, a calf muscle tear, a calcaneal stress fracture, and in children and teenagers, Sever’s disease affecting the growth plate. A hot, swollen, painful calf with no injury may indicate a deep vein thrombosis and needs urgent same-day assessment.
References
- NHS inform, Achilles tendinopathy – https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/leg-and-foot-problems-and-conditions/achilles-tendinopathy/
- NICE Clinical Knowledge Summaries, Achilles tendinopathy – https://cks.nice.org.uk/topics/achilles-tendinopathy/
- British Orthopaedic Foot and Ankle Society (BOFAS), Achilles tendon acute rupture – https://www.bofas.org.uk/hyperbook/trauma/achilles-tendon-acute-rupture
- MHRA, Drug Safety Update on fluoroquinolone antibiotics, 22 January 2024 – https://www.gov.uk/drug-safety-update
- NHS, Tendonitis – https://www.nhs.uk/conditions/tendonitis/
- StatPearls (NCBI Bookshelf), Achilles Tendon Rupture – https://www.ncbi.nlm.nih.gov/books/NBK430844/
- StatPearls (NCBI Bookshelf), Achilles Tendinopathy – https://www.ncbi.nlm.nih.gov/books/NBK538149/