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Overcoming what was deemed impossible is what I will take with me and cherish the most … That (coming back from injury) will be the number-one thing that stands out because I wasn’t even able to walk.

Olympic 100 meter sprint champion Donovan Bailey referring to his successful rehabilitation from Achilles tendon rupture—suffered playing pickup basketball. After rehabilitation, he ran sub-10 seconds for the 100 meters.

Modified from


The Achilles tendon is prone to injury with repeated high loads, and runners have a 15 times greater risk of Achilles tendon rupture, and 30 times greater risk of tendinopathy than do sedentary controls.1 Potentially even more concerning, Achilles—the legendary warrior and hero of Homer’s Iliad—died as a result of an injury to the midportion of his tendon. Despite these concerning facts, today’s patient with a painful presentation in this region usually has a good long-term prognosis, even for demanding activities such as running and court sports.2


In this chapter, we review relevant anatomy, provide a clinical perspective (history, examination, investigation), and then share clinically useful, evidence-based treatments for pain in and about the Achilles region according to the following clinical scenarios:


  • pain in the midportion region of the Achilles tendon

  • pain at the insertion of the Achilles tendon and the calcaneum (“enthesis organ”)

  • Achilles tendon rupture

  • posterior impingement (an important differential diagnosis).


Functional anatomy


The key areas of pain in the Achilles region (posterior heel and proximal toward the calf) are illustrated in Figure 37.1. The Achilles tendon, the thickest and strongest tendon in the human body,3 is the combined tendon of the gastrocnemius and soleus muscles. The tendon has no synovial sheath but has a posterior peritendon (also known as paratenon), which is continuous with the perimysium of the muscle and the periosteum of the calcaneus. Anteriorly, the deep surface of the tendon is supported by a fat pad through which the vessels and nerves enter the tendon (Fig. 37.1c). The sural nerve is close to the tendon through its length on the lateral side. The tendon attaches to the inferior half of the calcaneus. The posterosuperior process of the talus approximates the Achilles, often with a bursa between. This area can become symptomatic (insertional Achilles pathology) if a person has a large and rather square-shaped calcaneum.

Figure 37.1

The Achilles region

(a) Surface anatomy

Graphic Jump Location

(c) Stylized and magnified depiction to illustrate abnormal vasculature in Achilles tendinopathy

Graphic Jump Location

Clinical perspective


Overuse Achilles tendon injuries—tendinopathies—may arise with increased training volume or intensity; however, they ...

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