Achilles tendinopathy in children and adolescents
Achilles tendinopathy is a problem of the Achilles tendon, the structure that connects the calf muscles to the heel bone. In children and adolescents it may be linked to sports overload, a sudden increase in training or excessive tightness of the muscles at the back of the leg. Treatment is usually conservative. It is important to distinguish it from Sever's disease, which affects the calcaneal apophysis rather than the tendon.
- Typical age
- Mainly adolescent athletes
- Also known as
- Achilles tendon tendinopathy · Achilles tendinitis · Achilles tendon pain
What is it?
The Achilles tendon is the strongest tendon in the body. It connects the gastrocnemius and soleus muscles to the calcaneus and transmits the force needed to push off when walking, running, jumping or standing on tiptoe.
Achilles tendinopathy occurs when the tendon cannot properly tolerate the loads placed on it and develops pain and changes in its structure. Although the term tendinitis is often used, in persistent cases there is not always true inflammation, so tendinopathy is a more accurate term.
In adolescents who play sport, it may be linked to a rapid increase in training, repeated running and jumping, insufficient recovery between sessions or tightness of the muscles at the back of the leg. A shortened gastrocnemius–soleus complex can increase tension on the tendon, although it is not the only cause.
Achilles tendinopathy is less common in children than in adults. During growth, pain at the back of the heel may come from the calcaneal apophysis, where the Achilles tendon attaches. This condition, known as Sever’s disease, needs a separate assessment because its origin and treatment are not exactly the same. In younger children, pain at the back of the heel should particularly prompt consideration of Sever’s disease.
Signs parents may notice
Symptoms may include:
- Pain at the back of the ankle or along the Achilles tendon.
- Discomfort when running, jumping, climbing stairs or standing on tiptoe.
- Pain at the start of training or after intense sporting activity.
- Tenderness when touching the tendon or the area near where it attaches to the heel.
- Morning stiffness or a feeling of tightness in the calf.
- Reduced sports performance or having to stop training.
Sometimes a localised thickening of the tendon may appear. However, pain at the back of the heel without tenderness along the tendon may be due to Sever’s disease or another cause.
When to see a specialist
It is advisable to see a specialist if the pain persists, limits sport or comes back every time the child resumes activity.
An assessment is advisable when:
- The pain does not improve after temporarily reducing sports load.
- The child limps or has difficulty walking or standing on tiptoe.
- There is swelling or localised thickening of the tendon.
- Discomfort also appears at rest or at night.
- The pain keeps recurring over several weeks or progressively limits activity.
When is it urgent?
An urgent assessment is needed if there is sudden, severe pain during a jump or a run, a snapping sensation, a sudden loss of strength to push off with the foot or the child cannot stand on tiptoe. These symptoms may indicate a significant tendon injury or another acute injury.
How is it diagnosed?
Diagnosis is based on the medical history and physical examination. The specialist asks about sports activity, recent changes in training, where the pain is and how it has developed.
During the examination the Achilles tendon is palpated to find the painful area, its continuity is checked, and ankle movement, calf strength and the ability to stand on tiptoe are assessed. The length of the gastrocnemius–soleus complex and foot mechanics are also evaluated.
Imaging tests are not needed in every case. Ultrasound can help assess the structure of the tendon when tendinopathy is suspected. MRI is reserved for selected situations, such as persistent pain, a suspected significant injury or diagnostic doubt. X-rays may be useful if a bone problem or a condition of the calcaneal apophysis is suspected.
In growing children it is essential to distinguish Achilles tendinopathy from Sever’s disease, and to rule out overuse injuries and other causes of heel pain.
Treatment
Conservative treatment
Most cases improve with non-surgical treatment. The aim is to reduce overload on the tendon and gradually restore its ability to cope with the demands of daily and sporting activity.
1. Activity modification
Running, jumping and exercises that cause pain should be temporarily reduced. It is not always necessary to stop all sport: alternative activities that do not cause discomfort can be continued.
2. Physiotherapy and specific exercises
Physiotherapy may include progressive calf-strengthening exercises, restoring movement and improving load management. The programme should be adapted to the child’s age, level of pain and sport.
3. Stretching
When the muscles at the back of the leg are tight, gentle gastrocnemius and soleus stretches can help. They should be tailored to the child and avoided if they cause significant pain, especially when the problem may be in the calcaneal apophysis.
4. Footwear and supports
Comfortable footwear suitable for the activity is recommended. In selected cases, a temporary heel raise can reduce tension on the tendon, but it should be assessed individually and does not replace rehabilitation.
5. Symptom control
Applying cold through a cloth for about 10–15 minutes can help relieve discomfort after activity. If the pain persists, the diagnosis and exercise progression should be reviewed before adding other treatments.
Surgical treatment
Surgery is exceptional in children and adolescents with Achilles tendinopathy.
It is only considered in very selected situations, with persistent symptoms despite appropriate conservative treatment and after confirming the diagnosis and ruling out other causes. The decision depends on the specific injury and skeletal maturity.
Operating on ordinary tendinopathy, or lengthening the tendon just because of pain, is not recommended. If there is significant shortening of the gastrocnemius–soleus complex, it should be established whether it really contributes to the problem and needs specific treatment.
Outlook and recovery
The outlook is usually good, although recovery depends on the severity of symptoms, how long they have lasted and how sports load is adapted.
As a general guide:
- First 1–2 weeks: reducing painful activities and adapting training.
- Over the following 2–6 weeks: gradually restoring movement and starting or progressing strength exercises, depending on the clinical response.
- School: attendance can usually continue, as long as the child can walk without significant pain.
- Return to sport: once the child walks without pain, has regained the necessary strength and movement and can run, jump and perform sport-specific movements without symptoms during or after activity.
Mild cases may improve within a few weeks, while persistent cases may need several months of rehabilitation. There is no single timescale that applies to every patient.
The return to sport should be gradual. If the pain comes back as training intensity increases, it is best to reduce the load and reassess the recovery programme.
This page is for general information and does not replace an assessment by a specialist. If you are worried about your child's foot, talk to their paediatrician or book an appointment.