Step 1: Identify the cause of pain

Pain in the back of the ankle is usually the cause of achilles tendon tendinitis, where the achilles tendon attaches to the calcaneus bone. This type of injury is commonly seen in athletes who perform a lot of running or jumping, as the ankle moves into dorsi flexion and the achilles tendon rubs on the calcaneus with large amounts of tension and damages the tendon, achilles tendonitis can still occur however in more of the mid tendon, simply due to the amount of tension placed on the tendon. Often achilles injuries are not due to direct damage to the tendon, but due to damage and inflammation in the connective tissue known as the peritendon which surrounds it, still inflammation here can cause catching and clicking when the tendon it covers tries to move underneath.

To test for insertional achilles tendonitis, stand on the edge of a plate with your hands on a wall to support your balance, raise onto your tip toes than slowly drop your heel to the ground, if your ankle pain was only generated when the ankle dropped below the toes you likely have insertional achilles tendonitis as this is where the achilles grinds on the calcaneus. On the other hand if you experienced achilles pain before your heel dropped below your feet in this test you likely have mid tendon tendonitis, perform several single leg hops and if this also generates pain this is what you are likely suffering with. If your pain appears to be worse with slow and controlled heel raises or hops as compared to fast movements you are likely suffering with inflammation of the peritendon, as this slow movement typically generates more friction.

Tight gastrocnemius or soleus often results in achilles mid tendon tendonitis, this is because the ankle can not perform significant dorsiflexion to absorb load thus placing large amounts of stress on this part of the tendon. To test for this perform the 5-inch wall test, get into a lunge position with your lead leg 5 inches away from a wall, lunge forward, if you can’t touch your lead knee to the wall on each leg whilst keeping your foot firmly placed on the ground than your ankle mobility is likely a contributing problem, and stretches for the gastrocnemius and soleus must be performed.

Step 2: Addressing the identified issue

When dealing with ankle pain it is best to avoid all activity which creates pain, adding a heel insert to the shoe can help to place the foot in slight plantarflexion and take tension off the achilles tendon.

To stretch the gastrocnemius and soleus go up to a wall, put your target leg out in front of you, keep your heel on the floor but place your toes up on the wall of the ground, lean forward into the leg, keeping the knee extended will target the gastrocnemius more, while having a slight bend in the knee will target the soleus more. These stretching exercises should only be performed when the ankle pain has subsided as to not place too much tension on an already injured achilles tendon.

Thankfully there are other methods to restore ankle mobility and decrease pain, such as foam rolling of the achilles and banded joint mobilization, to do do this tie a band around a low object than around your affected ankle pulling it backwards, take a knee with the other leg to drop into a lunge, now lean forward and backwards to challenge the ankle.

When a tendon is inflamed it creates pain and causes cortical inhibition where the muscle can not produce as much force and become less functional, isometrics helps to strengthen the muscle by avoiding cortical inhibition and decreasing pain. A simple isometric is performing a heel raise and pausing for about 30 seconds at the top position for 3-4 sets, as this becomes too easy you can perform this exercise while holding dumbbells.

Following isometrics when the tendon is nearly back to normal it is time to introduce slow isotonic exercises, these exercises should challenge the gastrocnemius and soleus through a full range of motion, ideally off the edge of a step to achieve maximal dorsiflexion, perform a 3 second concentric and eccentric and perhaps add a 1 second pause between, over a couple of weeks you can go from 4 sets of 15 reps to 4 sets of 8 reps with a heavier load.

Following isotonics when the tendon is completely healed it is time to rebuild the tendons ability to store and release energy with plyometrics, although this part is only really necessary for athletes whose sport involves large amounts of running or jumping, such exercises include jumping from a box and once landing performing a counter jump forwards, performing several explosive jumps in a straight line and even short distance running. These exercises should be performed cautiously for only 5-15 reps at first every 3 days.