Achilles: What a Heel

I recently dipped my toe once again in Greek mythological waters with Stephen Fry’s excellent and witty Mythos, his 2018 book that ties many of these wonderful stories together into a continuous narrative. One tale that always amused, and bemused, me is that of Achilles, son of a deity and a mere man. 

His dad was Peleus, King of the Myrmidons of Thessaly and an argonaut (he joined Jason’s crew looking for the Golden Fleece) and mom was Thetis, a sea nymph.

Thetis had heard it foretold her lad would die young, so to protect this she exposed him to fire to strip away his human frailties. However, the alternative version that I prefer is that she dipped him in the river Styx to achieve the same goal by holding the stripling by his feet—a fatal mistake as his size 9’s missed the protection of those magical waters.

The fable goes that Paris ended Achilles’ life by throwing a spear at his heel, a wound that ended his life. The term Achilles’ heel came to mean a weak spot, first coined by Samuel Taylor Coleridge in the 1800s: “Ireland, that vulnerable heel of the British Achilles!” In the latter part of the 17th century, Flemish/Dutch anatomist Philip Verheyen wrote an anatomy primer called Corporis Humani Anatomia and named the cord of Achilles. Everyone in AOPA audience-land knows what Phil was talking about; that rounded cord that goes from your gloriously sculpted calf muscles to the back of your heel, the Achilles tendon, one of the strongest in the body.

But assuming not everyone knows what a tendon is, here is anatomy 101. In addition to the muscles in your gut and heart, skeletal muscles allow for body parts to move. Tendons are strong, white fibrous bands that join muscles to bones on either side of a joint, such that when muscles contract, the joint moves. The Achilles tendon is formed by the condensation of several muscles, the most superficial and prominent of which are the two bellies of gastrocnemius. When it and the other muscles contract, the ankle flexes, rather like pressing an aircraft rudder pedal to brake. Of interest, tendons have a minimal blood supply, which becomes relevant when considering the conditions we shall discuss;

When cut or harmed they don’t bleed much, so it is likely Achilles was shot with a poisoned weapon as he would not have bled to death.

Repetitive exercise, a new fitness regime, or increased age can expose tendons to forces that lead to inflammation, damage, and even ruptures. Just as elsewhere in the body, “itis” implies inflammation, so the Achilles tendon can develop tendonitis, where it becomes painful with all sorts of consequences. The resulting pain can be extreme, worse when trying to push down with the foot, and it may transfer into the calf and cause problems walking.

Upon examination, there may be heat and redness overlying the heel, painful swelling, and reduced movement. There may also be a “creaking” or grating sensation moving the foot. Untreated, tendinosis may develop, which represents a degradation in tendon integrity and can lead to a rupture; literally the tendon snaps. One might feel a sudden severe pain and even hear the break. And then any effort to press one’s toes down on the rudder will prove fruitless.

Rupture can also happen from a traumatic event, most commonly “missing” a step on a flight of stairs, or when the foot is unduly forced upwards, stretching the tendon beyond its capability to adapt. Examination of such patients shows a depression in the tendon line, and one will feel a gap between heel and muscle. The patient will not be able to stand on their toes, and when the calf muscles are squeezed, the foot does not move.

Diagnosis is based on the patient’s history and clinical examination, but an ultrasound or MRI might be deployed to confirm or refute what is going on. The condition can affect anyone, but does increase in frequency with age, obesity, high cholesterol, rheumatoid arthritis, and diabetes. Some drugs might make a rupture more likely, including steroids used to “calm down” inflammation in tendonitis and, bizarrely, one type of antibiotics called fluoroquinolones can contribute, as can drugs to treat high cholesterol, the statins.

One can reduce the likelihood of problems by seeking professional advice before starting a new exercise program, stretching before commencing any exertion, wearing proper footwear, and resting if pain develops. When that does happen, until recently, doctors recommended

RICE—Rest, Ice, Compression, and Elevation—to which one would add non-steroidal anti-inflammatory medications like ibuprofen. However, current thinking suggests PEACE and LOVE is the way to go:

Protection – avoid painful movement for the first few days.

Elevation – raise the limb.

Avoid anti-inflammatories long term – some say avoid icing.

Compression – a comforting bandage, not too tight.

Education – let nature play its part.


Load – reduce it; i.e., reduce weight-bearing and wear in-soles.

Optimism – being upbeat aids recovery.

Vascularisation – encourage blood flow by doing pain-free exercises.

Exercise – non-weight-bearing exercise such as swimming.


If this does not do the trick, a doctor or physical therapist may add other exercises or treatments like therapeutic ultrasound. Small steroid doses might prove helpful, but long-term risks must be considered. PRP (platelet-rich plasma) injections are of questionable benefit, but widely available; this is where the patient’s blood is drawn, spun down, and one element is reinjected into the heel. Other options are shockwave therapy, dry needling or prolotherapy, where dextrose or phenolglycerine are injected into the area; these are all, to my mind, yet to be confirmed as definitely helpful.

For inflamed tendons, if the above therapies do not work, surgical intervention is possibly beneficial, but comparing surgery to sham operations and physiotherapy, it seems to be as good as physio for mid-term and long-term pain relief, range of motion, and quality of life. But in the short term, surgery is better, always taking risks and benefits into consideration and the specific patient’s needs.

In rupture, some cases can be treated by placing the affected leg in a cast, but given the poor blood supply of tendons, and especially if the gap in the ruptured tendon is too great, it will require surgical repair, several weeks in a cast, and then slow and careful rehabilitation.

If one has chronic problems with Achilles tendonitis or a tight calf, your doctor may consider recommending operations such as the Strayer or Baumann procedures, whereby the muscles are effectively lengthened, providing more range of motion.

This is one of the most common tendonitis conditions, but others can affect the tendon around the kneecap, elbow, or shoulder, topics for another day.

As always, self-ground until fully recovered and remember to include details of the condition prior to your next flight physical.

Paris is one of the most magical cities on the planet and will be good for your heart and soul. Walking around Paris too much might inflame your Achilles tendon, but unlike the other Paris mentioned at the start, it won’t kill you!

Fly well!


I am excited to announce a new podcast I am doing with my old medical school colleague and dear friend, Dr. Nigel Guest.

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You can send your questions and comments to Dr. Sackier via email: [email protected]

Jonathan Sackier
Dr. Jonathan Sackier is an expert in aviation medical concerns and helps members with their needs through AOPA Pilot Protection Services.

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