As injuries go, Achilles tendon pain can be one of the most frustrating conditions for both runner and therapist.

Achilles pain is usually referred to as ‘tendinitis’ but in sports medicine and physiotherapy circles we now use the term Achilles tendinopathy, mainly because this term gives a more accurate description of what is happening within the tendon to cause the pain.

We can define Achilles tendinopathy (or tendonitis) as pain or stiffness in the tendon that joins the two main calf muscles (gastrocnemius and soleus) to the back of the heel.

Symptoms of Achilles tendinopathy

Signs that you might be developing Achilles tendinopathy are pain and stiffness in the tendon which is usually worse the day after running. People with this injury will often complain that on getting up in the morning they find themselves limping for a short while but that as they get moving the pain and stiffness eases.

Other signs can include swelling or thickening of the tendon, the presence of a nodule on the tendon or tenderness. However, these symptoms may or may not be present with everyone and each case needs to be looked at individually.

There are a number of risk factors that can lead to the development of Achilles tendinopathy. The most common are:

  • A sudden increase in activity or training. This could be an increase in intensity, speed, distance or gradient i.e. introduction of hill sessions.
  • Not enough recovery time between sessions.
  • Training on a different surface i.e. from grass to track.
  • A change of footwear, such as using trainers with a lower heel drop or moving over to ‘bare foot’ type shoes.
  • Biomechanics. We need to pronate when we run but too much can overload the Achilles tendon.
  • The weakness of the calf muscles.
  • Poor flexibility of the calf muscles.

Unlike other injuries, pain in the Achilles tendon will often improve once you start a run or a training session. Initially, it may feel stiff but that eases off and enables you to complete your session, only for the pain to recur a few hours later. It’s a maddening condition for a runner to experience!

In the past physiotherapy treatment would have been ice, rest, massage, maybe some ultrasound and stretching. With the current research and the experiences of runners who have had this condition, we have learnt that these treatments are often not very effective and don’t do much to help recovery from Achilles pain.

What tendon research has taught us is that tendons don’t like too much rest. In fact, in recovery from Achilles tendinopathy, you won’t find many therapists recommending total rest. Rest does indeed settle the pain down but it doesn’t help the tendon repair or improve its ability to withstand load. A typical pattern might be that the tendon feels better after a weeks rest, you feel okay to run but after you’ve tried a run you feel like you’re back to square one, needing another few days off from running. Not ideal!

We know that massage tends to have a very short term effect, ultrasound treatment probably only has minimal benefit if any for Achilles pain, stretching can occasionally aggravate it and rest make no difference.

So what’s a runner to do?

Don’t stop running or training. I know! When I tell my running clients this I get some quizzical looks because it goes against all out instincts when we are in pain. But it is because of the way that a tendon behaves and the way it responds to exercise which means we can keep training over the top of it. That’s not to say you should continue your 10-mile tempos or your pyramid track session.

What you need to do, with help from your therapist is find the right level of training or running that the tendon can cope with.

To start with it might be a 15-minute jog, which doesn’t seem much but what you’re on the look out for is the tendon’s reaction to that amount of load. If you find that the tendon doesn’t stiffen up and on getting up in the morning the pain isn’t making you limp, then you may have found your sweet spot and the starting point in your running rehabilitation. In sports medicine, it is being called ‘optimal loading’. We are finding the load that the tendon can cope with. It’s then best to leave a day between sessions to allow the tendon to recover. Over time you might well find that you can just nudge the barrier a bit further.

We are finding the load that the tendon can cope with. It’s then best to leave a day between sessions to allow the tendon to recover. Over time you might well find that you can just nudge the barrier a bit further along; 18 minutes, 20 minutes, 22 minutes and so on, essentially drip feeding a bit more running in each time. Mentally this is really tough for runners so this is where cross training such as aqua jogging, turbo trainers and rowing machines really come into their own and are invaluable when injured.

Alfredson’s heel drop protocol

There is an exercise protocol for Achilles pain which I have had success with both personally and professionally. Known as Alfredson’s painful heel drop protocol, this is a set of exercises which involves standing on the painful leg on a step and lowering the heel so that the foot becomes parallel with the ground. It is an ‘eccentric’ exercise.

There is good evidence for these exercises but anecdotally I ended up using these exercises myself after developing Achilles tendinopathy and I have to say they worked. That being said these exercises are probably best performed under the guidance of a therapist.

While physio treatment aims to settle the symptoms of Achilles tendinopathy it is also important to see if you can identify where the training error might have occurred. Has the training load changed dramatically? Have you changed your footwear? Has the physio identified an area of muscle weakness/tightness that you can work on to prevent this happening again?

Outside physiotherapy there are other options such as seeing a podiatrist if biomechanical issues around the foot could be a factor. Consulting with a sports medicine doctor is another option to ascertain whether investigations such as an ultrasound scan are needed.

Achilles tendinopathy isn’t the end of running but while you’re trying to treat it, it’s worth looking at how you train and looking at ways to prevent overuse injuries happening again. If you are struggling with tendon pain the best thing to do is to book an assessment with a chartered physiotherapist and get their expert advice!


About the Author

Kathleen Walker is a physiotherapist, runner and owner of Fast Track Physio, a physiotherapy and sports injury clinic based in Cardiff. A lover of track, road and cross country, Walker has over ten years experience in treating all levels of runners, from beginners to elite.

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