HEALTH & WELLNESS

Achilles Tendon Pain from Running: Causes, Treatment and Recovery

Runner holding the back of the ankle in pain

Quick answer: Achilles tendon pain in runners is usually Achilles tendinopathy, often called Achilles tendinitis: pain and stiffness in the tendon at the back of the ankle after it has been loaded more than it was ready for. Most people improve with a calf strengthening programme over about 3 months, and many can keep running at a lower level while the pain stays mild. Go to A&E or see a doctor the same day if you felt a pop or snap in your calf, or if you can’t stand on tiptoe.

What is Achilles tendinopathy?

The Achilles tendon connects your calf muscles to your heel bone. Tendinopathy means the tendon has become painful and less able to cope with load. “Tendinitis” suggests inflammation, but experts now prefer the word tendinopathy, which simply means tendon pain and loss of function linked to load.

  • Midportion tendinopathy: pain in the tendon about 2 to 6 cm above the heel.
  • Insertional tendinopathy: pain where the tendon attaches to the heel bone.

Symptoms

  • pain and stiffness at the back of the ankle, often worst first thing in the morning
  • pain at the start of a run that may ease as you warm up, then return afterwards
  • pain that is worse the day after exercise
  • tenderness, swelling or thickening of the tendon

Why runners get Achilles pain

  • Doing too much too soon: a sudden increase in distance, speed or hill running. In a study of more than 5,200 runners, a single run more than 10% longer than their longest run in the previous 30 days was linked to a higher risk of an overuse injury.
  • Tight or weak calf muscles.
  • Changing your technique or shoes quickly: for example, switching to a forefoot landing puts more load through the Achilles. See what the research says about foot strike.

Treatment

Adjust your running, rather than stopping completely

Complete rest is rarely needed. Cut back on distance, speed and hills for a while. In a small trial, people who kept running and jumping with pain below 5 out of 10 did as well as people who stopped for 6 weeks, as long as both groups did their exercises. The pain should also settle by the next morning and not build from week to week.

Calf strengthening: the most important part

Loading the tendon with strength exercises has the best evidence. Two well tested options are:

  • Heel drops (eccentric exercise): stand on a step on the sore leg, rise up on both feet, then slowly lower down on the sore leg only. The tested programme was 3 sets of 15 with the knee straight and 3 sets of 15 with the knee bent, twice a day, every day, for 12 weeks. A physiotherapist can check your technique.
  • Heavy slow heel raises: heel raises with added weight, done 3 times a week, taking about 6 seconds for each repetition, starting at 3 sets of 15 and progressing to 4 sets of 6 with heavier weight over 12 weeks.

The two approaches gave similar results. If your pain is where the tendon meets the heel bone, don’t let your heel drop below the level of the step.

Other treatments

  • Stretching: calf stretches may help if your ankle movement is limited, alongside strengthening.
  • Laser, insoles and heel lifts: laser therapy is not recommended. Heel lifts can be used for a short time to ease the load on the tendon. The evidence on insoles is mixed.
  • Shockwave therapy: may help long standing pain when used alongside an exercise programme.
  • Pain relief: anti-inflammatory painkillers can ease pain for a short time. Ask a pharmacist whether they suit you. They may not be safe if you are pregnant, take a blood thinner, or have asthma, a stomach ulcer, or a heart, liver or kidney condition.
  • Injections: steroid injections into the Achilles tendon are not recommended because they can cause the tendon to tear. Platelet rich plasma (PRP) injections lack high quality evidence.
  • Surgery: considered only if 6 months of non surgical treatment hasn’t helped.

Most people don’t need a scan. It is used when the diagnosis is unclear or the pain isn’t improving as expected.

Can I keep running with Achilles pain?

Often, yes, with changes. Run shorter, slower and flatter, keep the pain mild (below 5 out of 10), and check it has settled by the next morning. If running makes the pain build, or you start limping, stop and switch to cycling or swimming for a while.

How long does Achilles tendinopathy take to heal?

Usually weeks to months. Strengthening programmes in trials ran for 12 weeks, and even with early treatment the pain can last longer than 3 months. Keep going with your exercises, even when progress feels slow.

Returning to running

  • Check you are ready: you should be able to walk, do single leg heel raises and hop without much pain. A physiotherapist can test your calf endurance and hopping.
  • Start small: begin with short, easy runs on flat ground, and leave hills and speed work until later.
  • Build up gradually: avoid any run that is more than 10% longer than your longest run in the past 30 days.
  • Keep strengthening: carry on with your calf exercises after you are back to running.

A running assessment can help plan your return.

Achilles tendon rupture: warning signs

A rupture is a tear of the tendon. Signs include a pop or snap, a feeling of being kicked in the back of the calf, pain and swelling near the heel, and not being able to push off or stand on tiptoe on the injured leg. Go to A&E or see a doctor the same day. Some antibiotics (fluoroquinolones, such as ciprofloxacin and levofloxacin) and steroid injections raise the risk of a rupture. If your tendon starts to hurt while you are taking one of these antibiotics, stop taking it and contact your doctor straight away. Treatment may be with or without surgery. Without surgery, the foot is usually held in a boot for at least 6 weeks.

Is it Achilles pain or something else?

Pain under the heel, especially with your first steps in the morning, is more likely to be plantar fasciitis. Pain at the back of the heel can also come from an irritated bursa (a small fluid filled sac) next to the tendon. A physiotherapist can tell these apart.

When to see a doctor or physiotherapist

See a doctor or physiotherapist if the pain is severe, getting worse or not better after 2 weeks, or if you have tingling, loss of feeling or diabetes. See a doctor the same day or go to A&E if you felt a snap or pop, or you can’t walk or stand on tiptoe.

Frequently asked questions

Can I run with Achilles tendonitis?

Often, if you cut back on distance, speed and hills, keep the pain below 5 out of 10 and check it has settled by the next morning. In a small trial, this worked as well as stopping running and jumping for 6 weeks.

How long does Achilles tendonitis take to heal?

Usually weeks to months. Exercise programmes typically run for 12 weeks, and pain can last longer than 3 months even with early treatment.

What are the best exercises for Achilles tendon pain?

Calf strengthening: heel drops on a step or heavy slow heel raises, progressed over about 12 weeks. If the pain is at the heel bone, don’t drop below the level of the step.

Should I stretch a sore Achilles?

Calf stretches may help if your ankle is stiff, but they work best alongside strengthening, not instead of it.

Do I need an injection or surgery?

Rarely. Steroid injections into the tendon can cause it to tear, and surgery is only considered after 6 months of non surgical treatment.

Sources

Need help with this? Our sports injury and running rehab team at Total Health by Hong Kong Sports Clinic can assess you and start treatment in your first session, in Central, Kai Tak or Tin Hau. Message us on WhatsApp to book.

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