Achilles Tendinopathy: Learn More About this Common Running Injury
Achilles tendinopathy is one of the most common running related injuries and can have a significant impact on people’s lives. In fact, runners have a 30x greater risk of tendinopathy as they age compared to sedentary controls. That’s huge!
Clinically, it can be slow to settle but quick to aggravate. Runners often experience flare ups throughout the rehab process which can be challenging. In this blog, I’m going to do a deeper dive into what Achilles tendinopathy is and what you can do about it so that you can get back to running without pain.
In this blog, I’ll cover:
What is the Achilles Tendon and What Does it Do?
The Achilles tendon attaches your calf muscle to your heel bone. It’s the thickest and strongest tendon in the body.
Like a spring, the Achilles tendon is highly effective at storing and releasing energy during running. The Achilles tendon is important for absorbing loads when we first impact the ground while running, then it must release that energy when we toe off so that we can propel forwards.
Our calf muscles and Achilles tendon absorb forces up to 8x our body weight when we’re running. So this is a VERY important area when it comes to running!
What Causes Achilles Tendinopathy?
The most common cause of Achilles tendinopathy is a new, unaccustomed and repetitive high load. However, causes of running injuries are complex. You can read more about the many causes of running injuries in my blog HERE.
When it comes to Achilles tendinopathy, several different factors have been recognized in the research as possible causes.
A 2016 study recognized the following factors as possible causes of Achilles tendon pain:
Intrinsic Risk Factors:
Muscle power/strength - particularly the calf, but also glutes, quads, hamstrings
Reduced ankle dorsiflexion (aka your ability to push your knee over your toes)
Weight/obesity
Foot alignment/pronation
Previous lower limb tendinopathy and recent injury
Advancing age
Gender (male more common)
Steroid exposure (has been shown to weaken our tendons)
Extrinsic Factors:
Changes in loading (e.g. returning after a break)
“Training errors”
Sudden spikes in training levels
Change in load type (e.g. hill running)
Increased training intensity/speed
Change in training duration
Increased session frequency
Weekly distance changes
Activity levels
Footwear
Training surface - softer surfaces surprisingly place more load on the Achilles tendon
Features of Achilles Tendinopathy
How does Achilles tendon pain usually present? There are often some classic features that we look for as clinicians to diagnose this injury, including:
Pain localized to the tendon. Often you can point to the area of pain with one finger
Often comes on gradually
Associated with an increase in load volume or intensity
Pain at the start of an activity or after a period of inactivity (i.e. sitting)
Pain and stiffness the morning after activity
What Stretches Should I Do for Achilles Tendinopathy?
While a lot of runners feel like they want to stretch out their calves to help their Achilles tendon, this isn’t always the most effective strategy. When stretching our calf, the Achilles tendon is placed in a position of compression. While this isn’t inherently bad for a tendon, when dealing with a tendinopathy it has been shown to cause irritation at the site of the tendon.
So rather than spend your time focusing on stretching, a better strategy is to focus on strengthening your calf muscle to improve the function of your Achilles tendon.
Top 3 Exercises for Achilles Tendinopathy
Tendons require a good amount of stiffness in order to be effective. A stiffer tendon is a healthier tendon. The best way to develop this stiffness is to keep your calf muscles strong.
There are many exercises that can help, depending on the stage of your tendinopathy. Working with a rehab specialist will give you the opportunity to work on an individualized exercise plan based on your specific needs.
These 3 exercises can be very helpful during certain stages of rehabilitation for Achilles tendon pain:
Isometrics - in sitting or standing, rise onto your toes and hold this position for 15-20 seconds. Rest and repeat. This is a great place to start if you are experiencing pain with daily activity. While you are still loading your calf and Achilles tendon, it is a lower load and generally a nice place to start when rehabbing your tendon.
Single leg calf raise - If your symptoms are more controlled, introducing a single leg calf raise can help to build up tendon strength and capacity. Since running is primarily a single leg sport, doing a calf raise on one foot is a great way to load your tissue for the demands of running. It will also give you the opportunity to compare your injured leg to your non-injured leg.
Calf raise on step - standing on the edge of a step and slowly lowering yourself below the step can be a great way to load your tendon and muscle eccentrically. This means that the muscle is contracting while lengthening. Eccentric loading has been shown to be a very effective loading technique for tendons.
When it comes to strengthening your Achilles and calf, the goal should be to gradually add more load. Remember, our calf needs to be STRONG to tolerate the demands of running! Aim to start at an amount where you can tolerate about 15 reps in a set, and progress your load by adding weight. Work towards something that feels more challenging for about 8 reps over a 12 week period.
Another key to successfully strengthening your tendon is to go SLOW - aim for at least 3 seconds up, 3 seconds down for each rep. This will feel more challenging, but it has been shown to be really effective for our tendons.
Can I Run if I Have Achilles Tendinopathy?
This needs to be considered on a case-by-case basis, as every runner is different.
Often you can continue running while rehabbing Achilles tendinopathy, but we need to determine where your sweet spot is. This means finding an amount of running that you can do where your pain remains stable throughout the run and does not flare up the following day after.
For some runners who have been experiencing Achilles tendon pain for a long period of time or who are having significant pain with daily activities, it may be best to avoid running until symptoms settle down further.
Since running requires a significant load on the Achilles tendon, you may need to build up your load tolerance again first before starting back.
A few considerations for returning to running that we know from the research:
Allow 48-72 hours between higher energy storage activities (aka running) for tendon adaptation
Older Achilles tendons can take 24-36 hours to regain stiffness after a long run due to slower collagen turnover
So when you first get back to running, you’ll want to consider taking a rest day between runs to allow your tendon to recover and so that you can monitor how it is responding to the level of running that you’re doing.
If you aren’t experiencing any lingering pain the next day, you are likely ready to progress your running gradually.
Will Exercise Cause More Damage to My Tendon?
The short answer is no! Remember earlier when I told you about how the Achilles tendon is the strongest tendon in the body? It takes a LOT of force to cause damage here. This doesn’t mean that exercises won’t cause pain in your tendon. But pain doesn’t always mean you are causing damage. In fact, we know that when it comes to rehabbing tendons, some degree of pain is normal and to be expected. What we want to aim for is a tolerable level of pain that settles down within the next 24 hours after loading.
How Long Does it Take to Recover from Achilles Tendinopathy?
Tendons take time. They are a challenging area to rehab because they can be quick to flare up. Be prepared to work at your rehab for at least 6-12 months. It’s important to maintain consistent, ongoing self-management of this injury, so keep doing your exercises and following your rehab plan, even if you aren’t seeing improvement right away.
Many people with Achilles tendinopathy can continue to have symptoms and strength deficits for a long time. It could take 2-3 months before your symptoms start to show signs of improvement.
If you have Achilles tendinopathy, I don’t want this section to discourage you. Tendons have the capacity to improve, but we need to be realistic so that you aren’t expecting miracles.
A lot of people give up on their rehab too soon. Keep going. Trust the process. Working with a physiotherapist or another rehab professional can help to keep you on track and manage any frustrations that may come up throughout the process.
In conclusion, many factors can contribute to Achilles tendon pain in runners. We know that this can be a frustrating injury to manage, but there are a lot of strategies that can help. Patience is key when it comes to rehabbing this common running injury. You may not need to stop running altogether, but modifications to your training can be helpful. Look for a rehab professional that works with runners to help you on your rehab journey.
More About Emma Vaillancourt, Running Physio & Coach
Emma Vaillancourt is a Registered Physiotherapist in the Province of Ontario, Canada. As a runner herself, she has a special interest in the assessment and treatment of running injuries. She started Rehab to Racing as a way to provide virtual care for runners, focusing on finding the true cause of injury and working with runners to come back from their injury even stronger.
Emma is also a trained Athletics Ontario Endurance Coach. She approaches her coaching with a focus on long term development and finding joy in the process of training. After all, a happy runner is a successful runner! Emma works with runners of all age levels and abilities as well as all distances. She also works with runners who are returning to training after injury. Her goal is for you to remain healthy and happy throughout her training programs, while still finding success at whatever race distance or goal you have.
Interested in working with Emma? Book a complimentary discovery call today!
These articles are not designed to replace medical advice. If you have an injury I recommend seeing a qualified health professional.
