Achilles Pain in Runners
Achilles pain is very common in the running community. In fact, it’s one of the most common running injuries, especially in cities with hilly or mountainous terrain. And, it’s an injury that you don’t want to ignore. If changes aren’t made to promote healing, the tissue may become more damaged and turn into a significant and chronic issue.
There are typically two types of achilles pain: insertional and mid-portion pain. Insertional achilles tendinopathy occurs over the heel area while mid-portion tendinopathy is felt further up the tendon above the ankle joint.
What causes achilles pain?
Running injuries are often multifactorial, but let’s try to make this as simple as possible. Most running related injuries occur from doing too much too soon. Training errors such as increasing volume or intensity of training more than a tissue can tolerate may lead to muscle, tendon, or bone pain.
Training errors that may lead achilles pain:
Increase in elevation that the achilles isn’t prepared for
Increasing training frequency too quickly
Significant increase in duration of training sessions
Marked increase in intensity especially during speed work
Change in footwear- for example: drastic change of shoe drop (high drop → low drop)
Think of your running health as a scale. One side is your tissue’s (ex: achilles) current capacity and ability to adapt and the other side is load. If we increase the load too much, that tips the scale. The greater the scale tips, the less likely we are to quickly recover from these mistakes and injury can occur.
For example, if you notice some achilles discomfort after an intense speed session and then run a long, hilly route the next day, it’s likely that will exacerbate your pain even more. Instead, this is where you want to think about taking a rest day or running something flat and easy in order to let the scale balance out again.
Of course there are other variables that contribute to whether or not we recover/adapt to our training and possible mistakes.
Other variables to consider within training and rehab:
Nutrition
Sleep
Stress (physical, emotional, mental)
Social support
Physiology
Making sure we pay attention to and address any deficits in these other variables, improves our likelihood of recovery, even when we make training errors.
Common symptoms
Symptoms can vary from runner to runner, but here are the most common:
Pain over the achilles while running
Pain over the achilles after running (directly after or even the next day)
Morning stiffness/pain in the achilles
Usually with the first few steps out of bed
Symptoms can range from a dull ache to sharp depending on the severity. It is also common for the pain to “warm up” while running (or exercising)- meaning that pain is noticeable toward the beginning of the run/activity, but then starts to subside. Discomfort/pain may come back if the run is a longer duration than the tissue can tolerate.
If I think I have an achilles issue, can I keep running?
It depends.
I know, I know. That’s never the answer we want. But it’s true.
When dealing with tendon pain, I have runners like you rate your pain on a scale of 1-10 in order to decide if it’s okay to continue running. A 1/10 is very mild discomfort and 10/10 is the worst pain you could ever experience. I like to use a traffic light in order to make this hit home.
Red light = stop running
Pain level: 7/10-10/10
Yellow light = proceed with caution or make a change
Pain level: 4/10-6/10
Green light = continue running
Pain level: 1/10-3/10
It’s important to pay attention to the level of discomfort while running, as well as the day after. If the pain is between 1/10 to 4/10, I usually encourage runners to continue running, as long as your symptoms are back to your baseline 24 hours after the run. When pain levels start to worsen and get into the 4-6/10 range, I recommend modifying the run.
Running modifications to take stress off the achilles:
Increase running cadence (steps/minute)
Decrease elevation
Decrease speed work (intensity)
Wear a higher drop shoe/addition of heel lift
Complete a walk/run instead of continuous running if needed
Pain levels anywhere from 7/10 to 10/10 are pretty severe. If this level of pain occurs, I recommend pulling back short term in order to let the tissue calm down. During this time, fitness can be maintained by cycling.
Treatment
Rehabbing achilles pain consists of a combination of the running modifications I mentioned above, strength work, and making sure there is a solid foundation to build from including looking at sleep, nutrition, stress management, and overall health status.
First, you want to calm the symptoms (pain) down- this is where the running modifications come in handy. During this phase, overall lower body strength should be emphasized. Things like squats, deadlifts, single leg exercises, and even heel raises are beneficial.
Next, we build up the tissue’s capacity. A heel raise progression is the main focus, but maintenance of other lower body strength remains important. This is where rehab for insertional tendon pain may differ from mid-portion pain. There is nuance to how your specific injury will need to be rehabbed, and I always recommend working with a physical therapist to ensure your specific needs are being met. If you're in the Nashville region or state of Tennessee, I can see you at my clinic or virtually- book a discovery call and we can chat about how to get you running healthy again.
Before returning to previous training levels, I recommend adding in some basic plyometrics/jumping. These types of exercises don’t build tendon strength, but they do improve its tolerance to energy storage and release- which is exactly what the tendon must do while running.
Return to Run
This is the part of the rehab process that I see the greatest need for improvement. Runners are either given no direction of how to gradually progress back into running and training, or the information you’re given isn’t specific enough.
Not only should there be a plan for easing back into running volume, but there also needs to be a conversation about how to add previously aggravating variables back into your training plan. Some guidance about when and how often to include hills and speed work is the bare minimum we owe runners who trust us with their rehab.
How long does recovery take?
Recovery is dependent on the severity of the injury. If you are dealing with mild symptoms and seek help early you may only need a few weeks to get your pain under control, whereas those who deal with pain longer may need more time (usually months).
It’s important to understand that pain improves quicker than tendon health. This is when re-injury is most likely to occur. You start to feel good, like you can tolerate previous volume or workouts, and end up doing more than the tissue can handle. That’s why it’s crucial to have a plan on how to gradually return to your prior level of training.
For those dealing with moderate- severe achilles pain, complete recovery may take 3-6+ months. Mid portion achilles tendinopathy may take 3-6 months to properly rehab, whereas insertional tendinopathy can take 6+ months.
What are we aiming for in “recovery”?
Pain levels are greatly reduced
Tendon health is improved
Back to prior levels of training
This can be such a challenging injury to rehab and return to running from.
If you’re struggling to get back to training, click the button in the upper right hand corner of this page and book a consult. Let’s make a game plan to get you back to running!
