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Running Injuries Series: Achilles pain

In the second in our running injuries series, we are looking at one of the most common causes of ankle pain in runners; Achilles tendinopathy.

Anatomy of the Achilles tendon

The Achilles tendon is formed from the visible fleshy gastrocnemius calf muscle and the deeper lying soleus muscles which combine to form the thick Achilles tendon at the back of the ankle which inserts into the heel bone. The Achilles is the thickest tendon in the body and it’s structure is designed to facilitate rapid propulsion by storing and releasing energy, rather like an elastic band. So it is a particularly important in sports that involve running and jumping.

What is Tendinopathy?

Tendinopathy simply means tendon pain. Tendons don’t become inflamed in the same way other tissues might, but they become painful as they try to adapt to sudden or excessive loads placed upon them. Like most tissues in the body the tendon’s response is to lay down new tissue to cope with these demands, but it doesn’t always adapt efficiently enough, which results in changes in how the tendon looks and feels, and how it deals with loads such as running. So rather than ‘damage’, tendinopathy is a maladaptive response of the tendon. The good news is we can influence this response with the right type of therapeutic exercise to get it back on track.

Achilles tendinopathy is characterised by pain and tenderness in the mid section of the tendon.


Pain in the Achilles tendon is usually a result of overload; which might occur suddenly or as a result of repetitive loading to which the tendon isn’t accustomed. It could be a sudden increase in volume of running or the introduction of something new which changes the load the tendon is used to dealing with; for example, a lot of hill training or running in different footwear. Sometimes the tendon and surrounding structures can be irritated by other types of stress and strain; including compression (trainers with a high heel tab can sometimes cause this) and also the side-to-side movement of the ankle which causes more of shearing stress around the tendon.


Tendon pain is normally characterised by pain during ‘high load’ activities such as running or jumping and often it is worse afterwards. Doing a heel raise exercise will often be painful, particularly when performed standing only on the affected leg and it may be tender to touch.

Diagnosis can be confirmed by a Physiotherapist; there are other structures both around the tendon and in the surrounding area which can be the issue, and it’s important to have your diagnosis confirmed to ensure you’re doing the right thing for your recovery. A tendon irritated by compression won't respond to the same type of management as a tendon irritated by the tensile loads of running and jumping.

Scans tend not to be used for this injury as it can be diagnosed by specific tests your physio will perform, so radiographic imaging won’t change your treatment or help recovery.

Managing your tendon pain

The management of tendinopathy is underpinned by managing the type of loads through the tendon to reduce pain and support a return to normal activity. Firstly, it’s important to identify the loads that cause the tendon to be painful – they tend to be the quick, high load movements of running or high volumes of time on your feet. You’ll be able to identify them – it’s the activities that are most painful, and it’s these most painful and provocative loads that you’ll need to refrain from in the short term. However, tendons don’t do well with complete rest; it can make things worse - so remain active with activities you can perform comfortably and seek advice. Your Physiotherapist will be able to guide your rehabilitation and return to sport and may consider a tendon loading programme, particularly if your Achilles tendinopathy has been problematic for a long period of time.

Activities to reduce/modify:

Running (if painful)

Hill walking/running (if painful)

Wearing unsupportive footwear

Stretching your calf muscles

What is tendon loading and how does it help?

Not all loads on the tendon are equal – there are some types of work for the tendon that actually help to reduce pain and move you back towards sport and exercise. These are specific types of exercise that target the tendon and ‘work’ it in a way that can be beneficial, normally with slow controlled movements with heavy loads - so different to the provocative quick and springy demands of running and jumping on the tendon. These exercises are known as ‘tendon loading’ and can be very effective for some improving pain in some types of tendinopathy (remember you need to get an accurate diagnosis first). Your Physiotherapist will be able to guide you as to when and how to do these and progress you rehabilitation for a return to sport.

Research indicates that surgery and injection therapy is no better than exercise management for tendinopathy; though it’s fundamental that this is underpinned by a correct diagnosis and that you are given the appropriate type, dosage and progressions of exercise.

Physio-guided tendon loading programmes support recovery for some types of tendinopathy.

What else can help my recovery?

Evaluation of other factors such as strength and balance in the foot and ankle, but also an assessment of strength and movement qualities further up the leg can be important. Weakness in key muscle groups at the hip and knee can contribute to what stress and strain is occurring in the lower part of the leg and ankle.

Other strategies such as taping the ankle and lower leg can be helpful for pain management in the short term and a review of gait and your biomechanics can also be helpful as you build back into running.

It is also helpful to identify the factors that caused the ‘overload’ on the tendon. If you can work this out, then it can be addressed and modified, and at the very least it will ensure you don’t repeat it in the future. Was it a change to new running shoes, or did you suddenly increase the amount of training?

When can I start running again?

The million dollar question! Unfortunately there isn’t a one size fits all answer here. Your physio will guide you on timeframes for return to running. If your tendon has just been painful for a short period of time then you may not necessarily need a long period of rehab. If you have Achilles tendinopathy that has been problematic for months or years then research supports a block of progressive rehab over the course of several months to address the issue.

If you are taking time out from running, doing types of exercise such as cycling and swimming will help to maintain your cardiovascular fitness and there are several types of leg strength you will be able to work on to maintain your conditioning while you’re rehabbing your tendon.

What now?

If you have Achilles pain, your best starting point is to obtain an accurate diagnosis from a Physiotherapist as to whether your tendon itself is the main issue; from there you’ll be able to be guided as to the best pathway to support your recovery. Get in touch here to make an appointment and find out more.

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