Achilles Tendon Pain in Runners: The Complete Guide

You noticed it after your last long run on the Newton hills. Got home. Stretched a little. Scrolled instagram for a while as you recovered on the couch for an hour.

Then you got up, and felt a big pull in your achilles tendon as you walked to the kitchen to get a snack.

If you landed here after going down the google rabbit hole, you’re in the right place. Achilles tendon pain in runners is very treatable with the right approach.

I’ve been helping runners get rid of achilles tendon pain for over 8 years, and here’s what I’ve learned:

You need a plan, and it needs to be specific to you.

Without structure, or with the wrong approach, you’ll end up in an endless cycle of rest, return, re-injure that leaves you feeling frustrated and stuck. 

Why does this happen so often? Because trying to fix all achilles tendon pain with heel raises is like trying to build a house with only a hammer. You definitely need a hammer! But you need to use it at the right time, for the right task.  

Is It Actually Your Achilles?

First, let's make sure we're dealing with the right problem

Most achilles tendon pain falls into one of three categories. Identifying the right one can make the difference between making it better, and flaring it up.

First: Midportion Achilles Tendinopathy. This is the most common cause of achilles tendon pain, and you’ll feel it in the middle of the achilles tendon (between the lower calf and the heel). It usually feels the worst with hopping, but not so bad with heel raises.

Second: Insertional Achilles Tendinopathy. This type hurts closer to the back of the heel bone. Hopping might feel worse than heel raises, but heel raises off of a step might flare it up more.

Third: Bursitis or paratenonitis. This is a true inflammatory problem. This might feel just as bad with hopping and heel raises, and you may feel some swelling and warmth in the area.

Doing heavy heel raises off the edge of a stair might help with midportion achilles tendinopathy, but could really flare up an insertional achilles tendinopathy or a bursitis. That’s why figuring out which type you’re dealing with makes all the difference.

The full guide includes a differential diagnosis chart to help you figure out exactly which one you're dealing with.

Download The Guide

What's Actually Happening in the Tissue

Why "tendinitis" is the wrong word and why it matters

The word “tendinitis” ends with “-itis”, which implies inflammation. But most achilles tendon pain is actually not inflammatory, which is why we use a different word to describe more chronic injuries to tendons: tendinosis. 

Why does that matter? Because inflammation needs rest. But that’s the opposite of what a tendon that’s been chronically overloaded actually needs. If your achilles tendon has been hurting for 3+ weeks, you are likely dealing with a tendinosis.

Tendinosis is a disruption of the collagen in tendons that causes weakening of the little tendon fibers, sort of like a frayed rope. It’s painful, but not because it’s inflamed. Think of it as “chemically irritated.”

The good news is that these tendon fibers respond well to load. The problem is that rest removes that signal. That’s why runners go through this “ping-ponging” between resting and running and never actually make progress.

The catch is that loading your achilles tendon the wrong way can just flare things up more. Especially if you have insertional tendinopathy or paratenonitis. But this guide shows you exactly where to start and how to progress.

What Triggered It

Achilles tendon pain is almost always a load management problem

Most runners with achilles tendon pain can point to a specific change they made before symptoms started. A jump in weekly mileage. A switch to a lower drop shoe after reading about their benefits online. An uptick in hilly runs to prepare for the Boston Marathon.

Normally, the achilles tendon adapts to gradual increases in training intensity. But when training intensity spikes, it can get injured.

While midportion and insertional achilles tendinopathies are typically triggered by spikes in load, paratenonitis and bursitis can be triggered by lots of repetitive ankle movement or wearing shoes with an uncomfortable heel. 

One of the easiest ways to differentiate between these three different types on your own is the pinch, point, or rub test. Download the guide to learn how.

What Actually Works: The Treatment Framework

The gold standard treatment isn't what most runners expect

Tendons need load, not rest

Achilles tendon pain that has been present for 3+ weeks despite relative rest should be treated as achilles tendinosis. The initial inflammatory phase lasts about 7-10 days, so if your tendon is still irritated well after that, it’s unlikely to feel better with more rest.

But why does achilles tendinosis respond well to loading?

It’s actually really cool. The tendon tissue has this ability to sense mechanical load, and signal the body to grow and repair the damaged tissue in a process called mechanotransduction. Basically, you can show your body where to send the “construction crew” by where you apply load in your body. This is similar to strength training in general- the muscles that you work out are the ones that get bigger and stronger.

The exercise progression

The type of exercise that triggers the mechanotransduction process the best is moderate intensity, slow eccentric heel raises. The “up” part of a heel raise is the concentric phase, the “down” part is the eccentric phase. 

However, starting with those might not be the right first step for every case.

The achilles tendon loading strategy needs to be responsive. You can’t just do the exercises without thinking to check the box. You need to pay attention to how you feel during and after to make sure you’re applying the right intensity of load. This is where a lot of runners get stuck! They just start doing heel raises with reckless abandon and hope that they start feeling better.

The first step is to find an entry point, which is the level of load one can apply to their achilles tendon with less than 4/10 pain during the exercise, and return to baseline within 24 hours. If that entry point is eccentric heel raises off of a deficit for midportion achilles tendon pain, great! If not, then isometrics or heel raises to flat ground might be a better entry point.

All of the heel raise variations, sets, reps, and guidance for how to be responsive to your achilles tendon loading is in the free guide. 

Download The Guide

How to interpret pain?

Part of having a responsive loading strategy is knowing how to respond to pain. The reality of tendon rehab is that there will be some pain along the way, but you need to know how to react to it. Here are some examples:

You identify that you have midportion achilles tendinosis and you have 2-3/10 pain during your loaded heel raises off the edge of a step, but it gets better as you go and feels better than baseline the next day. 

You identify that you have achilles paratenonitis and you also did loaded heel raises off the edge of a step. It felt consistently a 4-5/10 pain and felt worse than your baseline 24 hours later.

One of these examples hit the right intensity of achilles tendon loading on the nose, when the other missed the mark and flared things up, even though they did the same exercise. 

First, you need to know what type of achilles tendon pain you’re dealing with, because they all respond a little differently. Next, you need to make sure that your pain does not exceed a 4/10 pain during the exercise, and that you return to your baseline within 24 hours. Otherwise, the load or the exercise type is wrong.

Secondary strategies

Progressive loading is an important part of any type of achilles tendon pain rehab, but there are some strategies to offload the achilles with walking and running that can help runners continue to train.

Tendons don’t love the compression that happens to them when they are fully stretched. This is why the achilles tendon will often feel worse when running in a low drop or zero drop shoe. Running in a higher drop shoe temporarily or adding a small heel lift to the shoes can help offload the achilles while running. That way, it has ample opportunity to respond to the strain applied in rehab without overloading it.

Typically, runners who use a forefoot strike are more likely to develop achilles tendon pain. Adjusting to more of a midfoot or heel strike can reduce the load on the achilles tendon.

What to avoid

It can be tempting to just pop a few ibuprofen before heading out for your long run, but that’s just kicking the can down the road, and potentially making the situation worse.

NSAID medications like ibuprofen (advil) block the normal inflammatory response. But that includes blocking the specific process that damaged tendons use to repair themselves. Even if you’re just trying to get through a race, it’s best to avoid these medications.

What about cortisone shots? Cortisone injections cause an increased risk of tendon rupture, and are generally not recommended for treatment of achilles tendinopathy by the scientific community. 

There are other adjunct treatments like PRP injections or extracorporeal shockwave therapy (ESWT) that have some promising research regarding their effectiveness for the more stubborn or chronic cases of achilles tendon pain. But when it comes to anti-inflammatories, best to avoid them altogether.

Preventing It From Coming Back

Once it's healed, here's how to keep it that way

You can’t prevent any injury 100%, but there are definitely things that runners can do to reduce their risk of achilles tendon pain. 

Strength training is the most powerful tool that runners can use to decrease their risk and improve their resilience. A progressive strength program done 2-3 times per week at the appropriate intensity has been shown to improve tendon stiffness, and therefore strength.

But the body needs strain – recover cycles. Strength training is just the signal, but the healing and building response happens mostly while we sleep. The body releases rebuilding hormones when we sleep like growth hormone that helps promote tissue growth and repair. But if you don’t get enough sleep after lifting, you won’t get nearly as much benefit from all of your hard work.

There is some research to suggest that the qualities of a runner’s gait may have some influence on their risk of developing achilles tendinopathy. However, the scientific community hasn’t reached a consensus on this topic, so a progressive loading program and getting sufficient sleep will likely be more effective than specific gait retraining. 

When to See a PT

When to stop self-treating and get professional eyes on it

Taking ownership of your rehab is good. But if you’ve been dealing with pain for longer than you should be, then that’s a problem.

Runners who have been dealing with achilles tendon pain for more than 6 weeks, who are ping ponging between taking time off and coming back too quickly, or who can’t figure out which type of achilles tendon pain they have should see a PT. 

I treat achilles tendinopathy at my Boston office very often, and I’ve found that achilles tendon pain confuses a lot of runners. They struggle to navigate their symptoms during rehab and running, and they end up ping ponging. But once they have a more robust plan, they start to actually make some meaningful progress. If you’re a runner dealing with achilles tendon pain local to Boston’s Back Bay, I’d be happy to help! Book a free discovery call to see if Alterra is a good fit for you.

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Achilles Tendon Pain in Runners: Conclusion

Achilles tendon pain is one of the most common running injuries, and one of the most mismanaged. Most runners spend months in the rest-and-return cycle not because they aren't trying, but because the standard advice doesn't match what's actually happening in the tissue.

Three things worth holding onto from this guide. First, this is a tissue repair problem, not an inflammation problem. That distinction changes everything about how you treat it. Second, tendons heal through load. Extended rest removes the signal your tendon needs to rebuild. Third, most runners can stay active through recovery with the right approach. You don't have to choose between your Achilles and your training.

If you want the full picture including the exact exercise progression, sample training weeks, and the self-assessment test to confirm which type of Achilles problem you're dealing with, it's all in the free guide.

Download The Guide

And if you've been dealing with this for a while and feel like you keep spinning your wheels, that's what we're here for. A fresh set of eyes on the full picture including your training, your history, and your specific symptoms changes the equation pretty quickly. Click here to book a free call with Dr. Jordan.

Disclaimer: The information in our blog posts is not a substitute for professional medical advice. Consult a healthcare provider before making decisions related to your health. Use our content at your own risk.