Common Running Injuries Pt 2: Achilles Tendinopathy

Defining Achilles tendinopathy and providing evidence-based treatment

Jordan Clevenger DPT

Published in

Runner's Life

5 min readDec 31, 2020

Picture of a runner with the focus on his achilles — Photo by Andrea Piacquadio from Pexels

Roughly 7–9% of runners and up to 18.5% of ultramarathons runners have Achilles tendinopathy¹

What is Achilles tendinopathy?

Achilles’ tendon

The Achilles tendon is also known as the heel cord and is the tendon at the bottom of the calf. This tendon connects your calf muscles to the heel bone (calcaneus) with the primary job of transferring force from the muscle to the bone. It is crucial in helping the foot push-off during walking, running, jumping, and many other activities.

Tendon Changes

When a tendon begins to degenerate, the fibers of the tendon start to become misaligned. See the picture below as an example. The goal is to stop the degeneration by optimally loading the tissue. The exercises described later in the post will help you find this optimal loading.

I’m frequently asked by patients if tendinitis and tendinopathy are the same. Ten years ago, many people used tendinitis because they thought the tendon was inflamed (-itis is the suffix meaning inflammation). As tendons are researched more, it has been shown that this is not an inflammatory condition but rather a degenerative problem. Thus, the name has been changed to tendinosis or tendinopathy. However, many people still call it tendinitis because that is the term they are used to.

Signs and Symptoms

Pain in the morning that gets better throughout the day
Pain with walking, running, jumping, or other dynamic movements
Increased thickening or swelling along the tendon
A single leg heel raise is painful

Risk Factors

Obesity: Higher body weight places increased stress on tendon
Genetics: 5x more likely to have tendinopathy if someone in your family has had it¹
Poor glute coordination: Examples are if your knees often rub each other while running or knees cave in frequently
Age: Most common in people aged 40–60 years
Activity levels: A rapid increase in training frequency or miles running per week

Treatment

Education

Length of symptoms: If the pain has just begun, try avoiding painful activities for two weeks. For example, instead of running, try swimming or rowing. Once the pain calms down, ease back into running and perform the exercises below. If you have had Achilles pain for longer than two weeks, continue your usual recreational activity and exercises within pain tolerance. Try to keep pain below a 5 out of 10.
Body alignment: Avoid sitting or laying with excessive plantar flexion (toes pointed down). For example, when sitting, keep your feet flat on the floor vs. under your chair. Also, put a pillow between your feet and the foot of the bed bringing the feet to a 90 deg angle while sleeping.
Recovery time: One study found it took an average of 82 days for runners to recover from Achilles tendinopathy.¹

Strengthening Exercises

The treatment with the best evidence is calf strengthening. The key is to go slowly and perform an exercise that feels heavy. It should be difficult to perform the last couple of reps and is okay if it is a little painful — try to keep it below a 5/10 pain. I recommend doing exercises both with the knees straight and with the knees bent.

Here is an example progression to perform. Once one exercise gets easy, you can progress to the next.

Start with double heel raises → Then progress to the middle photo, go up with both legs and then down with one leg → Lastly, single leg heel raises
You should do 3 sets of 15 reps, 3x/week for about 3 months. Perform 3 sets with the knees straight and with them bent.
To progress these exercises, perform them on a step where the heel can drop down off the edge into farther range of motion

In addition, strengthening the glutes via bridges, clamshells, and lateral walks can be helpful as well. These are especially important for runners that notice their knees often rub each other.

Stretching Exercises

Performing calf stretches can also be beneficial. I recommend performing one set with the knee straight and another with the knee bent. Perform each stretch at least for 60 seconds 2x/day.
Many runners have tight hamstrings, so I recommend stretching the hamstrings with the exercise below for 60 seconds 2x/day.

Modalities

There is some evidence that using rigid tape on the foot can be beneficial for reducing heel pain. This is usually done by a physical therapist or other healthcare professional. The evidence is best for rigid tape vs kinesiotape or other stretchy tapes.
Orthotics have mixed evidence but may be beneficial for those with flat feet.

Key Takeaway

If you are having pain in the Achilles tendon, try to perform heel raises 3x15 slowly and make sure they are difficult. Do 3 sets with knees straight and 3 with knees bent 3x/week with a day of rest in between. With all activities, including these exercises, keep pain below 5/10. Finally, stretch the calves twice a day and always after performing physical activity.