11 Experts Weigh-In On Return To Running With Achilles Tendonitis
Do you have questions about running with Achilles Tendonitis that need answers ASAP?
This article compiles the best evidence to common questions around running with Achilles Tendonitis and seeks out experts in their fields to give their responses.
Firstly, some may wonder what Achilles Tendonitis actually is, and how it relates to running.
Prefer to skip ahead?
– Tips from Click Physiotherapy
– When to start running after Achilles Tendonitis
– How do I progress my running?
– Tips for running with mid-substance vs insertional Achilles Tendonitis
– How can I stop Achilles Tendinopathy from happening again with running?
– How far should I aim to run after Achilles Tendonitis?
Achilles Tendonitis – now referred to as Achilles Tendinopathy is extremely painful and can limit your running, or even walking. It is important to understand what causes this injury and how to implement a proper treatment.
What is Achilles Tendonitis?
Achilles Tendonitis is an injury caused by too much stress or load on the Achilles Tendon. This can be caused by a sudden change in your activity level.
The injury process is complex and involves changes to the tendon with the main symptoms being pain, morning stiffness and commonly a lump in the tendon can develop. Click in our Ultimate Achilles guide to get a better understanding of the injury.
The main treatment for Achilles Tendonitis is to manage the load placed on the tendon. You can do this by stopping the aggravating activities for a short time and focusing on exercises that will promote small loads on the tendon.
Tips from Click Physiotherapy
Runners often develop Achilles Tendonitis when they increase their training load too quickly and the tendon doesn’t have a chance to adapt to the change in load. This will result in pain either before a run if symptoms are severe, or they will experience pain at some point through the run.
Tips that we would offer runners with Achilles Tendonitis would be:
Don’t stop all activity
If possible, try not to stop activity altogether. It is important for the tendon to still have some loading, and although complete rest might be needed at the very start, its important you attempt to walk even for very short distances.
You can monitor if this is too much for the tendon by seeing how the Achilles reacts after the walk. If symptoms worsen in the next couple of hours, you have gone too far, and the tendon is not quite ready. Pain after activity often means an inflammatory response which is good to avoid where possible.
Alter the load on your Achilles during running
There are several ways you can alter the loading of your Achilles. You could try a new shoe, especially if you have run in the same shoe for a long time. Other techniques like taping and heel lifts or self-massage can also help in the short term.
Another technique you could try is to try and shorten your stride length with running. This means as you run at a certain speed, your number of steps will increase slightly. Increased cadence (or number of steps) can help to change the forces on your lower limb and Achilles Tendon.
Exercise outside of running
It is crucial that you are doing the correct exercises for Achilles Tendonitis. If you need help with this, check out our Achilles Academy. This course will give you the tools you need to improve your Achilles pain.
If pain persists, see an expert
If you haven’t had a formal diagnosis of Achilles Tendonitis, you should seek medical advice. This is important as some diseases can mimic Achilles Tendonitis and will need further investigation and treatment.
Also if it is Achilles Tendonitis, sometimes getting further advice can be helpful as all advice in this article will be beneficial, but generic in nature.
When to start running after Achilles Tendonitis
Dr Julia Rosenthal – Empowerpt.nyc
Achilles Tendinopathy in runners is often related to repetitive use or rapid changes in loading (in addition to other factors). This means it’s important to ensure that people don’t go back to too high a volume of running too fast. Some of the things I like to achieve before letting a person return to running include:
- 1. making sure they have sufficient ankle dorsiflexion range of motion (how far they can get their knee over their toe) and that they can achieve end range ankle dorsiflexion without pain
- 2. making sure they have sufficient ankle plantarflexion strength and endurance (plantarflexion in standing is going up on your toes)
- 3. making sure they can walk comfortably on variable surfaces
While working towards these goals, it’s important for the client to remain active. If running is painful, they can maintain cardiovascular fitness with other, non-painful activities such as biking. Once walking is not painful, PT would include a supervised return to running scale that includes walk/run intervals to build endurance in the structures while avoiding exceeding a pain level of 4/10.
Strength training
Physiotherapy will also include strength training exercises to help the client address any weak points that may have predisposed them to the injury and help increase the body’s preparedness to decrease the chance of future injury.
These could include general strengthening for the upper body, core, hips, and ankles as tolerated. It would also include intentional loading of the Achilles tendon to the client’s tolerance (no pain greater than 4/10).
There are many studies showing eccentric muscle loading can be beneficial, and more recent studies have shown that isometric training and heavy, slow resistance training are equally beneficial. What is important is for the exercise administered be tolerable to the person performing it.
Once resistance training is tolerable, the patient can begin doing plyometric training (jumping, hopping, skipping, etc) to increase the load on the tendon.
Other Considerations
Finally, it’s important to mention that tendon health can be related to many non-musculoskeletal factors including metabolic and endocrine system factors.
It’s therefore important to consider whether the person has other things going on that may have contributed to the symptom presentation. These can include hormonal changes related to pregnancy or menopause, endocrine system changes related to diabetes, nutritional changes, or any other factors that may be affecting blood and nutrient flow to the tendon.
Damien Howell
The symptom of discomfort/soreness or pain will be the most significant factor in determining when a patient is ready for running.
Below is a table with my approach based on priori and experience in the field.
| Eligible to progress running | No joint soreness after last session |
| Eligible to progress running | Joint/tendon soreness after last session gone by next morning |
| Stay with same amount of running | ‘Morning after’ soreness is ‘3 or less’ out of 10 or a mild level of soreness |
| Stay with same amount of running | Joint/tendon sore for 24 hours after last session then eased |
| Regress the amount of running | Joint/tendon sore for more than one day after last session |
| Regress the amount of running | Morning after soreness is greater than ‘3 out of 10’, or a moderate level soreness |
Dr Alexandria Dsouza
Broadway Chiropractic & Wellness Centre NYC
Returning to running too quickly after Achilles Tendinopathy accounts for a majority of cases with an injury recurrence.
Factors such as not taking enough recovery periods, non-graded programs, inadequate strengthening and failing to address your running gait as well as other biomechanical challenges account for these issues.
It is important to assess if you are first pain free with basic tasks such as your first few steps in the morning, stair climbing as well as impactful activities such as hopping which have such large forces of impact on your body involved in comparison to walking.
Any pain, discomfort or fear associated with doing these activities will need to be addressed before even considering returning to running. The Achilles is the strongest tendon in our bodies, and it transmits forces up to three times our body weight. This load also increases depending on speed, incline and striking style.
I would emphasize a gradual increase in training load by 10% per week, eccentric training of the calf muscles, use of a heel lift/orthotic depending on your gait analysis with timely removal of the same and avoiding excessive stretching.
There is no one-size-fits-all routine since everyone’s needs and foot shape vary, but I would also pick either speed or longevity/endurance as your focus before designing your custom program. Usage of a contrast bath or icing after a run, progressive ankle strengthening and mobility exercises under guidance of your Physical Therapist are all also extremely valuable for recovery.
Happy Running!
How do I progress my running?
Kris Ceniza – Kneeforce
Initially during rehabilitation and training, it’s important to remember that reinjury is still a possibility. Taking the time to do the boring work is crucial to minimize this risk.
Start of with walks and reassess your pain levels after two days. Pain usually spikes after some exercise but should return to baseline levels (if not lower) after those couple of days. If all goes well, then it is possible to proceed to more intense exercises.
Walking is my initial treatment of choice because with activities involving forceful contraction like running, jumping and cutting there is a small risk that you can rupture the Achilles Tendon.
Walking is a more controlled movement that also helps maintain ankle mobility, so it’s not only safer but also crucial for the later parts of rehabilitation.
How to progress running using a treadmill
For progression, start with a small distance on the treadmill at a comfortable pace. Watch out for pain during activity, if there is any, this should resolve to similar levels or below within two days. If this occurs, then the start distance for next walk would be the same. If pain increases, try reducing the distance slightly.
During the next session check pain levels about a minute before the timer runs out. If the pain level remains the same, add about 3-5 minutes on the timer.
When you reach 15 minutes walking without any significant change in pain ratings, gradually add an incline to the treadmill to safely challenge the injured tendon on the next sessions.
Next comes jogging and then, finally, back to running. This entire routine would last about 6 weeks or longer, depending on how the client responds and how severe the injury is.
Tips for running with mid-substance vs insertional Achilles Tendonitis
RT Hill – The Stride Shop
The Achilles is one of the largest and strongest tendons in our body. For runners, it is crucial for absorbing impact forces and releasing them to spring us forward. This tendon takes eight to twelve times our body weight when we run. Therefore, it’s not surprising that runners frequently injure this tissue.
Achilles Tendinopathy can develop for multiple reasons including:
- Poor ankle range of motion
- Abrupt changes in training
- Overtraining with speedwork or hills
- Atrophy or weakness in the calf muscles
- Poor footwear
When treating, we break it into one of two zones. Returning to running after injury is different for each of these. The zones are Mid-Portion and Insertional Achilles Tendinopathy.
Return to running Mid-Portion Achilles Tendonitis
If the pain is mid-portion, we want to load that tissue before sending someone out running.
If that tissue can’t handle the load when you’re not running, it doesn’t have the ability to tolerate the demands when you are.
This means you must tolerate heavy heel raises and plyometrics with that leg before even attempting to run.
Once someone can handle hopping on one leg, a slow return to running is appropriate, which may mean a jog/walk program. With successful, pain-free runs, they can increase their jog time and decrease their walking.
Return to running Insertional Achilles Tendonitis
Insertional Achilles issues occur where the tendon attaches to the heel bone. In this case, you want to avoid stretching that tissue and unload the tendon.
This would be an instance where inserting a heel lift may be helpful. As pain decreases, you would test with single leg hopping and fast walking followed by a jog/walk program.
Additional considerations for managing Achilles Tendinopathy:
- If running is tolerated, choose flat surfaces. Avoid running uphill or on uneven terrain such as trails
- Avoid running on a treadmill when possible
- Attempting to increase your step rate by 5% can decrease the load on the Achilles tendon
- Using a temporary heel lift may reduce stress (especially for insertional Achilles Tendinopathy)
How can I stop Achilles Tendinopathy from happening again with running?
Matthew Likins – Health Quest Physical Therapy
Most Achilles issues except for outright ruptures are now classified as tendinopathies – which is a fancy way of saying a pathology of the tendon.
This is a transition away from calling all tendon pain tendonitis – which would imply active inflammation, which after the first 4-6 weeks of tendon pain is not usually present. Treating a tendon problem as simply an inflammation is not usually fruitful.
Achilles Tendinopathy recurrence rates range from 27-44% in the literature. It is believed that this is because eliminating pain is not the same as reaching a full structural recovery.
The tendon itself undergoes changes at the tissue level that must be corrected before you can return to fully loading of the tendon without recurrence.
Too many runners simply rest enough to get their symptoms to subside but do not undertake the work of restoring normal tissue mechanical properties before returning to loading activities (running).
Current gold standard for treatment and reducing reoccurrence
Progressive loading of tendon tissues via exercise (mechanotherapy) is the current gold standard of treatment. Tendon loading exercises upregulate muscle-tendon metabolism and increase collagen synthesis essential for tendon healing.
It used to be believed that the type of load was important – with a push to eccentric heavy slow loading; but the evidence at this time does not support the use of one type of loading program over another.
We currently use the “Pain-Monitoring Model” for activity progression. We allow patients to proceed with activities when their pain level with the activity or the morning after does not exceed 5 on the 0-10 pain scale. This allows for a return to activity with reduced risk of worsening the condition.
A simple change is to use the fact that heel strike at initial contact produces significantly lower forces on the Achilles tendon than a mid-foot strike pattern.
Return to running is a challenging process!
Dr John Martinez
Identify the reason they developed the Achilles tendinopathy in the first place.
Was it sudden increase in mileage, poor running biomechanics or other issues?
If you don’t find the reason “why” then there is a risk of re-injury.
Tips to help reduce pain whilst running with Achilles Tendonitis
Dave Candy – More 4 Life
1. Don’t return to running too quickly
If you’ve had a recent, acute injury to your Achilles tendon, initially relative rest and offloading the tendon are the best treatments. Achilles Tendinopathies involve some degree of over-stretching, or even partial tearing of tendon fibres.
The WORST thing to do is to return to running too quickly and risk a complete tear of the tendon, which will keep you out of running for a long time.
2. Offload your Achilles tendon
Wearing a gel heel lift in your shoes can help offload the Achilles tendon. This helps prevent you from further overstretching the tendon.
If you need to offload, you need to offload all the time, not just when running, so wear the lifts in your shoes all day, even when inside the house.
Additionally, even if you only have an injured Achilles on one side, it helps to wear lifts in both shoes to avoid creating a leg length difference that could lead to other problems in your knees, hips, or lower back.
3. Return to running gradually
When you do return to running, you should be able to do it relatively pain-free (2 or less on a scale of 0-10). “No pain, no gain” does not apply with Achilles Tendinopathy. Start going back to running a short distance (1 mile or less) on non-consecutive days to allow for recovery in between.
Then gradually increase your running volume by small amounts each run, provided you don’t have a flare up at your current volume. While traditional running wisdom suggests not increasing training volume more than 10% per week. At this low of mileage, there’s a little bend in that rule, but initially you still don’t want to increase more than 1/4 to 1/2 mile per run.
4. Eccentric exercise can help
Eccentric exercise is the most highly studied form of exercise when it comes to Achilles Tendinopathy. This means doing heal raises on 2 legs, then lowering on one leg slowly.
Initially research suggested a standardized 3 sets of 15 reps, twice per day, even to the point of pain, more recent research suggest that an “as-tolerated” protocol may be more effective.
5. Don’t overstretch
Again, many Achilles tendon problems are caused by overstretching of the Achilles tendon. Therefore, you don’t want to further overstretch the tendon.
While gentle calf stretching can be helpful, if you’re “feeling the burn” in your Achilles tendon, you’re probably overstretching. It helps to keep the arch lifted and the ankle in a neutral position when stretching.
Foam rolling the calf or using a massage roller stick on the calf is another alternative as it allows you to target trigger points (“knots”) in the calf muscle belly without loading the tendon.
6. Proper shoe wear and orthotics
The Achilles tendon is very strong and resistant to tensile loads, meaning straight up and down forces along the tendon. However, shear forces that go horizontally across the tendon fibres can put the tendon at risk for injury.
Wearing running shoes and/or or orthotics that allow your foot the proper combination of stability and cushioning can prevent over-pronation or over-supination, both of which can put you at risk for Achilles injuries.
A flat foot that pronates easily requires more stability such as a stability shoe or motion-control shoe.
A high-arch foot that doesn’t pronate well requires a neutral shoe that helps cushion and absorb shock while still allowing some pronation.
Off-the-self and/or custom orthotics can further help customize the fit of your shoe to your foot.
7. See a physical therapist that has experience working with runners
If you’re really serious about getting back to running, and you want to do it right the first time, get help from an expert.
Just as athletes have coaches to guide them through training, your physical therapist is your coach to guide you through the injury recovery process as quickly and safely as possible.
Not all physical therapists are the same though. Interview a few physical therapists and find one that has experience working with runners.
Dr Madathupalayam
Achilles Tendonitis is due to the overuse of the Achilles tendon and it most commonly occurs in runners who increase the intensity or duration of their runs abruptly.
Kinesiology tape can be used for an Achilles tendon injury. It enhances overall healing and gives the injured area time to heal. But avoid taping in the following instances – torn or ruptured Achilles tendon, bone fracture, skin wounds or injuries, tape sensitivity, or circulation problems.
You can take anti-inflammatory painkillers like NSAIDs (non-steroidal anti-inflammatory drugs) to help reduce the pain and swelling.
You may use a heel lift to insert in your shoe while you recover.
Rocker bottom shoes have been designed to reduce some of the load on the Achilles tendon. It will help protect your Achilles tendon from further stretching.
Stretch and strengthen your calves. It includes exercises like flexibility stretches, soleus stretches, heavy resistance exercises, and eccentric strength techniques Reduce your uphill running. Stop your exercises if you feel the pain or tightness in the back of your calf or heel.
How far should I aim to run after Achilles Tendonitis?
Kieran Sheridan – Gulf Physio
After an Achilles injury, we recommend not aiming for how you ran before the injury. If you ran 10 kilometres before the injury, don’t aim for that when you come back. Instead, pace yourself and use intervals (explained below).
When easing yourself back to running, it’s best to start off by running up to 2 or 3 minutes, and then walk for 1 to 2 minutes, gauging the pain of your tendons. This method avoids any flare ups when getting back into your fitness routine.
The distance at which to aim running after injury depends on each person.
There’s no set distance that you should follow when recovering from the injury. What should be kept in mind is that they should identify the pattern of the pain.
Once you have identified the pattern, you can run as far as you can before the pain gives you a hard time. From there, you can go a greater distance each day, adjusting as your injury heals.
Conclusion
It is possible to return to running with Achilles Tendonitis. First get on top of your symptoms with relative rest. Then slowly build into running using small progressions over time.
Depending on how long the symptoms have been present it can take some time. Consulting with experts in the field can help to improve you outcomes.
If you are interested in rehabilitating your Achilles back to running please see our Achilles Academy.
Frequently Asked Questions
Can you run with Achilles Tendonitis?
Yes you are able to run with Achilles Tendonitis but it is recommended in acute stages to begin with rest and then progress to walking before trying to run again.
If its painful to run should I stop?
Generally speaking it is ok to run with a little Achilles Pain as long as the symptoms subside fairly quickly and it doesn't pass around a 4/10 if 10 was the worst pain you could imagine and 0 was no pain.
What shoes should I wear running with Achilles Pain
You will need shoes with arch support that are flexible at the front and they should have good heel support to cup your heel. You should also aim for a shoe with a drop of around 12mm or higher especially for insertional Achilles Tendonitis.