Achilles Tendinopathy in Runners


  • Is characterized by pain, stiffness, maybe some swelling or thickening of Achilles tendon
  • Common running injury – prevalence varies but may make up 6-8% of all running injuries
  • 58% male to 42% female
  • Important to note the following differences but generally treatment remains the same
    • Insertional tendinopathy vs mid tendon tendinopathy – best determined by a physiotherapist
    • Different stages of tendinopathy exist – best determined by a physiotherapist
  • Tendinopathy is tendon tissue disorganization – not tissue damage

Modifiable Intrinsic Risk Factors (*Best evaluated by a Physiotherapist*)

  • Reduced muscle power/strength
  • Reduced ankle dorsiflexion
  • Weight (Increased BMI)
  • Biomechanical abnormalities – foot alignment/pronation
  • Muscle imbalance and inflexibility

Extrinsic Risk Factors (*Best evaluated by a Physiotherapist*)

  • Change in loading – return to running/activity after a break
  • Training errors
    • Increased volume/intensity too quickly
    • Change in pace
    • Change in training type (i.e. increased hills)
    • Change in training duration
    • Increased training frequency
    • Change in weekly distance
  • Footwear – Achilles load is higher in minimalist shoes/barefoot compared to standard shoe regardless of where the foot strikes
  • Running style – A forefoot strike increases Achilles load by 15%
  • Training surface – Running on a treadmill has been shown to mildly increase Achilles load

Treatment Principles

  • Despite different areas of Achilles tendinopathy and stages of tendinopathy the general treatment principles remain the same
  • Identify and address potential causes (i.e. intrinsic and extrinsic factors)
  • Reduce Pain
  • Improve load capacity of muscle-tendon unit
  • Improve load capacity of kinetic chain as a whole
  • Gradual return to training
  • Advise on long term management

Pain Reducing Tips for Runners

  • Initial relative rest and ice
  • ?NSAIDs – discuss with family doctor
  • May need to avoid ankle dorsiflexion initially which can contribute to tendon compression
  • Change type of training – bike, swim, walk
  • You may still be able to run!! BUT avoid training/activity that pushes pain past a 2-3/10 and does not settle within 24 hours
  • Potential running modifications to keep pain down during rehab
    • Run every other day
    • Increase cadence by 5% and build up to 10%
    • Cut down on hills and speed work
    • Perform strength training and running on separate days
    • Gradually increase training as pain allows
    • Monitor response of tendon after activity – keep pain below 2-3/10 – find the sweet spot between no activity and too much
  • Wear good standard running shoes
  • Long hold isometrics – 5 x 30-45 second holds mid-range 70% max voluntary contraction

Exercise Progression – Improving Load Capacity (Guided by a Physiotherapist)

  • Phase 1: Isometrics – mid range isometric calf raises
  • Phase 2: Isotonics – heavy eccentric calf raises with straight and bent knee
  • Phase 3: Plyometrics – increase speed of calf raises, jumping, skipping, hopping, jogging on toes

For more info feel free to reach out to the author, David Burnett, at