Achilles tendon pain after running is a common complaint among active individuals. Tendons are composed of strong, tightly packed collagen fibres that transmit forces from muscles to bones, allowing movement. The Achilles tendon is the largest in the body and is frequently injured. So what are the causes of Achilles tendon pain, and how do we manage it? 

Causes of Achilles Tendon Pain after Running

Many different tendon conditions can cause Achilles tendon pain after running.  Additionally, a few non-tendon conditions can present, such as Achilles pain. As each condition is treated differently, an accurate diagnosis is essential.

Common causes of Achilles tendon pain after running

Achilles tendonitis 

This condition is the most common cause of Achilles tendon pain. Excessive load on the tendon over a short period causes tendon swelling, leading to collagen breakdown. This deterioration of collagen leads to pain during and after activities such as walking, running, and sports. Generally, Achilles tendonitis pain is felt in the middle of the tendon or low down in the heel.

Less common causes of Achilles tendon pain after running 

Achilles paratenonitis 

The Achilles tendon is surrounded by a sheath that allows smooth movement. Sometimes, the sheath becomes inflamed rather than the tendon swelling, leading to acute paratendinitis. Often, people report tendon swelling and a feeling of creaking or ‘crepitus.’

Achilles tear or partial tear 

Sometimes, rather than swelling, the collagen fibres tear. Often, there is a sudden, sharp pain in the tendon during sport. It is important to diagnose an Achilles tendon tear, as the treatment differs from that for tendonitis.

Plantaris and Achilles tendon pain 

The plantaris tendon runs close to the inside of the Achilles tendon. In some individuals, the plantaris tendon rubs against the Achilles tendon, leading to Achilles tendon pain. We think that this particular cause of Achilles pain requires a different exercise program and is somewhat more challenging to treat. Sometimes, injections and surgery are needed.

Os trigonum (and posterior ankle impingement)

Os trigonum is a bone at the back of the ankle that fails to fuse with the prominent ankle bone. Sometimes, due to an injury such as an ankle sprain, swelling develops around this extra bone, leading to ankle pain. Often, people confuse this pain with Achilles pain.

Subtalar joint arthritis

The subtalar joint is located just above the heel bone (the calcaneus). This joint extends to the posterior aspect of the ankle, near the lower portion of the Achilles tendon. If the subtalar joint becomes swollen due to arthritis, pain may be mistaken for Achilles tendon pain.

Kager’s fat pad oedema 

Kager’s fat pad sits between the Achilles and the heel bone. Oedema of Kager’s fat pad can cause swelling and discomfort at the back of the ankle. Kager’s fat pad oedema often co-occurs with Achilles tendonitis.

Diagnosis of Achilles tendon pain after running

Generally, we recommend a thorough assessment to obtain an accurate diagnosis.

Typically, Achilles tendon pain is warm and improves with activity but worsens after activity. Pain is located at the Achilles tendon and rarely moves above or below the tendon. Achilles tendon pain is worse after calf raises, jumping, or hopping. Also, touching the tendon is painful.

Assessing calf strength is also essential. We recommend assessing standing and seated calf raise strength to detect underlying calf weakness.

Imaging Achilles tendon: Ultrasound or MRI? 

Imaging is often used to confirm a diagnosis of tendonitis and to rule out paratendinitis, partial tear, or other causes. Nonetheless, in most cases, we find typical tendonitis changes and treat these cases with loading. However, a routine tendon scan indicates that a non-tendon cause (such as subtalar joint arthritis) is more likely.

Ultrasound is cheap and easy to perform during the assessment. It often shows changes in collagen thickening and disorganised collagen fibres.

MRI also shows tendon changes and other causes, such as os trigonum or subtalar joint arthritis.

Treatment of Achilles tendonitis 

Overall, we suggest conservative management for Achilles tendonitis. Generally, the earlier treatment is started, the better.

Modify activity 

Typically, the first step is to modify your activity.  If your pain is mild, reducing or changing your training may be sufficient. Examples include reducing running duration or eliminating hill runs. If you play sports, you should reduce the number of games per week or the time you play.

As a general rule, we suggest reducing the step count and/or running by 50%.

However, if your pain is severe, you should stop running altogether.

Can you exercise through Achilles tendon pain after running? 

Generally yes. We think exercising through pain is ok as long as the pain is stable. Stable pain is tendon pain that occurs after exercise, is low-level, and lasts for less than a day. Some people use numbers – say less than 2-3/10. Alternatively, unstable pain is pain that is high level (greater than 3/10), lasts for greater than 24 hours, and requires tablets such as ibuprofen. Generally, you should aim to rehab and train with stable pain. Moreover, unstable pain means you’re doing too much for the tendon to handle.

Achilles tendonitis exercises 

 

women doing standing calf raise at gym
man doing seated calf raise at gym
male skipping to get over Achilles pain
crossfit

This is the most crucial component of your treatment. We recommend calf-strengthening exercises. Overall, exercise reduces pain by altering tendon, muscle, and nerve function. 

In general, we recommend calf exercises 2-3 times per week. You should perform bent-knee and straight-knee calf raises. Usually, we recommend single-leg exercises. Once you can perform eight repetitions, we recommend adding weight. We will give you strength goals to achieve before moving to the next step. For example, you should aim to lift about 0.5x body weight with a standing calf raise, and 1-1.5x body weight with a seated calf raise.

Once you’ve reached your strength goals, you should add plyometric exercises. Examples of plyometric exercises include skipping and hopping. Plyometric training can progress from double- to single-leg jumps and hops. The highest-intensity hopping is the ‘pogo’ hop, which involves hopping with a stiff knee. Another simple way of adding plyometrics is to perform stiff ankle stair climbs to a metronome at 90-100 beats per minute.

If you can tolerate plyometrics, you’re ready to start a running program.

Finally, it is also essential to strengthen the quadriceps, hamstrings, and pelvic muscles.

Adjuncts to physiotherapy for Achilles tendon pain after running

GTN patches 

GTN patches contain a substance called nitric oxide. Recent studies suggest that nitric oxide is essential for tendon healing. By placing a patch on the skin of the Achilles tendon, the tendon incorporates it into the collagen fibres. Overall, GTN patches reduce pain associated with tendinopathy.

In general, we recommend GTN patches for 2-3 months to support an exercise program. Potential side effects include headaches and a skin rash.

Shockwave therapy 

Shockwave therapy produces sound waves that stimulate tendon healing. In addition, we think that shockwave stuns pain nerves. Evidence suggests that shockwave therapy is effective in reducing pain in Achilles tendonitis.

In general, we suggest one session per week for five sessions.

Collagen supplements for tendonitis 

Hydrolysed collagen supplements taken 30 minutes before Achilles tendon loading exercises show a more significant improvement in tendon pain compared to exercises alone. We recommend taking collagen supplements to enhance the effect of exercise therapy. 

Injections 

 

doctor performing a tendon injection for the ankle

 Tendon injections are used to reduce pain and help with tendon healing.

Corticosteroid injections are commonly used to treat tendonitis in the upper and lower extremities. Cortisone is a potent anti-inflammatory agent and exerts multiple effects on cellular metabolism and hormone levels. These effects are powerful, resulting in a rapid reduction in tendon pain. However, Cortisone also weakens tendon structure, increasing the risk of tendon rupture. Overall, we avoid cortisone injections in large weight-bearing tendons, such as the Achilles tendon.

Alternatively, we use other injections to help with tendons. Firstly, some doctors repeatedly needle the tendon. This procedure is also called needle tenotomy. Another option is to inject platelet-rich plasma (PRP) into the diseased tendon. PRP contains growth factors, which we think improve the healing of tendons. Recent evidence suggests that PRP injections, overall, are not particularly effective for Achilles tendonitis. A summary of all the high-level studies reveals no difference between PRP and placebo.

However, we should consider one injection only, as less invasive and simpler treatments have failed.

Tendon scraping for Achilles tendonitis 

Recently, some doctors have performed tendon scraping procedures. Doctors can accomplish this either with surgical instruments or with a specialised needle with a blade.

We know that tendonitis leads to abnormal growth of blood vessels and nerves. We detect these vessels by using ultrasound. Subsequently, the blood vessels and nerves are destroyed by scraping them with a specialised needle, thereby reducing tendon pain.

Recent evidence suggests that tendon scraping is effective for certain tendons, such as the Achilles and patellar tendons.

Any role for surgery? 

We know that traditional surgery, such as excising the diseased tendon or tendon implantation, yields disappointing results for Achilles tendonitis. A recent study found that tendon surgery is no better than physiotherapy and carries significant risks. Overall, we reserve surgery for cases that fail all other treatments.

Other Frequently Asked Questions on Achilles Tendon Pain after Running:

Do we treat Achilles paratendinitis differently from tendonitis?

Yes. Achilles paratendiitis is an inflammation of the sheath of the Achilles rather than the tendon. Generally, pain is sharp and may involve ‘creaking’ of the tendon with the movement of the ankle.

Treatment of paratendinitis differs from that of tendonitis. Typically, we begin with complete rest from running and anti-inflammatory therapies, such as ice and ibuprofen tablets. Then, as the pain subsides, we allow gentle, gradual running. We rarely recommend a corticosteroid injection to reduce inflammation.

How should we treat a partial tear of the Achilles tendon? 

A partial tear of the Achilles tendon is challenging to diagnose. There is often a history of sudden pain in the Achilles tendon. Sometimes, people say they have felt someone kick them in the back of the Achilles tendon.

We think there are two types of ‘partial tears.’ One form is the acute partial tear, which is sudden and very painful. The other type is the partial degenerative tear, which should be treated as tendonitis.

Treatment of an acute tear (sudden onset) is often complete rest in heel raises or a walking boot, followed by protected loading of the Achilles. However, if exercise is started too early, we think that people risk a complete rupture.

What about an ultrasound finding of an Achilles ‘delamination’ partial tear? 

We think this change is typical of degenerative tendon changes and not an actual ‘acute’ tear. Therefore, we should treat these findings like tendonitis.

What diseases cause Achilles tendonitis? 

In addition to improper training and excessive running, certain diseases can lead to Achilles tendonitis. Examples include diabetes, psoriasis, inflammatory arthritis, and obesity. Additionally, some antibiotics can cause Achilles tendonitis.

Do heel raises or wedges work for Achilles pain? 

Yes. We suggest a 1.2cm heel wedge for Achilles pain. One study showed heel wedges were as good as eccentric exercise. We recommend using heel wedges for three months.

Do all cases of Achilles tendonitis settle with exercise and simple treatments? 

Unfortunately, no. A recently published study found that almost 1/5f of people with Achilles tendonitis still had symptoms at the 10-year mark.  However, we think your chances of being pain-free increase if you use the principles of exercise management discussed above.

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