Achilles tendon pain after running is one of the more common complaints in active people. Tendons are made up of strong and tightly packed collagen fibres that transmit forces from the muscle to the bones allowing movement. The Achilles tendon is the largest tendon 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. Also, a few non-tendon conditions can present, like Achilles pain. As each condition is treated differently, an accurate diagnosis is essential.
Common causes of Achilles tendon pain after running
Achilles tendonitis
This is the most common cause of Achilles tendon pain. Too much load on the tendon over a short period of time causes swelling of the tendon leading to collagen breakdown. This deterioration of collagen leads to pain during and after activities such as walking, running, and sport. 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 paratendinitis
The Achilles tendon contains a sheath allowing smooth movement. Sometimes, the sheath becomes inflamed rather than tendon swelling, leading to acute paratendinitis. Often, people report tendon swelling and a feeling of creaking or ‘crepitations.’
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 is different from tendonitis.
Plantaris and Achilles tendon pain
The plantaris tendon runs close to the inside of the Achilles tendon. In some people, the plantaris tendon rubs against the Achilles tendon leading to Achilles pain. We think that this particular cause of Achilles pain needs a different exercise program and is a little more challenging to treat. Sometimes, injections and surgery are required.
Os trigonum (and posterior ankle impingement)
Os trigonum is a bone at the back of the ankle that fails to fuse with the main 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 back of the ankle close to the lower part of the Achilles tendon. If the subtalar joint becomes swollen due to arthritis, pain can be confused with Achilles tendon pain.
Diagnosis of Achilles tendon pain after running
Generally, we suggest a proper assessment to get the correct diagnosis.
Usually, Achilles tendon pain warms up but gets worse 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 important. We recommend assessing standing and seated calf raise strength to detect underlying calf weakness.
Imaging Achilles tendon: Ultrasound or MRI?
Often, we use imaging to confirm a diagnosis of tendonitis and rule out paratenditis, partial tear, or other causes. Nonetheless, in most cases, we find typical tendonitis changes and treat these cases with loading. However, a normal tendon scan means a non-tendon reason (such as subtalar joint arthritis) is more likely.
Ultrasound is cheap and easy to perform at the time of the assessment. Often, ultrasound will show changes in 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
Usually, the first step is to change or modify your activity. If your pain is mild, reducing or changing your training may be all that is needed. Examples include reducing your running duration or cutting out hill runs. If you play sport, 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 that 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
This is the most crucial component of your treatment. We recommend calf-strengthening exercises. Overall, exercises improve pain by changing tendon, muscle, and nerve function.
Generally, we suggest calf exercises 2-3 times a week. You should do bent knee and straight knee calf raises. Usually, we recommend single-leg exercises. Once you can perform eight repetitions, then we suggest 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 1-1.5 x body weight with a seated calf raise.
Once you’ve reached your strength goals, you should add plyometric exercises. Examples of plyometrics include skipping or hopping. Plyometrics can be progressed from double to single-leg jumps and hops. The highest intensity hopping is the ‘pogo’ hops – which is 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 important to strengthen the quadriceps, hamstring, 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, we know that GTN patches reduce pain associated with tendinopathy.
Generally, we suggest GTN patches for 2-3 months to help with an exercise program. Potential side effects include headaches and 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 has a good effect on 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
Tendon injections are used to reduce pain and help with tendon healing.
Cortisone injections are commonly used for tendonitis in the upper and lower body. Cortisone is a potent anti-inflammatory and has many other effects on cell metabolism and hormones. These effects are powerful, leading to a sudden reduction in tendon pain. However, cortisone also leads to the weakening of tendon structure, increasing the risk of tendon rupture. Overall, we try to avoid cortisone injections for 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 platelet-rich plasma or PRP injection 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 only use injections when other less invasive and simpler treatments have failed.
Tendon scraping for Achilles tendonitis
Recently, some doctors have performed tendon scraping procedures. Doctors can do this either by surgical instruments or a special needle with a blade.
We know that tendonitis leads to abnormal growth of blood vessels and nerves. We detect these vessels by using ultrasound. Then, the blood vessels and nerves are destroyed by scraping these vessels with a special needle, leading to reduced tendon pain.
Recent evidence suggests that tendon scraping works for some tendons, such as the Achilles or patellar tendons.
Any role for surgery?
We know that traditional surgery, such as cutting out the diseased tendon or tendon implantation, has disappointing results for Achilles tendonitis. A recent study showed that tendon surgery is no better than physiotherapy but has 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 is different from tendonitis. Usually, we start with complete rest from running and anti-inflammatory therapies such as ice and ibuprofen tablets. Then, as the pain settles, we allow gentle and gradual running. Rarely do we recommend a cortisone injection to reduce inflammation.
How do we treat Achilles tendon partial tear?
A partial tear of the Achilles is challenging to diagnose. Often, there is a history of sudden pain in the Achilles. Sometimes, people say they have felt someone kicked 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 like 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 just a typical finding of a degenerative change of the tendon and not an actual ‘acute’ tear. Therefore, we should treat these findings like tendonitis.
What diseases cause Achilles tendonitis?
Apart from incorrect training and too much running, certain diseases can lead to Achilles tendonitis. Examples include diabetes, psoriasis, inflammatory arthritis, and obesity. Also, some antibiotics can lead to 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 1/5th of people with Achilles tendonitis still had symptoms at ten years. However, we think your chances of being pain-free increase if you use the principles of exercise management discussed above.
Related topics:
- Achilles tendon rupture: FAQ
- GTN patches for tendonitis
- Shockwave therapy for Achilles tendonitis
- Tendon injections: FAQ
- How to treat tendonitis from a tendon expert
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