Achilles tendon pain with running is super common, rivaling knee discomfort as the top complaint I encounter in my clinic. But here's the twist: not all Achilles pain is created equal. Assuming every twinge calls for heel raises could be your Achilles' heel in recovery.
Prepare to be surprised as we unravel the mystery behind your discomfort. In this eye-opening post, we'll expose the three most common culprits of Achilles tendon pain with running and arm you with the knowledge to pinpoint your true pain source. Ready to outsmart your Achilles and reclaim your running freedom? Let's dive in!
Culprit One: Achilles Tendinopathy
Achilles tendinopathy is the culprit that most runners are familiar with. The most important thing to understand about Achilles tendinopathy is that it is a breakdown of the tendon tissue, NOT inflammation (this is why I don’t call it tendonitis, the suffix “-itis” referring to inflammation). Let’s talk about when Achilles tendon pain with running is likely tendinopathy:
Characteristics
Feels worse at the beginning of a run or workout, feels better after warming up
Feels worse with quick loading (i.e. hopping) than slow loading (i.e. heel raises)
While relative rest can be helpful, it will not get better without progressive loading.
Treatment
Achilles tendinopathy is NOT inflammatory, meaning it will not be solved through the use of anti-inflammatory medications like advil. In fact, taking anti-inflammatories can disrupt the rehab process of a tendinopathy. Treatment should involve three things:
Temporary stressor modification
Progressive strengthening
Restoration of normal biomechanics
Stressor modification might involve putting a heel lift in your shoe to decrease the amount of movement that the Achilles tendon is under load and/or modifying your running environment like avoiding hills and performing walk runs.
Progressive strengthening should build up towards performing heavy slow resistance heel raises with specific parameters.
Restoration of normal biomechanics involves mobility and stability activities to help improve the alignment of the Achilles tendon with running activities.
Check out our other post, 5 Things Runners Need to Know About Achilles Tendinopathy for more info about what it is and how to fix it.
Culprit number two: Achilles Paratenonitis
Paratenonitis can be another cause of Achilles tendon pain with running, but it is NOT the same as tendinopathy. Some tendons have a paratenon, which is a connective tissue sheath that helps decrease the friction between the tendon and the tissues that surround it. This paratenon can become inflamed with repetitive sliding and gliding of the tendon in the sheath.
Characteristics
Likely no significant difference in pain level between hopping and slow heel raises
Can be uncomfortable and can feel “crispy” or “crunchy” to touch with active range of motion without load
Can be sensitive to low load repetitive movements like switching between the gas and brake while driving or cycling without maintaining a stiff ankle
Treatment
If the source of your Achilles tendon pain with running is paratenonitis, treatment should look differently than tendinopathy.
Anti-inflammatory medication may be beneficial for the very beginning of the rehab process.
Full range of motion heel raises should initially be avoided, while isometrics can be helpful (holding the up on toes position).
Full rest from running for 7-10 days would likely be helpful
The key thing to remember about paratenonitis is that it IS inflammatory, and it is sensitive to large amplitude and repetitive movements of the ankle. Doing heel raises off the edge of a step can make paratenonitis significantly worse initially, which is why it’s important to identify these differences!
Culprit number three: Sural Nerve Entrapment or Spinal Referred Pain
While this culprit is more rare, it can leave people chasing their tail for months because they are trying to fix the wrong problem. Like turning up the air conditioning to cool your house when your stove is on fire, simply doing heel raises to treat Achilles tendon pain that is coming from a nerve entrapment is not going to address the root cause of the problem.
Characteristics
Pain pattern can be difficult to pinpoint and may change locations or quality day to day
Pain worsens without changing load or position of the ankle
Higher likelihood of presence in those with a history of back pain or radiculopathy
May not change much with heel raises
Treatment
Treatment for this cause of Achilles tendon pain with running is more complicated and requires evaluation by a professional. However, when it becomes clear that the source of the pain is not from the local tissues (from the Achilles tendon or paratenon), treatment that targets the pain generator is the clear answer, whether that’s the low back or the tissues that can restrict movement of the sural nerve.
Final Thoughts on Achilles Tendon Pain With Running
Achilles tendon pain with running may seem straightforward. But if you’ve ever had persistent Achilles tendon pain that didn’t get better with simply doing heel raises, you know that it’s not always the obvious answer.
At Alterra, we specialize in helping runners get to the root cause of their injuries so that they can stay on track with their training and enjoy running without pain. If you're a local runner in Boston's Back Bay and are dealing with Achilles tendon pain with running, we'd love to help you eliminate it for good! Book a free discovery call to chat with a therapist today.
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Disclaimer: The information in our blog posts is not a substitute for professional medical advice. Consult a healthcare provider before making decisions related to your health. Use our content at your own risk.
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