Achilles Pain in Runners: How to Treat It and Keep Running Strong
This week we continue our series of posts where I (Jason, a non-physical therapist) interview my wife (Dr. Maria Leibler, PT, DPT, MTC) to learn more about a common running injury.
This week our topic is achilles pain in runners. I tried to ask her questions that would be useful for someone suffering from this condition.
Just to give you some quick context if you’re not familiar with us – Maria is a physical therapist who has dedicated her career to working with runners. She founded Fit & Function Therapy Solutions, which is a specialty physical therapy clinic for runners in Boise, Idaho.
In addition to working with runners all day every day, Maria never stops learning about the latest and greatest research and methods in physical therapy to help runners get out of pain and stay out of pain.
Without further ado – here’s the transcript from our interview together:
What exactly is Achilles tendinitis, and why do runners seem to struggle with it so often?
Maria: What people commonly call “Achilles tendinitis” is actually a form of tendinopathy. It’s a condition caused by excessive load that leads to structural changes in the tendon.
The term “tendinitis” is technically incorrect when talking about the Achilles tendon. The “-itis” suffix implies inflammation, but the Achilles tendon doesn’t have the blood supply or cellular makeup for true inflammation. Instead, the pain and stiffness runners feel often stem from irritation of the peritendon (the thin sheath around the tendon) or degenerative changes within the tendon fibers from repeated stress.
Achilles tendinopathy is essentially a breakdown of the collagen structure within the tendon due to too much stress. Normally, tendons adapt to stress, but when they don’t get enough recovery, small micro-tears accumulate faster than the body can repair them. This leads to thickening, stiffness, and pain—particularly in the morning or at the start of a run.
Runners are especially prone to this condition because the Achilles tendon absorbs and transmits enormous forces with every stride—up to 6–8 times body weight.
How can a runner tell if their Achilles pain is tendinopathy or something else?
Maria: The key is to look at two main factors: anatomical location and pain characteristics.
In the Achilles area, multiple structures could be causing pain—the plantaris tendon, Achilles tendon, peritendon, sural nerve, and surrounding tendons and blood vessels. The type of pain matters: Is it burning? Achy? Sharp? Dull? These characteristics help determine which tissue is involved.
For example, if a nerve is compressed, movement might initially warm up the area and increase blood flow. But if the pain worsens with continued activity, that’s a different signal than a tendon problem. Tendons actually prefer movement—they don’t like being completely sedentary. An acute tendon injury has a specific pain behavior, and typically, gentle loading is part of the treatment.
As a physical therapist who treats runners, is Achilles tendinopathy the most common diagnosis in that area?
Maria: In most cases, runners come to me with pain either right where the Achilles tendon connects to the heel bone or in the middle section of the tendon. Sometimes there might be some nerve-related issues, but typically it’s the tendon itself that’s causing the problem.
What are the early warning signs of Achilles tendinopathy that runners often ignore?
Maria: Generally, runners should watch for stiffness during prolonged rest, or pain that seems to warm up and improve after the first few minutes or miles of a run.
What are the most common causes of Achilles tendinopathy in runners?
Maria: Several training mistakes can lead to Achilles tendinopathy:
-Taking on elevation gain too quickly without gradual adaptation
-Increasing mileage too rapidly
-Pushing beyond the tissue’s current capacity
-Insufficient recovery between intense training sessions
Essentially, it’s about overloading the tendon faster than it can adapt. The key is progressive, careful training that allows the body time to adjust.
Does running form contribute to Achilles tendinopathy?
Maria: Running form itself isn’t typically the primary issue. What matters more are sudden, drastic changes in running variables. For instance, switching from shoes with a high heel drop to zero-drop shoes overnight, especially during a high-mileage week, can stress the calf complex and Achilles tendon.
Generally, I don’t believe runners need to completely overhaul their running form. Instead, they should focus on gradual adaptations and understanding how changes in footwear or terrain might impact their body.
Are certain types of runners more prone to Achilles issues?
Maria: Yes. The faster you run, the more load shifts toward the forefoot, which puts additional stress on the calf complex. Sprinters and runners doing speed work are potentially at higher risk compared to those maintaining a steady, slower pace.
Can Achilles tendinopathy be treated at home or does it require professional intervention?
Maria: If addressed early and carefully, runners can often manage Achilles issues themselves. However, many people inadvertently make their condition worse by doing what seems intuitive—like stretching or complete rest.
Tendons need careful, progressive loading. Simply stretching an irritated tendon can cause more harm. Complete rest is often counterproductive. The goal is to find a sweet spot of movement and controlled loading.
Should runners completely stop running if they have Achilles tendinopathy?
Maria: Not necessarily. Many times, runners can continue training safely with some modifications. The key is managing load and pain:
-Runners with high pain might focus on level or downhill routes
-Those with low pain can incorporate gradual warm-ups
-Cross-training and a targeted rehabilitation program can help maintain fitness while supporting tendon recovery
What treatments actually work for Achilles tendinopathy?
Maria: Loading is the number one intervention. Tendons need “mechano-transduction” to heal – meaning they require movement and controlled stress. Contrary to popular belief:
-Icing doesn’t significantly help
-Stretching can often irritate the tendon
-Complete rest can make the condition worse
-Heel lifts can be helpful in specific cases, particularly for managing pain at the tendon’s insertion point. The goal is to avoid positions that overly compress the tendon while providing gentle, progressive loading.
What muscle weaknesses contribute to Achilles tendinopathy?
Maria: It’s about looking at the entire kinetic chain. Key areas include:
-Calf complex strength
-Hamstring and glute support
-Overall leg muscle balance
-Biomechanical factors like excessive foot pronation can play a role. While not a definitive predictor, I often see a correlation between excessive foot movement and medial-sided Achilles pain.
How does someone know when it’s time to go see a physical therapist of they’re suffering from achilles pain?
Maria: Consider professional help if:
-Pain is consistently worsening
-You’re unable to run without limping
-Your own management strategies aren’t improving the condition
-You’re experiencing symptoms beyond simple tendon pain
What does physical therapy for Achilles tendinopathy involve?
Maria: A comprehensive approach that includes:
-Strength and conditioning-style loading programs
-Soft tissue work on surrounding muscle groups
-Detailed analysis of running mechanics
-Personalized training program modification
-Strategies to keep training intensity below the pain threshold
Are there treatments runners should avoid?
Maria: Treatment depends on the specific tissue involvement, but generally:
-Avoid stretching the irritated tendon
-Be cautious with positions that put excessive strain on the tendon
-Avoid heel positions lower than the toes in certain cases
Are runners more likely to experience Achilles tendinopathy again once they’ve had it?
Maria: Yes. Prevention involves:
-Understanding your body’s specific weaknesses
-Recognizing early warning signs
-Learning to listen to your body
-Avoiding constant year-round progression
-Incorporating off-seasons and cross-training
-Allowing proper recovery time
What strength exercises can help prevent Achilles issues?
Maria: Focus on a well-rounded approach:
-Strength training for all major leg muscle groups
-Plyometric work
-Exercises that improve tendon energy storage and release
-Compound movements
-Upper body conditioning
Bonus question: What’s the average prognosis for achilles tendinopathy? How long does it take to get over this on average?
Maria: (gives Jason a look because she hates these types of questions where she is forced to make blanket generalizations…)
(Jason laughs). Ok, let’s say if somebody does everything you tell them to do and they don’t flare it up?
Maria: Well, first off, it’s rare for someone to go through a rehab program without at least a small flare-up. The goal is to minimize those setbacks as much as possible so they can keep making progress. But some pain along the way isn’t necessarily a bad thing—it actually helps guide us. Pain tells us if we’re pushing too hard or not enough, and that feedback is crucial for understanding where to start and how much load the Achilles can handle.
If someone catches this early and manages it well, they can usually recover within weeks to a few months. The pain itself can take time to settle, but even after it’s gone, rehab isn’t over. We still need to build strength and improve the tendon’s capacity so it doesn’t come back. That process takes a minimum of six to eight weeks beyond the pain relief phase.
For more severe cases—especially chronic tendinosis, where the tendon has degenerated—recovery can take many months to a year, sometimes longer. The more the tendon has broken down, the longer it takes to rebuild.
Any closing advice?
Maria: Mostly, listen to the warning signs—the check engine lights your body gives you along the way. When we look back at a runner’s training history before an Achilles rupture or before the pain becomes severe, we often see clear spikes in training load that could have been managed better.
The key is paying attention to your body in real time, rather than realizing months later that something was off. It’s common for injuries to show up four to six weeks after the actual overload happened. That’s why having a broader perspective on training and recovery can help prevent these issues before they turn into a bigger problem.
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