Achilles Tendinopathy in Runners: Causes, Treatment & How to Return to Running Pain-Free

A scientific, plain-English guide · Reviewed against current sports-medicine research · Movaia

Feeling a nagging ache at the back of your lower leg, just above the heel — worse when you climb out of bed or in the first minutes of a run, then easing as you warm up? There’s a good chance you’re dealing with Achilles tendinopathy, one of the most common running injuries. This guide breaks down what’s happening, why it happens to runners, and the step-by-step plan that gives you the best shot at recovering fully and avoiding re-injury — so you can get back to moving faster and pain-free.

What Does Achilles Tendinopathy Feel Like?

You’ll likely notice it first as a small niggle or ache at the back of your lower leg, above the heel. The pain is typically worse after periods of inactivity — getting out of bed in the morning or at the very start of a workout — and eases as you warm up.

Other warning signs include poor ankle flexibility or a faint cracking sound when you move your ankle, caused by scar tissue rubbing against the tendon.

Pain location helps identify the type: insertional Achilles tendinopathy causes pain right where the tendon attaches to the heel bone, while mid-portion tendinopathy causes pain about 5 cm (2 inches) higher up.

What the Achilles Tendon Does (and Why Running Stresses It)

The Achilles is the largest and thickest tendon in your body. You can feel it just above your heel, where it connects your calf muscle to your heel bone.

As your calf contracts, the Achilles transmits that power to lift your heel and push your toes into the ground. It also absorbs shock on landing and helps stabilise your body. During running, the Achilles copes with forces equivalent to roughly 12× your body weight. (1) That enormous, repetitive load is exactly why runners are so prone to Achilles problems.

Why is it called the Achilles tendon?

The name comes from Achilles, the hero of the Trojan War in Greek mythology. (2) When his mother dipped him in the River Styx to make him invulnerable, she held him by the heel — the one spot the water never reached. That “weak spot” is where the Achilles tendon sits, a metaphor many runners know all too well.

Tendonitis vs Tendinosis vs Tendinopathy — Why the Difference Matters

Achilles tendonitis refers to true inflammation of the tendon. But the tendon often isn’t inflamed at all — instead the collagen that makes up the tendon degenerates, a condition called Achilles tendinosis. Both fall under the umbrella term Achilles tendinopathy.

Tendinitis is thought to result from sudden or forceful overstretching that causes micro-tears, while tendinosis results from overuse without enough recovery. Tendinosis is likely the more common of the two — but it’s frequently misdiagnosed as tendonitis.

This matters because the treatments can differ. Anti-inflammatories or corticosteroid injections aimed at “inflammation” can actually inhibit the collagen healing that tendinosis needs. (3, 4) That’s why many clinicians now avoid those treatments in favour of approaches that work for both conditions (covered below).

How Long Does Achilles Tendinopathy Take to Heal?

Achilles tendinitis can often be settled within days and usually within about 10 weeks. Tendinosis is slower — expect anywhere from 3 to 9 months, because rebuilding healthy collagen simply takes time.

What Causes Achilles Tendinopathy in Runners?

At its core, Achilles tendinopathy is caused either by force that stretches the tendon beyond its capacity, or by ongoing overuse without recovery. A Delphi study of world-class tendon experts identified the main risk factors. (6)

Intrinsic factors (specific to you)

• Previous injury
• Advancing age
• Reduced calf strength
• Reduced ankle dorsiflexion (flexing your foot toward your shin)
• Higher body weight
• Excessive foot pronation
• Exposure to steroids (e.g. injections for inflammatory conditions)
• Certain antibiotics (e.g. fluoroquinolones)

External factors

• Rapid changes in training load — distance, frequency, intensity, or new stimuli like hills and speed work
• Footwear
• Running surface

How to Treat Achilles Tendinopathy (Works for Both Tendinitis and Tendinosis)

The priority in treatment is to restore range of motion and rebuild strength in the lower leg. Every approach below serves that goal.

1. Relative Rest & Load Management

Recovery starts by reducing your running volume while keeping a base level of activity to maintain strength. Depending on severity, that might mean a big drop in mileage, switching to walking, or cross-training with swimming, cycling or resistance work.

Can You Keep Running With Achilles Tendinopathy?

Pain is your guide. If an activity causes or worsens pain, reduce the volume or switch activity. If pain is severe enough to change how you run, it’s time to rest. Experts suggest a maximum of “3” on a 10-point pain scale as the threshold for continuing to run at lower volume and intensity. (5, 6) See the return-to-running guide below.

2. Ice

While the exact mechanism isn’t fully understood, icing is proven to help many tendon issues. Apply ice (in a bag wrapped in a thin towel) for 15–20 minutes several times a day, and after any activity that stresses the tendon.

3. Check Your Running Form

Your running form can be a cause or a contributing factor — and correcting it both aids healing and reduces re-injury risk. Evidence is mixed on which exact factors matter, but expert practitioners recommend these changes: (7, 8)

• Reduce overstriding
• Increase step rate (cadence)
• Transition a pronounced forefoot strike toward a midfoot strike

A too-rapid switch to minimalist shoes or barefoot running — or doing so with poor form — can also drive Achilles tendinopathy.

Eccentric Strengthening Exercises for the Achilles

Eccentric strengthening means loading a muscle while it lengthens under contraction. Its effectiveness for Achilles tendinopathy is very well documented — it stimulates collagen production, alignment and cross-linking to make the tendon stronger, while also delivering stretch benefits. (9–15)

Perform them slowly, once or twice daily, for about three months.

Double-Leg Heel Raise (Tip Toes on Both Legs)

• Stand with legs straight, holding a wall or rail for balance.
• Lift up onto your toes using your good leg.
• Lower down on your injured leg, assisting with the good leg if needed.
• 3 sets of 15 reps, twice daily.

Modification: repeat with knees bent. Progress to single-leg once you no longer need support to lower down.

Single-Leg Heel Raise (Tip Toes on One Leg)

• Stand on your good leg, holding a wall or rail.
• Lift up on the good leg, switch to the injured leg, and lower down.
• 3 sets of 15 reps, twice daily.

Modifications: bent knees; performed on a step with the heel dropping below step level; add load with a weighted vest or backpack.

Light Stretching

Gentle stretching supports recovery in two ways: it prevents shortening and can lengthen the muscle-tendon unit (reducing tension during running), and it improves blood flow to accelerate healing. Move slowly, avoid sudden movements, and stop if you feel sharp pain.

Soleus Stretch

Gastrocnemius-Stretch

Heel Drop

• Hold a wall or rail for stability.
• Place the ball of your injured foot on the edge of a step.
• Drop your heel below the step, letting the other leg hang loose.
• Hold 45 seconds, 3 reps.

Massage

Massage from a physiotherapist can accelerate healing. Deep-friction massage encourages new collagen, reduces pain and improves strength and mobility, while myofascial techniques relieve tendon tension, smooth the fascia and release trigger points in the connected muscle. (16, 17)

Nutrition

Diet can both hinder and help. Alcohol appears to be a risk factor for Achilles tendinopathy, while supplements — especially collagen-derived peptides — are linked to better clinical outcomes. Discuss any changes with a nutrition expert for a safe, individualised plan. (18)

Advanced Treatment Options

Most runners recover with the measures above and never need these. For the minority who do, the following are typically considered after consulting a medical provider.

Extracorporeal Shockwave Therapy (ESWT)

A non-invasive treatment that directs shockwaves at the tendon to break up scar tissue and promote healing. There’s good evidence for its efficacy in chronic Achilles tendinopathy. (19)

Platelet-Rich Plasma (PRP) Injections

Made from your own blood, PRP contains growth factors theorised to speed tendon healing, injected into or around the damaged area. Several studies are promising but many have limitations and need further research. (20)

Dry Needling

A thin needle is used to deliberately stimulate the tendon, prompting an inflammatory/healing response. Usually performed under local anaesthetic. (21)

High-Volume Injections

A mix of saline, local anaesthetic and sometimes corticosteroid, usually guided by real-time ultrasound, aiming to improve pain and function. (21)

Glyceryl Trinitrate (GTN) Patches

Originally used for heart disease, GTN patches placed over the painful tendon open blood vessels. The exact mechanism isn’t fully understood, but they’ve been shown to reduce pain effectively. (22)

Surgery (Last Resort)

Where basic and advanced treatments fail, surgery is considered only as a last resort. The surgeon removes damaged tendon tissue and may use tissue from elsewhere for repair. A 2016 study found an 83.6% success rate across open and minimally invasive surgeries — with minimally invasive procedures carrying fewer complications. (23)

Return to Running After Achilles Tendinopathy

Tendinosis changes the tendon in ways that make re-injury more likely, so return slowly and progressively. A clinical commentary in the Journal of Orthopaedic & Sports Physical Therapy recommends running is acceptable when pain is minimal (1–2 / 10) during daily activities. (24)

Keep up your strengthening and stretching program as you return. Start with slow speeds on forgiving surfaces, and use this phase to gradually introduce form changes — such as moving from a pronounced forefoot toward a mid- or slight rearfoot strike.

The table below helps guide your training. Match each activity to a pain level and take the recommended rest days. (Recovery exercises continue on both rest and active days.) As pain reduces and fitness returns, the “Light / Medium / High” examples are upgraded in consultation with a professional.

Table adapted from Silbernagel et al. (24)

When Am I Fully Recovered?

Consider yourself “fully recovered” after running a full season without symptoms returning. Throughout that period, stick to a gradual, progressive training plan plus preventive strength and flexibility work — and supportive measures like massage and nutrition — to give yourself the best chance of staying pain-free.

Finally, take comfort that you’re not alone: about 10% of runners experience Achilles tendinopathy, and around 80% recover within a year with an exercise protocol alone. (25, 26) With the plan in this article, you’re giving yourself the best chance to shorten recovery and avoid re-injury.

Häufig gestellte Fragen

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