The sun slowly cracks through your window as you slowly wake from a restful night’s sleep. You throw your feet over the side of the bed ready to attack your day. Then “BAM!” an invisible foe sticks an imaginary knife in the back of your heel, rendering you motionless and ready to crawl back under the covers.
This is a familiar scene for many runners.
Dealing with achilles pain is frustrating. It’s painful, limiting, and often has a long shelf life. This series is the practical approach I take with patients to get them from hobbling out of bed to crushing their next race.
Achilles tendinopathy is the technical term for “achilles tendinitis” a clinical diagnosis assigned when a runner displays three things: heel pain, swelling of the achilles tendon (AT), and a loss of function. This diagnosis hits one of three different locations1.
Runners usually blame this on shoes, their arch height, or how much they pronate. Tight calves and weak glutes are often falsely accused too. The truth is AT pain typically happens when we have a change in training and don’t allow enough time for the structures of our body to adapt. The story goes like this. A runner notices some low-level pain that “warms up” as they run. Over a few weeks, that pain starts earlier during runs and finally affects day-to-day activities, forcing the runner to seek help. At this point, they are normally hobbling through their runs or have been off running for longer than they’d like.
The tendon gets angrier, louder, and more aggressive, like a kid screaming for a snack.
DAD! GIVE ME AN APPLE JUICE!
Achilles Anatomy
It’s important to understand the culprits at play. Our calf muscle (i.e., gastrocsoleus complex) blends into our AT, which attaches itself to the back of our heel bone. Like a slingshot, our body builds tension in this unit with every footstrike allowing us to spring forward while we run. Every footstrike requires our AT to deal with up to 1000 pounds of force2.
Every. Single. Footstrike.
No wonder this thing gets angry.
Our body deals with different types of forces on a daily basis. Two forces that are important with painful tendons are tension and compression.
The word tendon comes from the Latin word “tendonem” meaning “to stretch”. Our tendons are designed for handling tensile or stretching forces. Imagine a game of tug-of-war, hanging from the monkey bars as a kid, or pulling a rubber band apart.
Ten-dons are built for ten-sion.
As our foot hits the ground, our calf, achilles, and foot store energy that releases and propels us forward along our path. Like a slingshot being stretched and ready to fire, our Achilles tendon tenses as our foot hits the ground and allows us to spring forward.
Tendons are picky and don’t like to multitask. They want to deal with one type of force at a time. As our foot strikes the ground and tension increases, the front of our AT compresses against the back of our heel. When the achilles is irritated, it often does not like this combination of forces. This is particularly problematic with insertional achilles tendinopathy3.
This picture helps depict this combination of forces. As we move into more dorsiflexion (our shin tilts forward), tension increases toward the black dots while our AT gets compressed against the back of our heel.
Getting off to a good start
So what am I supposed to do with that information?
To run your ankle has to get into the above position. This is why runners often report pain activities that place high loads on the AT like running and jumping and compressive activities like stairs, walking uphill, squatting, and lunging exercises.
My first priority with runners is removing as much compressive force as possible. That means eliminating positions of compression, movements that increase compression, and footwear that creates more compression. Let’s break down each of those situations.
Stretching
The gut instinct when something hurts is often to stretch the area. With the AT that usually means standard calf stretches like these.
Stretching your calf places your AT in the aggravating position we already covered. Normally, runners say they feel like they should be stretching, but actually going through a stretching regimen either makes it worse or doesn’t do anything. This can be crucial when the tendon is at its angriest. If someone says this makes their symptoms feel better, they can have at it. I just don’t see that in clinical practice.
Drop Height
Once we’ve removed stretching and other bothersome positions, we critically analyze their shoes. When we have pain in our ankles or feet, shoes can be a big culprit. Drop height is the difference between the shoe’s heel and forefoot height. Lower drop shoes place our AT in more relative compression, while higher drop shoes place our AT in less compression. In the early stages, getting in a shoe with a higher drop is helpful.
Heel Counter
The last factor we look at is the actual makeup of the shoe’s heel. A heel counter is a small plastic insert in the back of a shoe’s heel that gives the foot more support and a tighter fit. Irritable tendons don’t like aggressive heel counters because of the extra compression it creates on the typical site of pain. Getting in a cushier heel counter can be very helpful.
Try out this test
Grab the back of your shoe and squeeze the heel as the above pictures depict. Is it stiff as a rock or soft and meshy? Do this test with any shoe that you are currently wearing. If the heel counter isn’t very forgiving, put it on the shelf for the time being.
Knowing what achilles tendinopathy is and how we initially manage pain is vital. Once we’ve established an initial plan off these principles, we can progress back into exercises. Drop your email below so I can update you on when the next post “Programming Exercises for Runners with Achilles Pain” drops!
Thanks for reading!
Nathan Carlson PT, DPT, USATF
- Silbernagel K, Hanlon S, Sprague A. Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. J Athl Train. 2020 May; 55(5): 438–447.
- Fletcher J and Macintosh B. Achilles Tendon Strain Energy in Distance Running: Consider the Muscle Energy Cost. J Appl Physiol 118: 193–199, 2015.
- Cook J and Purdam C. Is Compressive Load a Factor in Developoment of Tendinopathy? Br J Sports Med. 2012 Mar;46(3):163-8.
- Martin R, Chimenti R, Cuddeford T, et al. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Journal of Orthopaedic and Sport Physical Therapy. 48 (5)2018.
- Vaishya R, Agarwal A, Azizi A, et al. Haglund’s Syndrome: A Commonly Seen Mysterious Condition. Cureus 8(10). 2016.