Returning to Running with Achilles Pain

You’ve reached the final blog in my Achilles tendon series!

You mastered managing the painful days in part one.
You built a strong, resilient calf and tendon in part two.
Now, let’s tackle the most crucial question of all…

How do I start running and not end up back at square one!?

This very question has been echoed in rehab clinics across the world. Let’s highlight what I’ve found helpful as you get back to running, training, and racing. 

Paying attention is likely the most crucial element of a quality return to run plan. It’s essential to be diligent about implementing running and how your body responds. You have lots of options back to your ultimate goal. I’ve found it helpful to change one variable at a time every one to two weeks. For example, only change the duration of your running, not the duration and intensity). This allows you to fine-tune your approach if spikes in pain occur. When dealing with cranky Achilles tendons, I’ve found it helpful to progress training in the following order. 

Frequency (how often you run)
⬇️
Duration (how long you run)
⬇️
Running on Consecutive Days
⬇️
Intensity (how fast you run)
⬇️
Racing (running as fast as possible)

Progressing down that list in an orderly fashion helps your body get readjusted to the demands of running without overdoing it. Don’t throw everything on the calendar at once. Stay patient and track your progress. 

Navigating Pain

Rarely do I have a patient that has 0/10 pain from the first day we meet to the day they return to competition. I don’t think you need to be completely pain-free to run, train, and compete. This is important. Keeping runners with tendon pain away from training often puts them in a worse spot. Low-level symptoms that aren’t worsening as we do more are very typical. Whether an athlete is still training or simply debating returning to running, we should follow simple guidelines. 

  • Day-to-day tasks should be relatively pain-free.
  • You shouldn’t have large spikes in pain that last for more than 24-48 hours. 
  • You should be able to complete all the drills listed in my second blog. 
  • You shouldn’t get a visible inflammatory response following cross-training, exercises, or plyometrics (i.e., redness, swelling, and pain around the tendon)
  • You shouldn’t need to alter your running mechanics due to pain. NO LIMPING! 

If you can’t check off this list, we might need to investigate. 

The Daily Load Test

It can be tricky tackling decisions about what’s ok and what’s not on your own. Having a daily self-assessment you can perform can help guide your decision-making1. For the Achilles tendon, I’ll use single-leg heel raises to failure or single-leg hopping as a daily test to monitor progress during rehab. If suddenly you can’t perform those due to pain, it might mean we are progressing too quickly. Stress the area daily and monitor for any changes. 

How to Modify Your Training:

Simple modifications can make a world of difference with painful tendons. There are three easy principles I’ll often apply to the Achilles as we navigate our way back to 100%. 

Keep it Flat

We discussed the role of compression in Achilles tendinopathy in the first post of this series. Prioritizing relatively level ground can be helpful as running on inclines places our Achilles into more tendon compression. If you live in a hilly part of the world or navigate a lot of inclines during training, taking extra effort to keep your running flat can be worth the investment. Once you have a solid block of running under your belt, head back to the hills. 

Treadmill Versus Outside

Running on a treadmill and running outside are pretty similar, with one crucial exception. Running on a treadmill places more stress on your Achilles tendon. Willy et al2 found treadmill running resulted in…

  • 12.5% greater peak Achilles tendon force
  • 15.6% greater loading rate of Achilles tendon force
  • 14.2% greater estimated cumulative Achilles tendon force 

Take a similar approach to treadmills as we do hills. Stay away early, and ease back into the treadmill as running improves. 

Slow Down!

You have to hit the ground harder to run faster, placing more demand on our Achilles. Prioritizing slower running is helpful in the beginning. If the goal is to get back to faster-paced efforts, allow a 24 hour recovery period after faster efforts to give the tendon a chance to recover. This also allows you to assess your response to yesterday’s effort.

The tables below highlight a typical schedule for my patients as they start their return to run progression and a runner actively training six days a week.

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Nathan Carlson PT, DPT

References: 

  1. Malliaras P, Cook J, Purdam C et al. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. Journal of Orthopedic and Sport Physical Therapy. 45 (11). 2015. 887-898.
  2. Willy R, Halsey L, Hayek A et al. Patellofemoral Joint and Achilles Tendon Loads During Overground and Treadmill Running. JOSPT. 2016. 46 (8). 664-672. 
  3. Hebert-Losier K, Wessman M, Alricsson M et al. Updated Reliability and Normative Values for the Standing Heel- Rise Test in Healthy Adults. Physiotherapy. 2017: 103 (4) :446-452.
  4. Sancho I, Willy R and Morrissey D. Education and Exercise Supplemented by a Pain-Guided Hopping Intervention for Male Recreational Runners with Midportion Achilles Tendinopathy: A Single Cohort Feasbility Study. Physical therapy in Sport. 40 (2019): 107-116. 

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