Achilles Tendon Pain After Running? Here’s What To Do About It
If you’re a runner with Achilles tendonitis or Achilles tendinopathy, here is expert advice from a physical therapist.
How can we best facilitate return to sports participation for athletes with midportion Achilles tendinopathy while minimizing risk for reinjury? If you have Achilles tendon pain after running or with sports, this clinical commentary provides a guide to clinical decision making during the return-to-sport phase when the risks of re-injury are high.
Midportion Achilles Tendinopathy in athletes
High reinjury rates - 27% to 44% found in soccer players
Higher reinjury rates of reinjury following short recovery periods
Higher reinjury rates without assistance during the return-to-sport phase
So how long should recovery periods be during the return-to-sport phase? What does appropriate guidance look like? And how much pain or stiffness is okay?
Gradual progression into the specific sport activities are generally recommended while monitoring symptoms such as stiffness, pain, and swelling during training, after training, and the next day after training. In later stages of rehab, athletes may not feel pain during their training so it is important to monitor their symptoms up to 48 hours after training to avoid overloading or reinjuring the tendon. This can assist in determining the appropriate progression in training intensity, volume, and frequency. Since a decreased loading capacity occurs with Achilles tendinopathy, it is important to gradually rebuild the tendon's ability to tolerate load even after symptoms have decreased. The pain monitoring model was proposed to help guide the evaluation of symptoms such as stiffness, pain, and swelling, and can assist in determining appropriate increases in training intensity or volume.
Pain Monitoring Model
1. Pain is allowed to reach 5 on the NPRS during activity
2. Pain immediately after activity is allowed to reach 5 on the NPRS
3. Pain the next morning after activity should not exceed a 5 on the NPRS
4. Pain and stress should not increase from week to week
Before returning to any running or jumping activity, the athlete should have minimal (1/10 to 2/10 on the NPRS) to no pain with all activities of daily living.
Next, a classification scheme is used to classify specific activities as light, medium, or high level, based on pain rating during and after the activity, and the athlete’s rating of perceived exertion (RPE) with regards to the Achilles tendon. The athlete is required to document pain and symptoms daily and to grade their RPE after each activity.
The Classification Schema
Light Medium High
Pain level during activity, NPRS (0-10) 1-2 2-3. 4-5
Pain level after activity (next day), NPRS (0-10) 1-2 3-4 5-6
The athlete's RPE (regarding Achilles tendon) (0-10) 0-1 2-4 5-10
Recovery days needed between activities 0 2 3
Examples of activities for a runner
Walking for 70 minutes Light
Jogging on flat surface for 30 minutes Medium
Running 85% of preinjury speed for 20 minutes High
A Light-level activity can be performed daily while a medium-level activity requires 2 days of recovery where no medium- or high-level activities can be performed. A high-level activity requires 3 days of recovery where no high-level activities can be performed. As the athlete improves, a new activity classification is performed to adjust the levels of activity appropriately to their current loading capacity. This activity reclassification should occur every 3 weeks.
Athletes with midportion Achilles tendinopathy typically begin returning to sport at 6 weeks to 1 year after the initial injury. However, the athlete is only considered completely recovered once he or she has participated for a full season without symptoms.
The pain monitoring model and activity classification schema should be used in conjunction with a daily eccentric exercise protocol.
The Eccentric Exercise Protocol
Heel raises with knee extended 3 sets of 15 repetitions twice daily
Heel raises with knee slightly flexed 3 sets of 15 repetitions twice daily
Total: 180 repetitions daily
Do the exercise even if it is painful (up to 5/10 on NPRS) and perform until it becomes pain free. Once pain free, progressively add loads (weights or backpack) until the exercise is again painful (up to 5/10 on NPRS). A typical heel raise progression is from double leg heel raise, to eccentric heel raise (2 up, 1 down,), to single leg heel raise before adding additional load. We started off on the floor and progress to performing heel raises off of a step.
Double Leg Calf Raises - Straight & Bent Knee
Double to Single Leg Calf Raises - Straight & Bent Knee
Single Leg Calf Raises - Straight & Bent Knee
What’s The Takeaway:
Pain is okay and actually encouraged to adequately rebuild the loading capacity of the Achilles tendon. But keep the pain at a 5/10 NPRS or below during activity, after activity, and the next morning to prevent overloading the tendon. Allow appropriate recovery days after activities of various intensities but the eccentric exercise protocol should be performed daily.
If you are experiencing Achilles pain from running, basketball, soccer, etc., please contact us below to speak with a physical therapist.
Disclaimer: This is not intended to be formal medical advice. Your individual needs should be met by the appropriate health care practitioners. Please consult with a trusted provider.
Dr. Vincent Liu, PT, DPT
Doctor of Physical Therapy
The Game Plan Physical Therapy