There are 4.1 million runners in the United States which is a 30% increase since 2000.1 Nearly 80% of runners sustain at least one overuse running injury per imgresyear,2 and 70% to 80% of these injuries occur between the knees and the feet.3 The most common running injuries include patellar tendonitis, plantar fasciitis, iliotibial band syndrome, patella femoral pain syndrome, shin splints, Achilles tendon pain, hamstring strain, stress fractures, and ankle sprain. This month’s Runners Edge article will focus on Achilles tendon pain.

The Achilles tendon is one of the largest tendons in the body. It is formed by the gastrocnemius and soleus muscles and serves to attach these lower leg (calf) muscles to the heel (calcaneus) bone. Unique to the gastroc-soleus-Achilles complex is the fact that this muscular-tendon group crosses three joints (knee, talocrural ankle joint, subtalar ankle joint). The Achilles tendon, therefore, is responsible for powering push-off during running and absorbs torsional stress placed upon the associated lower extremity joints. Achilles tendon soreness is common in runners. A rapid increase in running mileage, a drastic change in shoe cushioning or shoe drop, or a significant increase in hill running can all lead to Achilles pain. Poor calf muscle length and mobility as well as poor proximal hip and core functional strength also results in increased Achilles tension during running.

Soreness in the Achilles must not be ignored due to its limited blood supply which can make healing and inflammation reduction challenging. Acute Achilles tendonitis symptoms include pain during the push-off phase of walking or running, tenderness

to palpation a few inches above the calcaneus. Acute symptoms may also include a “squeaky” sensation in the Achilles tendon as you move your foot up and down in to dorsiflexion and plantarflexion. This “squeaky” sensation represents inflammation in the Achilles tendon sheath and warrants immediate rest, ice, and medical treatment to reduce inflammation. Chronic Achilles inflammation and soreness results in the formation of a thickened “knot-like” structure within the

Achilles and is referred to as Achilles tendinosis or Achilles tendinopathy. The thickened tendon represents scar tissue formation which will not resolve with rest alone.

Treatment of Achilles tendonitis in its early stages should include complete rest from running. It is vital to reduce inflammation by modifying activity level. Anti-inflammatory medication may be prescribed, and ice/elevation will aid in pain reduction. Because the blood supply in the Achilles is limited, healing may take some time. A physical therapist will help determine the underlying cause of your Achilles symptoms as proximal weakness or a muscle imbalance which lead to poor running mechanics. If acute Achilles tendonitis is not treated in a timely manner or if symptoms are ignored, then Achilles tendinosis may develop. The associated tendinosis “lump” of scar tissue decreases the elasticity of the Achilles and may lead to bone irritation at the Achilles attachment (calcaneus). Addressing the scar tissue with properly applied physical therapy cross friction massage, instrument assisted soft tissue mobilization (IASTM), and anti-inflammatory modalities such as Iontophoresis are beneficial. If symptoms do not resolve in a timely manner, orthopedic options such as platelet rich plasma (PRP) injections should be considered. Once pain is gone, running mileage and uphill running should be resumed very gradually. Strengthening the Achilles tendon and calf musculature in an eccentric (lengthened) manner will reduce injury recurrence.

Do not ignore Achilles pain. See treatment immediately to expedite your return to running. Because of the unique dynamic musculoskeletal forces and complex synthesis of movement involved in running, treatment of running injuries must not focus solely on static, passive interventions. Physical therapy is a vital component in returning to full running ability following an Achilles tendon injury. Rest and pain relief alone will not insure a full return to running. A physical therapist with experience treating running specific injuries and a firsthand understanding of the mechanics of running will insure a successful return to running. Learn more about our comprehensive running and physical therapy services at

John Fiore, PT

Sapphire Physical Therapy

1 Wilk B, Muniz A, Nau S. An Evidence-based Approach to Orthopaedic Physical Therapy: Management of Functional Running Injuries. Orthopaedic Physical Therapy Practice. 2010; 22:213-216. 2 Van Gent RN, Siem D, van Middelkoop K, et al. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. J Sports Med. 2007; 41:469-480. 3 Ballas M, Tyrko J, Cookson D. Common overuse running injuries: Diagnosis and management. Am Fam Physician. 1997: 55(7):2473-2484.