What Causes Achilles Tendon Pain?

Achilles tendon pain is common in runners and those who have recently increased their exercise duration. The pain of an achilles tendon injury often appears at the start of a run and then eases out as the run continues. because the pain improves by continuing the run, people often assume that continuing to run is harmless, or might even be helpful in alleviating the pain. Unfortunately, continuing to train through the pain frequently gives rise to more severe and intractable pain. The longer the pain is present then the longer it takes to heal.

What is the best treatment for achilles tendon pain?

Does Running Technique Impact on Achilles Tendon Pain?

A biomechanical running technique assessment is a vital component of assessing an achilles injury. There are two types of foot strike that are generally discussed in the literature: a forefoot and a rearfoot strike. A forefoot strike is where the runner lands on the ball of the foot with the heel off the ground. A rearfoot strike is where the runner hits the ground with the heel first and follows through with the forefoot

How does Foot Strike Impact Achilles Loading?

The way an athlete strikes the ground while running will have a big impact on the overall loading of the knee and ankle joints.  A forefoot strike, for example,  is associated with higher loading of the achilles tendon. Excessive loading of the achilles tendon is the main stimulus for injury and therefore modifying the loading overall training load is vital to recovery. A cycle of tendon overload, followed by inadequate repair forms the basis for achilles tendon pain. Recovery from injury will prove challenging unless improvements in running technique are implemented. 

“Fallen arches” tends to be one of the main reasons that patients give for their achilles pain. The evidence for foot pronation as a cause of achilles tendon pain is weak, despite patients consistently mentioning this as the source of their pain.  

Other running technique factors such as overstriding has been linked to heel and knee pain. This is where the runner, in an attempt to take a long stride, stikes the ground with their heel and transfers significant ground reaction forces up through the leg.

Some simple tips for improving running technique include:

  • Increasing your step rate (research on olympic athletes suggest that a step rate of 180 per minute was optimal for reducing impact forces)
  • Decreasing stride length
  • Striking the ground with a flat foot directly under your hip

What is the best treatment for achilles tendon pain blog

Walking Re-Education in Achilles Tendonitis Management

Any negative thoughts regarding pain can give rise to limping. This may be rationalised as “taking pressure off my heel”. Continuing with this movement pattern can give rise to wasting of the muscles and tendon and can prevent recovery if the person does not relearn how to walk properly again.

In terms of running technique, if you have been largely injury free then you are best to maintain your current foot strike pattern. Messing with your running technique can give rise to unnecessary injury. If you really feel the need to change your technique then it should be done on a very gradual basis.

Research on Exercise Rehabilitation for Achilles Tendinitis

There has been a lot of talk about eccentric resistance training for managing achilles tendon injury. Eccentrics involve slowly lowering the heel from a raised position to create tension on the achilles tendon.

A recent randomised controlled trial compared the effectiveness of 12 weeks of eccentric training (ECC) versus heavy slow resistance training (HSR) among 58 patients with achilles tendinopathy of greater than 3 months.

The authors concluded that both eccentric and regular resistance training were equally effective in the management of achilles tendinopathy

How effective is Acupuncture for Achilles Tendinopathy?

Recent research published in the journal ‘Physiotherapy Practice and Research’ examined the effect of acupuncture in treating achilles pain in  twenty-two patients. The participants were randomised to receive either acupuncture or the control sham acupuncture treatment

The authors concluded that an acupuncture protocol could be used as a second line treatment alongside a physiotherapy guided exercise rehabilitation programme.

This corroborates the findings of Zhang et al. (2012) who reported significant functional improvement and decreases in heel pain in individuals undergoing acupuncture


Zhang BM, Zhong LW, Xu SW, Jiang HR, Shen J. Acupuncture for chronic Achilles tendnopathy: a randomized controlled study. Chin J Integr Med. 2013;19(12):900-904. doi:10.1007/s11655-012-1218-4. https://pubmed.ncbi.nlm.nih.gov/23263998/

Kishmishian, Berj, Richards, Jim, and Selfe, James. ‘A Randomised Feasibility Study Using an Acupuncture Protocol to the Achilles Tendon in Achilles Tendinopathy’. 1 Jan. 2019 : 59 – 67.

For further information on achilles tendon pain visit our achilles page at: https://www.physioclinic.ie/conditions/achilles-tendon-injury/