What Causes Achilles Tendon Pain?

Achilles tendon pain is common in runners and those who have recently increased their exercise duration or frequency. The pain of an achilles tendon injury often appears at the start of a run and then eases out as the running  (or walking) progresses. For this reason, people often assume that continuing to run is harmless, or even 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 and running assessment is a vital component of assessing an achilles injury. There are two types of foot strike that are generally discussed in the literature: these are 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 striker hits with the heel and then pushes off through the forefoot

How does Foot Strike Impact Achilles Loading?

A toe or 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 through modification of the overall training load is vital to recovery. A cycle of tendon overload, followed by inadequate repair and degenerative changes forms the basis for the condition. Recovery from injury will prove challenging unless the running technique element is addressed fully.

A heel strike tend to transmit greater loads through the knee and has been linked to runner’s knee. Most recreational runners have been shown to be heel strikers. A forefoot stike creates greater forces on the achilles and calf and can predispose to achilles overload and pain.

The evidence for foot pronation as a cause of achilles tednon pain is weak, although patients consistently mention this as their perceived potential cause 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 the 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) and 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 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/