Four reasons your Achilles may be hurting and how to manage Achilles tendonitis
Achilles pain can derail the plans of athletes and enthusiasts alike, often stemming from a blend of training habits, stress, biomechanics, and equipment choices.
This blog delves into five key reasons behind Achilles discomfort, examining the delicate balance of training intensity, the role of stress in pain perception, the importance of limb elasticity, and how your choice of surfaces and footwear can influence your running experience.
Our goal is to provide actionable insights to help you train intelligently, manage stress effectively, and choose gear wisely, keeping your Achilles strong and pain-free.
1.) Workload and Capacity
The workload for runners is determined by your program - it is the weekly miles you put in, the hours you spend on strength training and cross-training/aerobic activity as well as the intensities of these activities. Capacity is the physical exertion you can sustain[1].
Do you hit your training miles consistently, do you achieve the desired RPE in your working sets when weight training?
When there is a high acute workload, there is an increased risk of tendon injury because you are likely to exceed your current capacity. The acute increase in workload is key.
Under-training may increase injury risk, so this isn’t permission to train as little as possible.
The key, as detailed in the training-injury prevention paradox, is the graded prescription of high training loads. This will improve your fitness and may protect against injury.
Say you’re in Week 8 of a 12-week training cycle for your first half-marathon:
Under-training could look like still only sticking to 3-mile long runs when you need to be building capacity to run longer distances
High-acute workload could mean going from a 7-mile long run in Week 7 to a 12-mile long run in Week 8
The solution is to learn to train harder and smarter, in the words of Tim Gabbett. Runners need to improve their capacity to endure lower-intensity, higher-volume runs because this type of training can have a protective effect against pain and injury[2, 3].
2.) Stress management
In life:
Major, negative events in our lives can lead to injury or a heightened experience of pain while positive life stressors have no effect [4]. In a recent study, researchers found that it’s the relative change in negative stressors that can predict injury occurrence.
They studied college-level individual team and sports athletes in Britain who reported negative life stressors. If an athlete reported a score of 1 in the first questionnaire and 5 in the second, this would be 400% increase in negative life stressors.
While their net life stressor score was considered “Low”, these athletes were much more susceptible to injury [5].
In response to pain:
Stress management in your day-to-day life is important, but what happens if you’re already in pain?
We know that the more you avoid movement out of fear, the greater the intensity in which you experience pain. In a study that compared groups of people dealing with lower-limb injuries, the group that continued to move with some pain and discomfort scored greater in psychological outcomes and reported less pain over time.
Those who were not assigned to move and were surveyed for their psychological outcomes demonstrated fear avoidance and belief that exercise may worsen their pain, but they also reported greater psychological distress. Women especially reported higher rates of anxiety and depression due to their pain/injury [6].
This is why a good clinician who will ask about your life stressors as part of a comprehensive intake process. Knowing if you had a crazy week at work compared to a normal week you got injured helps paint a clear picture of what’s happened and why.
This is also why part of a good clinician’s job is to help rewrite your relationship with pain by creating a plan that helps you move better and feel more capable.
3.) Elasticity in the lower limb
We know in principle that the muscles and tendons in your lower limbs must work together to produce force.
Some studies have found that reduced eccentric contraction of the glute medius and rectus femoris (one of your quad muscles that helps extend your knee) may place greater stress on the foot and ankle, leading to increased Achilles load that can lead to pain.
Other studies have found distal lower limb muscles like the calves were culprits [7]. Because of inconsistencies in these findings, best practices currently center around addressing inconsistencies in gait (a few studies found that people with Achilles tendinopathy have less tibial external rotation compared to healthy runners [8].
Training your legs for strength and working on plyometrics to translate that strength into speed and greater elasticity in response to ground forces.
4.) Surfaces and footwear
The stiffness of footwear and its cushioning influence how you strike the floor and how the rest of your leg responds to load. One study investigated the effect of midsole cushioning on Achilles tendon stretch while running.
They found cushioning around the midsole increased the stretch of the Achilles, which increased energy returned by the Achilles tendon. The study authors argue it may be a valid mechanism to improve running performance [9].
Another study found Achilles tendon strain was most reduced in the least stiff shoe and stiffest surface [10].
The takeaway here is to pick a shoe that has some cushioning around the midsole (but should not feel like walking on clouds).
As counterintuitive as it may seem, try running on harder surfaces (wearing the right shoe) if you’re experiencing pain in your Achilles.
From managing workload to stress and choosing the right footwear, we’re here to support your running journey, which means navigating pain as it occurs.
Our team of physical therapists is here to help you train smarter, foster resilience, and create a plan for race day.
Let's work together to ensure your Achilles stays strong and pain-free for the road ahead, schedule your first session with us here.
Citations:
Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Boston: Butterworths; 1990.
Hulin BT, Gabbett TJ, Blanch P, Chapman P, Bailey D, Orchard JW. Relationship Between Running Loads and Soft-Tissue Injury in Elite Team Sport Athletes. J Strength Cond Res. 2012;26(4):953-960. doi: 10.1519/JSC.0b013e3182302023
Blanch P, Gabbett TJ. Has the athlete trained enough to return to play safely? The acute:chronic workload ratio permits clinicians to quantify a player's risk of subsequent injury. Br J Sports Med. 2016;50(8):471. doi: 10.1136/bjsports-2015-095445
Ivarsson A, Johnson U. Psychological factors as predictors of injuries among senior soccer players. A prospective study. J Sports Sci Med. 2010 Jun 1;9(2):347-52. PMID: 24149706
Fisher H, Gittoes MJR, Evans L, Bitchell CL, Mullen RJ, Scutari M. An Interdisciplinary Examination of Stress and Injury Occurrence in Athletes. Frontiers in Sports and Active Living. December 2020; doi: 10.3389/fspor.2020.595619.
Hanlon SL, Pohlig RT, Silbernagel KG. Beyond the Diagnosis: Using Patient Characteristics and Domains of Tendon Health to Identify Latent Subgroups of Achilles Tendinopathy. J Orthop Sports Phys Ther. 2021 Sep;51(9):440-448. doi: 10.2519/jospt.2021.10271.
Munteanu, Shannon E. and Barton, Christian J. Lower limb biomechanics during running in individuals with achilles tendinopathy: a systematic review. J of Foot and Ankle Research. 2011 May; 4(15). doi: 10.1186/1757-1146-4-15
Freedman BR, Gordon J.A., Soslowsky LJ. The Achilles tendon: fundamental properties and mechanisms governing healing. Muscles Ligaments Tendons J. 2014 Jul 14;4(2):245-55.PMID: 25332943; PMCID: PMC4187594.
Esposito M, Wannop J.W., Stefanyshyn DJ… Effects of midsole cushioning stiffness on Achilles tendon stretch during running. Sci Rep. 2022;12:4193. doi: 10.1038/s41598-022-07719-x
Firminger CR, Bruce OL, Wannop JW, Stefanyshyn DJ, Edwards WB. Effect of Shoe and Surface Stiffness on Lower Limb Tendon Strain in Jumping. Med Sci Sports Exerc. 2019 Sep;51(9):1895-1903. doi: 10.1249/MSS.0000000000002004