Achilles Rehab Essentials: Part 2 of 3 on Achilles Tendon Pain

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Since tendon pain often can be traced to doing too much, too fast, it's important to look at your training history for any trends that may have overloaded the tendon. These might include recent changes in intensity (adding more speed work), hill training, getting new shoes, or increasing your mileage. Evaluating & addressing these things can often enable you to make small changes while continuing to run versus completely shutting things down.

Learning what tendons do and don't like is also important in keeping them happy. For example, tendons don’t respond super well to compression. Prolonged calf stretches can actually lead to more irritation in many cases - the Achilles can get compressed against the heel bone. In addition, tendons do best with moderate workloads - both under- AND over-loading can change the tendon’s structure in negative ways. Part of the art of rehab is finding the sweet spot of loading to promote positive changes in the tendon, while avoiding the negative impacts of both rest and excessive stress. To see healthy changes in tendons, long-term, heavy & consistent loading is necessary.

If you’re having Achilles tendon pain, the first thing I suggest is to find a physical therapist who is knowledgeable about the demands of running - it’s important to have guidance throughout the rehab process.

To direct more specific Achilles tendon rehab, it can be helpful to classify it. In the acute stage, the tendon is sensitized & irritated from just one or a few bouts of overload. For example: if you went outside and did hill sprints for the first time in 2 years, your Achilles might get sore because it suddenly had to do a lot more work than it’s accustomed to. During this acute stage, calming things down is one of the main goals. Ways to do this without resorting to medications include: changing or avoiding painful activities (such as running) for a short period, avoiding aggressive calf stretching, and/or doing isometric exercises. While we know calming shi* down is important, treatments targeting only pain relief don’t address building that tendon back up. So you gotta do some other stuff to maintain the ability of the tendon to tolerate & do work! To do this, we need to apply some level of stress to the tendon. For very irritable tendons, this could be as simple as using the muscle against very low resistance (like a light resistance band), in a position that’s not uncomfortable. Isometrics, or contracting the muscle without moving, can get it working and also relieve some pain.

As the tendon starts to feel better, adding more resistance to isometrics (like switching from a band to a standing heel raise hold) or using the muscle through a range of motion (heel raises up and down) are good ideas for progressions. Again, finding the sweet spot at that particular point in time is important - you want to challenge it, but not overdo it. These exercises don’t necessarily need to be pain-free, either - working through a low level of discomfort does not delay progress & may actually be helpful in continued rehab. HOWEVER, for guidance on acceptable pain guidelines, it’s super helpful to have a knowledgeable PT on your team.

Along with exercise that focuses specifically on building the tendon back up, addressing muscles further up the chain is important. This could include lots of various things, but I encourage stuff like single leg bridges & side planks to challenge the hip without irritating the Achilles.

Examples of exercises for acute Achilles tendon pain are shown below. In all of these, it's important to avoid stretching the calf muscle through a big bend at the ankle, which can compress and further irritate the Achilles. These can be performed more frequently than typical resistance training routines particularly if they're allowing some pain relief.