Updated: May 28
Up to 44% of people returning to sport after and Achilles tendinopathy end up with a recurrence of the injury. Here are some things to consider if you think you are ready to return to running to reduce the risk of this happening to you.
In this article:
I also discuss it in this video:
1. Are you pain-free in the morning and when going down stairs?
If you are still experiencing pain when you first wake up in the morning, hobbling for the first few steps, or still walking very gingerly down the stairs, this is a good indication that the tendon is not ready to return to impact loading yet and is likely to flare up again. You’ll need to give the tendon more time to offload and strengthen before getting back onto the trails or it’s likely to become sore again.
2. Are you able to hop pain-free?
The ground reaction forces your Achilles will have to tolerate during running can be up to three times more than walking. Every step when you run involves controlling a single leg land and pushing off, using the elastic recoil of the musculotendinous unit of your calf and Achilles. Try hopping 10 times… If you still feel some soreness when you hop, then it is unlikely to tolerate a return to running unless you strengthen it further.
If you think how many steps you take when you run and how many hops that is equivalent to… it is a lot more than 10. The average amateur runner takes 52,661 steps to complete a marathon so by my basic calculations, that is approximately 2,000 steps per mile!
3. Have you completed a progressive rehab programme to strengthen the calf-Achilles complex?
This point follows on from Points 1 and 2. As said before, running involves forces of up to three times your bodyweight, but can specifically load the Achilles tendon even up to 6-12 times bodyweight. So, you need to have strengthened the calf and Achilles through bodyweight loading, progressing to strengthening with weights, altering the tempo from slow and controlled to increasing power and elastic recoil, and finally training to improve the Achilles’ tolerance to impact loading in a controlled way before hitting the road.
4. Have you addressed other biomechanical issues?
Sometimes, resting an injury can lead to relative deconditioning of other areas of the body. Is your core stability, hip strength, and knee control ready for a return to running? Were there any issues that may leave you predisposed to Achilles tendinopathy recurrence or some other overuse injury? Is your ankle mobility adequate to return to running?
Another consideration is running gait – forefoot running gait has many benefits but is also well documented to increase loading on the Achilles tendon, plantar fascia, and calf. If a change in running gait to forefoot strike contributed to the tendinopathy in the first place, have you conditioned well enough to continue this change, or will you revert back to your previous running style?
5. Have you planned a progressive, graded return to running?
If your running was going well prior to the onset of injury, you have to bear in mind that you will not be able to immediately pick up where you left off. You will need time to build this back up again. A written plan really helps, as otherwise the chances are you’ll feel so happy to be back out there that you will keep going and going and end up overloading it again (or at least, I would!)
Soft tissue overuse injuries tend to occur from sudden increases in load – more than the body can physiologically adapt to in the time you give it to adapt. Recent research has shown that increasing training load by only 10% per week resulted in less than 10% chance of injury. Increasing by >15% per week increased the risk of injury to up to 49%.
Also bear in mind that increasing distance, pace, or elevation are all components to be added one at a time. For example, build up your mileage before you build up your pace. Then add elevation later. Not all at once.
So… if the answer to all of these questions is a resounding “YES”… then you are good to go! There may still be times that you experience a flare-up. If this is the case, listen to your body and give it a rest for a few days to let it settle down again before continuing your build-up. Whatever you do, DO NOT push through the pain, or you will end up in the same boat as before.
How we can help
Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.
About the Author
Sibernagel and Crossley (2015). "A proposed return to sport program for patients with mid portion achilles tendinopathy: rationale and implementation." J Ortho Sports Phys Ther 45 (11): 876-86 doi: 10.2519/jospt.2015.5885.