What the intensity of your Achilles pain means and how to use it for rehab

One of the main reasons patients consult us is the level of pain they are experiencing in their injured Achilles tendon, which, in turn, is preventing them from doing the activities they love. This article explores what that pain really means and how you can use it to guide you in what to do next.

Remember, if you need help with an Achilles injury, you're welcome to consult one of our physio team via video call.

The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in most of our articles.

In this article:

1. Pain intensity vs. injury severity

2. How the pain alarm system works

3. How can I use this pain response to help me?

4. How we can help

We've also made a video to explain this:

https://www.youtube.com/watch?v=yekV47NcQOk

Pain intensity vs. injury severity

Culturally, we have been brought up to believe that the more pain we have, the worse the injury is or the more the damage is. But researchers have now found that this is not the case.

For example, in one study researchers found that, on average, the Achilles tendons of people reporting the highest pain levels didn’t show much evidence of damage. In contrast, the group whose tendons had the most damage and who performed the worst in strength tests reported the lowest pain levels.

This was of course not true for everyone in the study, but the take-home message is that just because your pain is very intense doesn’t necessarily mean that you have a serious injury to your tendon.

We now understand that we should view pain more like our bodies’ alarm system, and that this alarm system dials up or down in reaction to many factors.

💡 So, the intensity of the pain you feel does not correlate to the severity of the injury, but rather to how sensitive your alarm system is.

How the pain alarm system works

When we develop any injury, pain is a common symptom. It’s your body’s way to make you pay attention and look after the injury so that it can recover.

In an ideal world, the alarm system will calm down and the pain will decrease in line with how your injury heals – and for many people this is indeed how it works.

However, if the alarm system (which is managed by your subconscious brain) feels that you’re ignoring it, it might start increasing the intensity of the pain. This is why “mind-over-matter” and “trying to push through pain” don’t work; even if it doesn’t worsen the actual injury, it usually causes the pain to increase.

Interestingly, overprotecting the area and becoming too vigilant can also lead to disproportionate pain.

Also, resting your Achilles tendon can help the pain to calm down in the short term, but it doesn’t usually change anything with regards to the actual injury – you also have to restore the tendon’s capacity to tolerate your normal activities, which can only be done through a rehab exercise plan that gets progressively more challenging as your tendon gets stronger.

💡 So, for the best results, you have to find the right balance between rest and activity, and this is where we can use your pain levels to your advantage – how your pain responds to different situations can help us to figure out the best balance.

How can I use this pain response to help me?

Remembering that the amount of pain does not indicate the amount of harm is a great start. This helps us to view our tendon injury as something we can start to control and not something that is controlling us.

The current research suggests that experiencing a little discomfort during your rehab or other activities can be a positive thing and help your alarm system to calm down. However, if you consistently push into too much pain, the system might get over-sensitive and start shouting louder.

How to tell what an acceptable pain response is varies between people. A good guideline is to aim for “a niggle level” only; so, something that doesn’t make you wince, limp, or feel pain for a while after.

Tendons often have a delayed pain response. This means that everything can feel fine during an activity, but later on or the next morning the pain kicks in. Therefore the niggle level guide is for both during the activity and for 24 hours after.

Some researchers prefer to use a traffic light system based on a pain scale out of 10:

• 0 to 3 out of 10: Generally acceptable and will allow your alarm system to calm down.

• 4 to 6 out of 10: Warning sign that you might be overloading the tendon.

• 7 to 10 out of 10: Usually indicates that the tendon has been irritated too much.

Rehab exercises aren’t really useful if they consistently push your pain levels too high – your tendon might get stronger, but a strong tendon is of little use if you’re still in constant pain.

That’s why we teach our patients how to use this pain monitoring system for their rehab exercises as well as all their other activities.

How we can help

Need help with your Achilles or related 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 or at least 10 years' experience in the field. All of us have a wealth of experience working with athletes across a broad variety of sports and ranging from recreationally active people to professional athletes. You can meet the team here.

About the author

Alison Gould is a chartered physiotherapist and holds an MSc in Sports and Exercise Medicine. You can follow her on LinkedIn, Facebook, Instagram, and Twitter.

References

1. Silbernagel KG, Thomeé R, Eriksson BI, et al. Continued Sports Activity, Using a Pain-Monitoring Model, During Rehabilitation in Patients With Achilles Tendinopathy: A Randomized Controlled Study. The American Journal of Sports Medicine 2007;35(6):897-906.

2. Van Der Vlist, A. C., et al. (2021). "Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials." British Journal of Sports Medicine 55(5): 249-256.

3. Butler, D. and Mosely, L. (2013). Explain Pain. Noigroup Publications: Adelaide, South Australia.

4. 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.