The Ultimate Runner’s Guide to Achilles Tendon Injuries: The Scientific Signs, Symptoms, and Research Backed Treatment Options for Achilles Tendonitis and Insertional Achilles Tendinopathy

The Achilles tendon is the thickest and strongest tendon in your body, connecting your calf muscles to the back of your heel.

Virtually all of the force generated when you “toe off” the ground during running is transmitted by the Achilles, and this force can be as much as three times your body weight. And the faster you run, the more strain you put on the Achilles tendon.

As such, it’s prone to injury in many runners, but particularly those who do a lot of fast training, uphill running, or use a forefoot-striking style. Achilles tendon injuries account for 5-12% of all running injuries, and occur disproportionately in men. This may be because of the faster absolute speeds men tend to train at, or may be due to other biomechanical factors.

Achilles tendonitis typically starts off as a dull stiffness in the tendon, which gradually goes away as the area gets warmed up. It may get worse with faster running, uphill running, or when wearing spikes and other low-heeled running shoes. If you continue to train on it, the tendon will hurt more sharply and more often, eventually impeding your ability even to jog lightly.

About two-thirds of Achilles tendonitis cases occur at the “midpoint” of the tendon, a few inches above the heel. The rest are mostly cases of “insertional” Achilles tendonitis, which occurs within an inch or so of the heelbone. Insertional Achilles tendonitis tends to be more difficult to get rid of, often because the bursa, a small fluid-filled sac right behind the tendon, can become irritated as well.

The common causes of Achilles tendonitis in runners

The causes of Achilles tendonitis all appear to be related to excessive stress being transmitted through the tendon. Weak calf muscles, poor ankle range of motion, and excessive pronation have all been connected with the development of Achilles problems.The upshot is that all of these factors, plus training volume and so on, result in damage to the tendon.

While the term “tendonitis” implies that inflammation (-itis) is the root cause of the problem, in fact, the true cause is real, physical damage to the fibers of the Achilles tendon itself.

Much like a bungee cord is made up of tiny strands of rubber aligned together, tendons are comprised of small fiber-like proteins called collagen. Pain in the Achilles tendon is a result of damage to the collagen. Because of this, treatment options should start with ways to address this.

Research-backed treatment for Achilles tendonitis

For a long time, researchers and doctors muddled about trying to address factors like calf strength & tightness, ankle range of motion, and pronation, assuming that the Achilles tendon would heal itself once these factors were corrected. Unfortunately, it seems that the thick tendons of the body do not heal as rapidly or completely as we’d like.

The cause of this seems to be the collagen fibers: when a tendon is damaged, collagen fibers are ruptured. The body is able to lay down new fibers to replace the damaged ones, but it does so in a rather disorganized way. The new collagen fibers look much like a mess of spaghetti when viewed on a microscope, in contrast to the smooth, aligned appearance that healthy tendon fibers have.

So, while we might propose that runners do calf stretching to loosen up their calf muscles and increase their ankle range of motion, this often does more harm than good—tugging aggressively on the damaged tendon fibers is much like pulling on either end of a knotted rope.

Instead, the main objective in treating Achilles tendon injuries should be healing the damaged tendon. The exercise of choice is the eccentric heel drop, which has an impressive research pedigree backing its use.

Eccentric heel drop protocol for Achilles tendonitis

The strength protocol consists of two exercises: a straight-kneed and a bent-kneed eccentric heel drop. The protocol calls for three sets of fifteen heel drops, both bent-kneed and straight-kneed, twice a day for twelve weeks.

Standing on a step with your ankles plantarflexed (at the top of a “calf raise”), shift all of your weight onto the injured leg. Slowly use your calf muscles to lower your body down, dropping your heel beneath your forefoot. Use your uninjured leg to return to the “up” position. Do not use the injured side to get back to the “up” position! The exercise is designed to cause some pain, and you are encouraged to continue doing it even with moderate discomfort. You should stop if the pain is excruciating, however.

Once you are able to do the heel drops without any pain, progressively add weight using a backpack. If you are unlucky enough to have Achilles tendon problems on both sides, use a step to help you get back to the “up” position, using your quads instead of your calves to return up.

The eccentric exercises are thought to selectively damage the Achilles tendon, stripping away the misaligned tendon fibers and allowing the body to lay down new fibers that are closer in alignment to the healthy collagen in the tendon. This is why moderate pain during the exercises is a good thing, and why adding weight over time is necessary to progressively strengthen the tendon.

Exercise 1: The straight-knee eccentric heel drop.

 

eccentric heel drops achilles tendonitis

In this picture, the injured side is the left leg. Note that the right leg is used to return to the “up” position. This exercise is one of two used in cases of midpoint Achilles tendonitis. Once you can perform this exercise pain-free, add resistance using weights in a backpack.

Exercise 2: The bent knee eccentric heel drop.

 

eccentric heel drops bent leg achilles tendonitis

As with exercise 1, the opposite leg is used to return to the “up” position. This time, bend your leg at the knee and slowly lower yourself down. This is the second exercise for midpoint Achilles tendonitis. Add weight when you can do it pain free.

Exercise 3: Modifications for insertional Achilles tendonitis

 

eccentric heel drops insertional achilles tendonitis

Exercise 3: the flat-ground eccentric heel drop. This exercise is used for cases of insertional Achilles tendonitis, replacing exercises 1 & 2. Like the exercises for midpoint Achilles tendonitis, use the opposite leg to return to the “up” position and add weight once you can do it pain-free.

In the case of insertional Achilles tendonitis, the protocol is modified a bit: the exercise is done on flat ground, and only the straight-legged variant is done. All other aspects are identical (3×15 twice daily, adding weight, and so on).

Other possible treatment options

While you are addressing the damage to the tendon fibers through eccentric heel drops, there are some steps you can take to help ameliorate some of the other contributing factors to your injury.

  • While calf tightness and ankle range of motion are legitimate concerns, I still don’t think that aggressive calf stretching is an ideal solution, because of the tugging action on the tendon. Instead, try foam rolling your calves and applying a warm water bag to the muscle (but avoid heating the tendon!). Foam rolling your calf muscles can loosen them up without tugging too much on the Achilles tendon.
  • You can also stretch out your shins by leaning back in a kneeling stance to aid ankle range of motion.
  • Footwear concerns should also be addressed at this point. If you have been wearing low-heeled “minimal” shoes, racing flats, or spikes, you ought to stick to more traditional shoes with a higher heel until your tendon is healthy again. Once you’ve healed up, you can gradually do some running in low-heeled shoes or even barefoot (on grass) to help accustom your Achilles to moving through its full range of motion. Poor casual footwear choices should not be overlooked too, especially for women. Some shoes can also put pressure on the back of your heel, irritating the insertion of the tendon. Generally, the closer a shoe is to looking and feeling like a “running shoe,” the better it is for your foot.
  • Doctors and podiatrist may be keen to have you try out a custom orthotic to treat your Achilles problems. While it might be worth a shot, there isn’t a whole lot of scientific evidence backing their use in this case. Orthotics don’t reliably alter pronation, and even if they do, it’s uncertain as to whether this will increase or decrease stress on the Achilles.

Outline of treatment

Conservative treatments

These are cheap, easy to perform treatments that you can do it home in your own time. You should try to do as many of these as possible each day.

  • Eccentric heel drops – 3 sets of 15 reps, twice per day for 12 weeks (if you only do one thing, do this!)
  • Icing after each run
  • Heating before each run with warm water or heating pack
  • Contrast bath during the day – take two small buckets/trash cans and fill one with hot (hot bath temp) water and the other with ice water (cold enough so some ice still doesn’t melt) and put your whole leg (up to the calf) in the cold. Hold for 5 minutes and then switch to the hot for 5 minutes. Repeat 2 or 3 times, ending with cold. This helps rush blood in and out of the area, which facilitates healing
  • Don’t take anti-inflammatory like Advil or ibuprofen. These stop the body’s natural healing agents and we want as much natural healing to occur as possible.
  • Avoid excessive stretching – only very light, easy stretching until healed
  • Massage your calves with a foam roller or The Stick.
  • Heel lifts are a possible temporary solution. They restrict the Achilles’ range of motion, so can be helpful to get over the initial hump of the injury, but should be taken out after you are recovering.
  • Switch to more supportive or traditional running shoes (higher heels) during your runs and while walking around until your pain is completely gone, and avoid flats and high heels!
  • Ankle strengthening and mobility exercises.
  • Sleep in a Strassburg sock or nightsplint to gently stretch the Achilles while sleeping.

Aggressive treatments

These treatments are a little more expensive or time consuming and are only suggested for if you suffer from chronic Achilles pain or the conservative treatments are not working for you.

  • A custom orthotic might help alleviate the pain from excessive pronation. This is not a proven treatment, but for those runners who respond to orthotics, it can help.
  • Iontophoresis with dexamathasone. This is a treatment offered by physical therapists that involves propelling anti-inflammatory steroids into the tendon. You need a prescription and a physical therapist to administer the treatment, but research has shown the potential to have a positive effect on the treatment of Achilles issues.

Strengthening and prevention

  1. Eccentric heel drops
  2. Ankle strengthening and mobility exercises
  3. Achilles rehab exercises

Returning and continuing to run

You can still run during this twelve-week period, but only if your Achilles does not flare up while doing so.

Use warm water to heat up the tendon before you run, and apply ice afterwards, even once you’ve started feeling better. Using a foam roller and hot water packs to loosen up your calves in the morning and at night is also not a bad idea, and don’t forget to take a look at what you’re wearing in your daily life.

If you have insertional Achilles tendonitis, use the modified flat eccentric heel drop exercise instead of the two variants off a step.

A custom orthotic or heel lift may be helpful, but should not be a first-line treatment option.

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References

1. Taunton, J.; Ryan, M.; Clement, D.; McKenzie, D.; Lloyd-Smith, D.; Zumbo, B., A retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine 2002, 36, 95-101.2.
2. Marti, B.; Vader, J. P.; Minder, C. E.; Abelin, T., On the epidemiology of running injuries-the 1984 Bern Grand-Prix study. The American Journal of Sports Medicine 1988, 16(3), 285-294.3.
3. Maffulli, N.; Wong, J.; Almekinders, L. C., Types and epidemiology of tendinopathy. Clinics in Sports Medicine 2003, 22(4), 675-692.4.
4. Ryan, M.; Grau, S.; Krauss, I.; Maiwald, C.; Taunton, J. E.; Horstmann, T., Kinematic analysis of runners with Achilles mid-portion tendinopathy. Foot & Ankle International 2009, 30(12), 1190-1195.5.
5. Alfredson, H.; Pietilä, T.; Jonsson, P.; Lorentzon, R., Heavy-load eccentric calf muscle training for the treatment of chronic achilles tendonitis. American Journal of Sports Medicine 1998, 26 (3), 360-365.
6. Jonsson, P.; Alfredson, H.; Sunding, K.; Fahlström, M.; Cook, J., New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. British Journal of Sports Medicine 2008, 42 (9), 746-749.
7. Nigg, B., The Role of Impact Forces and Foot Pronation: A New Paradigm. Clinical Journal of Sports Medicine 2001, (11), 2-9.
8. Neeter, C.; Thomeé, R.; Silbernagel, K.; Thomeé, P.; Karlsson, J., Iontophoresis with or without dexamethazone in the treatment of acute Achilles tendon pain. Scandanavian Journal of Medicine & Science in Sports 2003, 13 (6), 376-382.

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66 Responses on “The Ultimate Runner’s Guide to Achilles Tendon Injuries: The Scientific Signs, Symptoms, and Research Backed Treatment Options for Achilles Tendonitis and Insertional Achilles Tendinopathy

  1. This is a great summary. I dealt with Achilles tendinitis for several months earlier this year and tried much of what you mention here, both conservative and aggressive approaches. While most of my experience is consistent with what you have written, I think going against the prevailing wisdom in certain areas actually promoted my recovery. I found not only custom orthotics to be a waste of money, but heel lifts also aggravated the situation for me – in fact, the more time I spent barefoot or in my Nike Free’s, the better I felt. Shoes with a “traditional” heel-to-toe drop made things worse. The night splint definitely helped, but what finally got me back on the streets was ART treatment.
    My chiropractor stated that running more miles can actually help one overcome AT by thickening the tendon and making it more able to “work around” damaged fibers, but I haven’t investigated whether there is research to support this.
    I spent most of this marathon season on the edge of recurrence, and finally found that active isolated stretching and foam rolling were the best tools for staying “healthy enough” to train fully. Now I’m counting on your Achilles routine (and a bit of Artemis) to get truly healthy for next year.

    • I also tried eccentric training several times for about two years. The issue was temporary resolved- but always came back when I increased my running. Desperately, I finally switched to forefoot striking and shoes with lower heels. Problem solved. I have now been symptom free for a year.

  2. Thank you for pointing out the difference between insertional and midpoint Achilles tendonitis. It’s a distinction that is often neglected and has important treatment implications. I was recently told I have insertional Achilles tendonitis, which probably explains why weeks of doing the traditional eccentric heel drops hasn’t helped much. I recently modified the heel drops, as you suggest, by doing them on flat ground, and am hopeful I will now finally see improvement.

    • Hi Jeanne,

      I am glad the article was helpful and the specific advice on the insertional tendonitis gave you some new strategies to attack the injury. I hope it clears up quickly for you. Best of luck!

  3. I’ve been following the rehab protocol for about 4 weeks. I’ve been gradually increasing the weight without experiencing any pain during the exercise, however, about an houjr after I’m finished, I start experiencing some pain that varies in intensity from about 1 through 4 on a scale of 10. The pain remains for the rest of the day but it’s gone when I awake in the morning. Any explanation as to what is going on? Do you think I should continue with the program?
    Thanks for any extra help you could give me.

    • Hmm, tough to say exactly, but I think what might be happening is that the tendon fibers are restructuring themselves after you do the lifts. It’s a good thing, since that’s what you want, but the pain is likely the result. I would continue with the program, but you also might want to see a PT, just to be safe.

  4. Hey,

    I have been struggling with insertional AT for about a year now and have been trying to do everything I can to get rid of the swelling and pain for the past 4 months. I play basketball and do a lot of basketball related drills (plyometrics and strength training) that most likely have contributed to my AT. I sleep in night splints and have drastically limited my activity in the last four months however, despite this rest I still have swelling and slight pain when I play. Its significantly better than when I played on it four months ago but I am doing a lot less than I did back then. I’m reluctant to continue playing through the swelling because I don’t want to back track in my recovery. I am only 21 so its very discouraging that my body is rebelling against my typical physical activity. Is complete rest beneficial in any way because relative rest didn’t seem to work? Does insertional AT ever TRULY go away?

    • Sorry to hear you’re having such problems, Alex. I would suggest seeing a podiatrist or PT. It’s possible you have some interference between the heel bone and the achilles. Sometimes, this causes rubbing/tearing between the two and can result in consistent swelling like you’re experiencing.

  5. I’ve been diagnosed with achilles tendonitis on my left ankle before and now I’m having similar symptoms again. This time I’ve begun to question whether tendonitis is the actual condition I’m having. For example, I have no swelling of any kind around the tendon, no crepitation and the area around the tendon isn’t tender even if I squeeze it doesn’t hurt at all. Running doesn’t hurt either. But I do feel something is not right with my ankle when I’m going about my daily business. The feeling isn’t pain it’s more like a mild discomfort. It’s transient in nature.

    I stumbled on this youtube video (http://www.youtube.com/watch?v=DgHoePuZaPw) where they explain that often times similar symptoms can be caused by tightness of the soleus muscle and recommend massaging the calf using a rolling pin. I’ve tried this and indeed it does make the feeling go away. In fact, just a little massaging of the calves does the trick, but the discomfort always returns after a while. What is interesting about the rolling pin is that after an exercise you can use it to locate painful spots on the calf muscles. This is interesting because the discomfort I feel on my achilles tendon correlates with my calf having these painful spots.

    So, is it likely that this is a mild case of achilles tenditinis or a problem with my calf muscles? What do you think?

  6. Yo.
    Thanks for all of your advice. So this insertion tendosis is the worst running injury I’ve ever had (10+ yrs of running 60 mpw). I’ve tried everything without success: eccentrics for months, physical therapy ART, nitro, kineso tapping, total rest, heel lifts. MRI shows less than 5% tear with retro calcaneal bursitis. There really appears to be no Improvement, and just a certain stepping or jogging shortly can exacerbate the tendon which remains symptomatic for days (typically only with gentle stretching). My sports doc (who is also a runner), states it can take up to 9-12 months (holy sh#%). Do you or anyone know any better the Natural History of this disease (insertional), better than “it can take 9-12months”. I mean why 12 months and not 24? What is the median months of return to running? Because at this point I’m going to have to drop a grand on a bike and kiss running goodbye, which would really suck. Anyway, hope all you suffers heal as quick as possible.
    Peace.

    • I have had insertional Achilles tendonopathy since last November. My GP gave me Achilles exercises which, after 6 weeks, did not help at all. I then saw the physiotherapist who told me that the exercises I had been given only made it worse! He has given me the exercises recommended for insertional AT and, though painful, appear to be helping. This week I was actually able to walk the dog with my husband, something I haven’t been able to do for months. No-one has given me a time frame for getting better.

    • I got IAT for the second time now, because of minimalist transistion to fast. The first time it took from sept 2011 to April 2012 to heal. I tried lots of stuff and I’m still not sure what made the difference. Maybe just time was necessary. One error for sure I was making was running everyday, the injury just came back, rest for week and try again. When I started running once every two days, it took 2 weeks and I was fully cured! But I had months of Eccentric calf drop done and I’m sure it help a lot. During the summer 2012 I overtrained again a got a stress fracture on the other foot, but my AT was OK. This winter I got IAT again with just 30Km/week training? Is it the cold? I was running twice a day to go to work, is that a nono? Anyway it’s two months now and still no improvement.

      Wish you all good luck.

  7. Hi, I have (midpoint) archilles tendonitis and the only advice I have been given is to take painkillers and rest it i.e. stop running. I have an upcoming charity run which I still want to take part in and so am unwilling to just ‘rest’ my foot.
    Every step i take on my bad foot results in sharp pain which increases in intensity as i run and even more so after a run. By continuing to run do I risk further damage to the tendon?
    Are there any other techniques you could suggest which will allow me to continue training with less pain?

    Many thanks, Abs

  8. I am now using a walker control after having a cast for 30 days. not sure what type i havebut it seems it will take longer time than usual since I am over forty an I am afraid that I have stopped training and started gaining weight.. any advice please

  9. I have pain just above my right heel and under my heel in the morning. I like to train in the morning but it takes time for my Achilles to warm up I do stretching exercises then after about a mile I’m pain free then after my run the pain comes back but not straight away do you have any suggestions what to do .i recently run a half marathon then I’ve rested for 3weeks I tried a short run but the pain has started to trouble me again

  10. How far down should you go re: the eccentric heel drops? Until there’s resistance, as in, you can’t go any further? Or should you stop before that? Thanks for the helpful information!!

    • Good question. I would say that you should go until you feel a good stretch and then stop there. You shouldn’t try to force it further than what feels comfortable.

      • Thanks for the swift reply! I hope you don’t mind three more quick questions:

        1. Am I supposed to feel the stretch primarily in my calves? That’s what’s happening at the moment.

        2. How slow is “slowly”? I was dropping my heel so slowly that my legs were very sore after 15 reps, so I’m assuming that’s too slow, but I don’t want to go too fast, either. I’ve been dealing with this issue for months now and don’t want to re-injure anything.

        3. I’m feeling a good stretch with the straight-leg version and no stretch with the bent-leg version. Is that a good sign? A bad sign? Am I doing something wrong?

        Sorry to pepper you with so many questions! This treatment is so promising, though, that I want to do it right. Thanks again,

        Ellen

  11. I have had insertional Achilles tendonitis for 2 years now. I am told by the surgeon / ankle specialist I saw that surgery is really the only solution. However the success rate of surgery is not too encouraging.
    Has anyone else had surgery for this condition? What was the outcome?
    I wore a cast for 6 weeks and was pain free for 2 months afterwards but the pain then returned.
    Does anyone recommend shoes (not running shoes – just for everyday wear)??

    • Holly,

      I’m in the a similar boat. I’ve now had IAT for roughly 2.5 years. I took a full year off of running the last time, yet I still can’t run more than twice a week (12 miles total, tops) for fear of it returning full fledged. Currently, my heel aches for a few days after a run and I just wait for it to subside before attempting to get out there again. I’m at a loss, I was thinking surgery was the only answer at this point, but reading your story really discourages me.

      Shoes that are almost over cushioned in the heel seem to make my IAT feel better. I have some Asics Blur33′s that I wear around when not a work or not running.

      As far as running shoes go, I’d like to get some advice, as well. When I originally got IAT I always wore light-weight training shoes and was a heel-to-toe striker. After the year off of running I tried to switch running styles to a mid-foot or fore-foot strike, also in light-weight training shoes. Neither style seemed to make a difference, as my IAT returned after a few months of training. I’ve recently purchased a pair of Newtons and I like them a lot (don’t have to think about mid-foot strike as they almost force you to mid-foot anyway), but they don’t seem to be helping me anymore than my previous shoes (Saucony Kinvara’s).

      • Whit,

        I’m sorry to discourage you re surgery! I think the stats are that for 70% surgery is successful; 20% get no benefit and 10% the pain becomes worse. So quite good stats in a sense! But having trained as a nurse I know that bone can often grow back after being cut away and I guess I just feel that surgery is a last resort thing – for me that is.
        But it would be great to hear from those who have had it.

        I wore an aircast for 6 weeks to give it complete rest and then saw a great physio and began stretching exercises for the Achilles’ tendon. After a while I started doing eccentric heel raises on a step but this brought pain and now (3 months since aircast came off) the pain has returned – largely through just living life! – walking on pavements etc etc (haven’t done any running). I think my mistake has been not having good footwear and at times wearing flat shoes.

        I have just bought a pair of Asics GT 1000 and I noticed the difference immediately. The pain decreased considerably and I didn’t hobble along anymore!
        So this has given me renewed hope. Having achieved a 3 month period pain free and now seeing the difference raising my heel makes (in order to stop the tendon rubbing on the heel,spurs) I have renewed hope. I’ll also start doing the flat ground eccentric heel raises.
        i think swimming may have helped – I did some for a couple of weeks . I may start doing that regularly ( not my favourite thing!)

        Best wishes

  12. not clear exactly “where” insertional achilles is located along the achilles – can U clarify with a diagram or clearer description – I’m unsure as to whether my injury is insertional or mid point ie where exactly is mid point?

  13. I have heard from a lot of others as well that the custom orthotics are a waste of money. But a lot of running stores have advised me to get insoles in addition to the structured shoes (Asics GT 2170) I own. Have you, or any of the readers, had any luck with them?

  14. I have had insertional achilles tendonosis for 2 1/2 years. I wrote about it in an above post. I just wanted to say that it seems to be cured after seeing a Podiatrist.

    He told me that the problem was the subtalar joint in my foot which was slightly dislocated. He manipulated it back into position and it’s better! I can’t believe it – feel like I’ve got my life back after 2 1/2 years of limping around. I’d seen a top surgeon and two physical therapists none of whom saw what it was. The Achilles’ tendon problem was a symptom not the root cause. The surgeon had said I needed surgery on my Achilles’ tendon/ heel bone – SO glad I declined his suggestion.

    So just to say if you have insertional achilles tendonitis see a Podiatrist – just to get another opinion. (They specialise in feet and ankles.) I’m sure most IAT is not caused by a dislodged talus bone but it’s just worth checking out as none of the specialist recognised it.

  15. I have been suffering from midpoint tendinitis for the last 3 weeks when should i start the heel drop protocol – I ran 10k on Sunday and Monday there was pain that gave me a limp. Tuesday that pain has reduced i get through 3-5 reps before i think i should stop (there is pain in every rep but builds per rep)
    I don’t want to be out of action for too long as i have a half marathon in September and don’t want this achilles pain to affect my build up for that.
    Should i wait until the pain lessens before doing the protocol or do as much as i can now and build up?
    Huw

  16. Hi there , i have just started a running club and although at present i am only doing a mile, I am really frustrated as I get very painful achilles while running! The pain eases off completely after a while, but like many others, would be stiff first thing in the morning. I have played ladies football in the past 15+ years ago (I am 43 now) and this has always been a problem for me. I did manage a leg of a marathon 3 years ago but again achilles pain was a big problem. Any advice where my first port of call should be?
    thanks
    una

  17. Hi Jeff,

    I developed bilateral AT in Nov 2011. (Caused simply by too much forefoot landing and too much barefoot running on grass… classic mistakes.) Since then I have read hundreds of articles on the subject and seen several professionals. I want to let you (and everyone else reading) know that this is one of the best articles on the subject that I have come across. There are other good articles out there but this one hits on all the major points and does a good job.

    There are a few things that your article doesn’t mention, which maybe you can expand on:

    1) Should we ice after doing eccentrics? You mention to ice after running but not after eccentrics. Is this because running (and any other concentric-heavy training) is bad and should be iced to inhibit change in the tendon, while eccentrics are good and thus the body should not be hampered from “doing it’s thing”? Most PTs will tell you to ice after these exercises, but I wonder if icing would actually diminish the effect of the eccentrics.

    2) I realize that the jury is still out, but does it seem that by doing enough eccentrics one can fully “heal” themselves of this injury? Or will the tendon always remain in a “weakened” state no matter how much we do of the eccentrics?

    3) WARNING. I would like to caution everyone who is doing eccentrics. Don’t load up on weight too fast, make every change very small and do that weight for a week or more before adding weight. This also goes for the amount that your heel drops below the step. I had worked up to a lot of weight and decided one day that I should be dropping my heal a little lower, thinking it would be necessary for running up hills. There was no pain during the exercises that day but guess what happened the next day? I developed bilateral Plantar Fasciitis and still have it a year later. Just like AT, PF is no joke. PROGRESS SLOWLY and BE CAREFUL. These eccentrics are not idiot-proof. (As I have shown!)

    Thanks Jeff for your answers to my two questions.

  18. Great article thank you. I do not have any Achillies injuries but many around me do and these put them out of action for considerable lengths of time. As a preventitive measure should I routeninly incorporate some eccentric heel drop excercises and is it ok to use the dropped leg to lift my heel up after the drop?

  19. This was a very interesting and helpful article, as someone who’s been running for over 35 years (varying in intensity through the years). My achilles tendon issues (20 years or so?) ebb and flow, with an increase in problems happening with more mileage. I have tried lots-rest, ice, advil, massage, electric stim, night splints, accupuncture. I also went to a place that analyzed my running gait for feedback about tendencies that may affect my achilles. Honestly, I believe that some of us are just simply prone to this despite some earnest efforts to make change and treat it. I have come to accept that this is part of running for me though I try to be careful, stretch more, get new shoes more often and avoid certain types of running that add to the problem (sprints, e.g.). For me, I treat it as one might who has diabetes or some other chronic medical issue–just trying to manage it, or keep the major pain “at bay”. Anyway, I feel for all of us who have it, as running seems so easy without it!!

  20. I’ve never been much of a runner, but recently after completing the C25K for the 3rd time in about 5 years, I was challenged by twice in one day by two different people to forge ahead and set a new goal of running marathons. I’m registered for a 1/2 in November and started training and immediately started having serious calf pain. I have a history of serious plantar fascitis (saw podiatrist, had steroid shots, regular PT, wore boot, heel lifts, better footwear had eventual recovery) and thought it might be relapse related to that and going back to bad daily footwear habits. When I found your article I started connecting my history of PF together with current calf and AT pain and treatment. At first the pain seemed to be referred to the soleus but I was pretty sure it stemmed from midpoint AT. The treatment you recommend has been spot on and amazing–especially compared to recovery rate on earlier PF. I’ve followed your treatment diligently including icing after runs, heating the muscle before runs, diligent eccentric heel drops twice daily, rolling with The Stick, calf strengthening, sleeping with the support and general leg/hip/quad stretches. Over the last 6 weeks having just transitioned from C25K to 1/2 marathon training, the pain has subsided in the calf area but shifted into insertional AT. I’m wondering if I’m stripping away referre pain and getting to the real root of the problem–back to the PF cause which was always AT related. My questions:
    1) Any evidence to back up this assumed connection?
    2) I’ve been wearing low heel Merrells for walking one day a week. Should I ditch them and switch to my higher heeled running shoes for walking, too, for now?
    3) Should I also switch from eccentric to flat heel drops since pain has shifted?
    4) And, as someone asked earlier, should I ice following stretches or not? Thanks!

  21. I’ve been diagnosed with insertional Achiles tendonitis with significant calcification on the posterior exterior of the AT. Fortunately, based on an MRI, it appears that the calcification has been confined to the exterior of the AT, and there is tendon itself has only been compromised minimally. The condition has severely limited any running or tennis and has started to impact my ability to hike. Surgery was presented as the only viable course of action and has been scheduled for next week. First question: Even though the calcification is a result of the problem and not the problem itself, is removal warranted? Second question: Would I be correct in assuming that once the calcification has occurred, no amount of flat-ground eccentric heel drop exercises will remove the calcification? Thanks for an informative article and real world advice on this problem. Ken

  22. Hello, thanks for the informative article…I just started running about 2 weeks ago, nothing very intense (about 4-6 km at an easy pace), and I’ve noticed that my Achilles tendons can get pretty sore during the run. The pain is relieved almost immediately after I stop and it isn’t bothersome except when I run (mostly if there’s an incline). Should I be concerned, or is this just a part of the process of getting used to running again? I guess what I’m wondering is whether soreness in the area while running is a normal thing to experience, since the body is getting used to a new activity. Thanks in advance.

  23. I have dealt with insertional achilles tendonitis for >18 months. I think it was induced by taking Ciprofloxin for a sinusitis. It never really hurt while running but only afterwards and for days later. After 4 marathons and 2 IM triathlons, I was really wanting to fix it.

    So I booted it for > 1 month; then a PRP injection followed by 3 weeks casted; then another 3 weeks booted. How could this thing still be sore(even slightly) with those first steps when I’ve been sitting awhile. . . seems like nearly 3 months would be allow it to cool off completely.

    1. I’m cycling and swimming but not sure what to wait for prior to introducing running again. Should there be zero pain anytime?
    2. How much weight do I add for eccentric (flat surface) contractions? 30 lb dumbbell?
    3. Is the Cipro-induced tendonitis different? In that it takes time to recover and rest for exercise is irrelevant? (and that’s why mine is still slightly tender?)

    Thanks. I need to get back to overtraining. :-)

    • Hi ron

      I wondered how you were getting on now? After a short course of ciprofloxacin I have been having some At issues. Never in my life before taking the medical. I’m a 30 year old runner from uk. I’m just wondering when I’ll be able to run again. Switched ti swimming and cycling fir time being.

  24. I’m 63 now and haven’t run for 25 years. About 28 years ago while running and cycling, I got achilles tendonitis for a year. Stretching was in vogue at the time and still is to judge by some of the bunkum above. After a year I stopped stretching totally and had heavy massage and I’ve never had it back. I’ve cycled about 7000 miles a year since. There is NO scientific evidence of any benefit of stretching and in fact most runners here in Ireland no longer stretch. My daughter is an international runner and I’m a retired doctor and have extensively researched the literature on it. My daughter’s coach who was an Olympian himself often says.. “Did you ever see a racehorse stretch?”
    Stretching is hocus-pocus for runners.

  25. Any specific running shoes that anyone recommends for AT issues. I currently run in the ASICS Nimbus. Has a really cushioned heel which I feel may be adding to the problem. Not sure if there is a shoe guide out there for a shoe with a stiffer heel area.

  26. Achilles problems can be some of the hardest injuries to overcome when training for a marathon. I had server Achilles problems training for the Paris marathon this year. In fact it almost prevented me from running completely. I decided to create a blog to document my struggle and the tips I used to overcome the injury and still finish my goal of a sub 4 hour marathon. You can find my blog here: http://achillesmarathonrecovery.com/ I hope you it interesting and useful.

  27. These exercises are amazing. After the stretches with tightness and soreness gone I am thinking about resuming my running full force. Because I am running Boston in 2014, I am worried about conditioning etc. and right now I run 3X a week and then stretch like mad. These are helping tremendously. Funnily enough I had the same issue with tendon on the other leg last year and did these exercises and was able to qualify respectfully for Boston. Thanks and I am this exercise’s biggest fan.

    • Hi, just wanted to know how much you were running during the eccentric heel drop phase of your rehab. And was it slower that your usual training pace? Thanks for your time.

  28. After researching a lot of material, I initially thought that I might have IAT. But now, I’m unsure if it’s that or non-insertional AT. Because of that, rehabbing it is confusing for me. Does insertional AT have to be directly over the heel bone? Or can it be literally RIGHT above the heel none in that softer spot where the back of the ankle contours inward? I see to have a little tenderness directly on the heel bone, but I also can feel a little tenderness immediately above the bone. It seems like the location of irritation for me is almost right between where the two different types manifest. I’m really unsure. Can anyone give me some insight? Thanks!

  29. I have been suffering from midpoint tendinitis about 3 month with lots of advice from various physios. I tried the eccentric heel drops and the pain subsided within 2 day. I very pleased. however I do have a bump about 7cm’s from my heal. My question is; when do I use ice? I have being icing after heel drops.

  30. Going on one year for midpoint AT. Eccentric heavy load up to 40lbs X12weeks did the trick to get it feeling normal. Then I raced a 5k and did a few other fast runs over a week or so and it CAME BACK. It seems to be a little higher in the tendon now. No pinch tenderness any longer, just a dull ache. I am now slowly increasing mileage (at slower that usual pace) and restarting the drops. I do drops with weight and eccentric stretches after runs daily. I am having slow improvement. Thanks for your time.

  31. Cold Compression therapy really does the trick to keep inflammation down. There is a company that makes great wraps that target the Achilles Tendon that are comfortable practical to wear. I always wear them after a run whether I am hurting or not. This way it prevents the inflammation from building up. If you do consider these wraps, definitely look into purchasing the accessory strap as well. I have small ankles and need the additional cinching to make it a bit tighter. A lot of people do not consider cold as preventative action but it works well for me. Worth a look into at least for some.
    http://www.kingbrand.com/Achilles_Injury_Treatment.php?REF=34PV8

  32. The standard Doctor’s direction for most Achilles Tendon injuries is to rest the injury and let it heal over time. Doctors usually recommend patients try to stay off their ankle as much as possible. To ease discomfort doctors often suggest taking something for the pain. With this course of treatment, in most cases, the Achilles Tendon will heal itself within 1 to 3 months. If you want superior treatment though, anyone can choose the same treatment used for Professional Athletes.

    With more severe or persistent Achilles Tendon injuries, or due to time constraints such as in the case of professional athletes, time is critical and a proactive treatment plan is required. For the most important patients, a regular routine of BFST (Blood Flow Stimulation Therapy) is typically undertaken to significantly accelerate healing. Where rapid recovery and complete healing of the Achilles Tendon are required, BFST is also required.

  33. Hello:
    Had plantar fasciitis since 2000. a year ago, I got some orthotics that seems to have eased the PF but the heel pain didn’t go away. a recent MRI then found insertional achilles tendinosis. not sure how long I have carried it. Ultrasound, myofascial release, exercise over the past two months have significantly eased the heel pain but…it’s not going away, even though I am not running. My physician is recommending PHP therapy. Should I be trying the eccentric exercises? any suggestions? thanks

  34. I was just wondering if doing eccentric heel drops on flat ground would have any good effect on midpoint tendonitis? I am aware the step variation is better for midpoint but i get better results doing the heel drops on the ground, if that makes any sense. Comments??

  35. Seeking advice. Have experienced what appears to be insertional Achilles tendinosis for 5+ years. Have run marathons every year until last year. Injury likely occurred when I changed training to include more speed work for Boston and also trained for Pikes Peak ascent (bad combo) in 2011. I quit running for 5 months this year and then did 4 weeks of eccentric drops. But I’m still getting pain on back of heel when I run. X-rays show what looks like bone spur or growth and I do have a visible bump at back of heel. Out of options I’m considering ESWT treatment. Will it be effective?

  36. I have unbearable pain if I take out my heel cups even for a couple hours. It has been a year and a half and nothing has changed. I don’t dare try anything here because I can’t even walk without a heel cup! (and by unbearable pain, I mean unbearable) Even not moving for a few hours I will feel throbbing pain on my achilles -out of options, any ideas for me? I’m about to move to Colorado where there will be all the mountain trails I’ve always wanted, and yet I think I will be tortured by the fact I can’t run on them instead while I’m there. I was considering getting Hoka One One Conquest shoes but honestly I feel doomed no matter what I do.

  37. I have IAT that is quite uncomfortable at the moment. Can’t run. Been running ~45 mpw with speed work, tempo runs, and a up tempo long run (Hanson’s plan).

    Would an elliptical be a reasonable cross training activity?

    thanks,

  38. Excellent article, thanks.

    Do you know if collagen supplements will help with achilles rehab?

    If heel drops cause new collagen fibers to grow, then perhaps an oral collagen supplement would accelerate the process a bit. Or perhaps not. I’ve searched around the web and can’t find any testimonies to this working. Cheers

  39. Question: Should both legs be exercised even if only one is injured? If so, should one use a box or step to get in the upward position on the injured side?

    I have mild discomfort near the insertion point following some aggressive hill work. Am trying to prevent it from becoming a larger issue using the suggested flat protocol.

    Thanks for all the great info you provide. You’re a great asset to the running/fitness community!

  40. I have had moderate IAT for the past 8 weeks which developed from cross-country skiing after a period of inactivity. I am seeing a physiotherapist, doing daily eccentric heel drops, etc. and I’m seeing a small amount of improvement, but progress seems to be slow.

    In the spring I usually add road cycling to my training regime, will cycling aggravate my IAT?

  41. I twisted my ankle really badly 3 years ago since then my form for walking and playing basketball suffered due to weakness in the foot. I continued playing and got really bad insertional achilles tendonopathy with a retrocalcaneal heel spur. It hurts like crazy after I run even a sort while. Swimming is probably the best exercise for my condition, I’ve given up hope and think this is a condition I will be suffering for the rest of my life. Surgery is really invasive and requires at least a year until you can be active again. I’m gonna see a podiatrist and a Chirac who specialize this type of injury.

  42. Hi,

    I got pain in my tendons from getting 2x500mg ciprofloxacin for 10 days.
    Does anyone know what to do?

    Regards,
    Mark

  43. Dear all – a word of warning for any of you runners that also do explosive sports, eg squash or tennis. I have played the former to a high standard for 25yrs, had minor injuries but never an achilles issue. I also occasionally run. In April I developed what I now know was tendinitis from the running – ignored this for 2 weeks – played squash with a little discomfort then “BANG” = achilles rupture. So into the plaster,crutches, boot, physio routine. So, my message is, if you have these warning signs, you may get away with running, but lay off the explosive stuff. Cheers Richard

  44. Davis! Thanks buddy, cool to see u got all sorts if good info. I got a bump in my achillies this shit was helpful mang! Hope ur well!

  45. I have an achilies insert problem, had it for 7 weeks and no better, I have stopped running and last week only went swimming. I done squats the other day and now can feel it worse than before every so often when I walk. I read your site but confused on what to do as rest along is not working

  46. I’ve had insertional achilles tendonitis since last summer. I tried the eccentric heel drops which honestly didn’t seem to do a thing for me. I finally took 5 months off with no running and the heel was still irritated. What finally helped me was the combination of switching to a shoe with a higher drop (12 mm) and being dedicated with the contrasting bath each day. I’m back up to nearly 30 miles a week and while I occasionally have a bit of a stiff achilles in the morning it isn’t painful at all. I’m going to continue with the contrast bath the rest of the year to be sure but it looks like a good outcome.

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