Achilles tendinopathy

We start with what changed before the tendon got sore. Common triggers are more hills or trail, a faster pace, new shoes, a first week of boot-packing, or a new season. Then we examine the tendon. We find where it is tender, in the middle of the cord or lower down where it joins the heel bone, because the two need slightly different loading. We check how far the ankle bends, and test calf strength and endurance, usually by counting single-leg heel raises on each side. We watch you walk, hop and run.

We also check it is the tendon, not the small fluid sac behind the heel bone (the bursa), the sole of the foot, or a sore bone. If something else is likely, we explain what we found.

Tendons get stronger with the right load, so exercise is the main treatment. We begin with calf raises the tendon can manage, often on both legs on flat ground. Then we make them gradually heavier: one leg, slow and weighted, then springy work and hopping. Some pain during and after is allowed, as long as it is no more than a little worse and has settled by the next morning.

Alongside the loading:

• A small heel raise: early on, a heel raise or heel cup in the shoe takes some stretch off the tendon, especially where it joins the heel bone. See splints and bracing.
• Running and hiking load: managed, not stopped. We work out how much the tendon can take now, and adjust as it improves.
• Hands-on treatment: for a tight calf, to ease pain while the exercises take effect.
• A running assessment: physiotherapists certified by The Running Clinic film you on a treadmill in slow motion and look at your stride and shoes. See running assessment.
• Shockwave therapy: one option for pain that lingers. Shockwave therapy sends focused sound waves into the sore tendon, alongside the exercises, not instead of them.

As the tendon takes more, the work moves into strength and conditioning, building toward what your sport or job asks.

The return to running and hiking goes in steps, judged by the tendon rather than the calendar. Runners usually start with short runs on flat ground, then add time, then pace, then hills. Hikers and boot-packers build climb and distance the same way, because steep climbs load the calf and the tendon hardest. You move to the next step when the current one leaves the tendon no stiffer the next morning.

Our Run RAD sheet, a warm-up from our physiotherapists, is there to print and do before each run. Keep the calf raises going after the pain settles: a strong calf helps the tendon cope with the next season.

Book an assessment if the tendon is stiff most mornings, if pain comes on earlier in each run or hike, or if the cord has thickened. Come in too before a big step up in training, such as a first season of ski touring, if the tendon has been sore before.

Go to the emergency department right away, or call 911, if any of these happen:

• you felt a sudden snap or pop at the back of the heel and cannot rise onto your toes on that leg
• one calf is swollen, warm and painful
• the tendon is hot, red and swollen, and you have a fever
• your foot is numb, cold or pale