Should you rest or exercise with Achilles tendon pain?

What is Achilles tendinopathy?

The Achilles tendon connects the calf muscles to the heel bone and is loaded heavily during walking, running and jumping. Achilles tendinopathy is a painful condition in which the tendon becomes irritated and less able to tolerate load. It commonly affects the middle portion of the tendon, a few centimetres above the heel, or the point where it attaches to the heel.

It is common in runners and people who increase activity suddenly, but it also affects less active people, particularly in middle age. Pain and stiffness are typically worst in the morning or at the start of activity, easing as the tendon warms up, and may return after exercise.

Why is rest not usually enough?

Rest can reduce pain in the short term, but tendons need load to adapt and strengthen. Complete rest allows the tendon and calf muscles to weaken further, so symptoms often return when activity resumes.

A clinical practice guideline on midportion Achilles tendinopathy recommends resistance exercise to reduce pain and improve function, together with education about load management 2.

Which exercises help?

A randomised trial of 58 people with Achilles tendinopathy lasting more than three months compared 12 weeks of eccentric training, lowering the heel slowly off a step, with heavy slow resistance training using weighted calf raises 1. Both groups improved significantly in function and pain, and improvements were maintained at 52 weeks 1.

Patient satisfaction at 12 weeks was 100 per cent with heavy slow resistance and 80 per cent with eccentric training, and exercise session compliance was 92 per cent compared with 78 per cent 1. The type of exercise can therefore be chosen according to preference and practicality.

How much pain is acceptable during exercise?

A common approach is to allow mild to moderate discomfort during exercise, provided it settles by the next morning and morning stiffness does not worsen. If symptoms flare, the load is reduced rather than stopping completely.

Loading programmes usually take several months, and many people continue for longer. Improvement is often gradual, with good and bad days along the way.

Can I keep running with Achilles pain?

Many people can continue running at a reduced volume or intensity if pain stays within acceptable limits and does not build up from one day to the next. Hill running, speed work and jumping place higher loads on the tendon and may need to be reduced temporarily.

Cross-training, such as cycling or swimming, maintains fitness while the tendon recovers. Footwear changes, such as a small heel raise, may reduce symptoms for some people in the short term.

What other treatments are used?

Shockwave therapy may be considered for persistent symptoms that have not responded to a well-conducted loading programme. Steroid injections into or around the Achilles tendon are generally avoided because of concerns about tendon weakening and rupture.

Surgery is rarely needed and is reserved for persistent, disabling symptoms after many months of appropriate rehabilitation.

How does insertional Achilles tendinopathy differ?

Insertional Achilles tendinopathy causes pain where the tendon attaches to the heel bone, rather than in the middle of the tendon. It can be aggravated by shoes that press on the back of the heel and by stretching the calf over the edge of a step.

Loading exercises for insertional tendinopathy are often performed on flat ground rather than dropping the heel below the level of a step. Heel lifts and footwear that avoids pressure on the back of the heel may help.

When is Achilles pain an emergency?

A sudden sharp pain at the back of the ankle, often described as feeling kicked, sometimes with a snapping sound, followed by difficulty walking or standing on tiptoe, may indicate an Achilles tendon rupture. This needs urgent assessment, ideally the same day.

Swelling, redness and heat around the tendon with fever, or Achilles pain in both legs together with other joint pains, should also be assessed.

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