Achilles Tendon Pain in Runners: What Are the Risk Factors?


Participating in any type of sport puts you at risk for related injuries. For runners, many of these injuries are suspected to be due to overuse or the pounding the body takes from repeated contact between the feet and a variety of terrains.

Achilles tendon injuries and the associated pain are difficult to deal with and can be hard to overcome. Identifying risk factors is complicated by the uncertainty of how these injuries originate. As a runner, you need to be aware of what might put you at risk and how to approach your training in the safest way possible.

An Aching Achilles

As the thickest tendon in your body, the Achilles is easy to spot. It runs down the lower part of the back of the leg, linking the calf muscles to the heel. Depending on the conditions, the tendon can experience as much force as three times your body weight when you run. This force is delivered every time your foot his the ground and may increase when you go up hills or run on difficult terrain.

Between five and 12 percent of all running injuries occur in this large tendon, and men seem to suffer from problems more often than women. Damage to the tendon is usually blamed on repetitive use or excessive strain, but many other factors may be involved in the pathology.

There isn’t much scientific evidence to support any single cause, and some studies done on the subject are undermined by fundamental flaws in design or interpretation. Although doctors and researchers have yet to pin down a specific reason for damage to the Achilles in runners, there are some known risk factors you can learn to avoid.

Risks for Runners

One of the most common reasons for just about any sports injury is doing too much when just starting out. The classic “weekend warrior” participating in heavy sports activity on an infrequent basis is more likely to get hurt than someone who has a regular training regimen. If you’re serious about running, you should develop a plan to increase strength and endurance over time rather than hitting the trails for miles every weekend and regretting it the rest of the week.

Other risk factors for Achilles damage include:

• Weak or fatigued calf muscles
• Ankles with limited range of motion
• Bad running form
• Improper or old footwear
• Age
• Flat or flattened arches
• Running on soft surfaces
• Previous injury to the tendon

Identifying and Treating Achilles Tendon Pain

Since runners can experience many different types of foot, ankle and tendon injuries, it’s important to know the symptoms associated specifically with Achilles damage so that you can take the proper steps to heal.

Injury to the tendon may present with:

• Initial stiffness or ache during activity
• Worsening pain when running on hills
• Loss of ankle flexibility
• Redness or heat over the painful spot
• Visible lump of scar tissue

These symptoms often manifest close to the heel and impede your ability to run or even perform normal daily tasks. Any pain you experience during or after running shouldn’t be ignored. Although it may be tempting to “push through the pain,” you’ll only make the problem worse if there is damage to the Achilles.

See a doctor or qualified practitioner of sports medicine if you suspect a tendon injury. Many treatment protocols for this type of injury exist, and these are as wide and varied as the suspected causes of Achilles injury. Follow the prescribed plan until the tendon is completely healed, and heed any additional advice when the time comes to return to running.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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