"Why does my heel hurt after trail running? Is it tendinopathy?"

Achilles tendon pain typically comes in 2 forms: mid-portion and insertional. These refer to the location of the symptoms with regard to the tendon. Mid-portion (or midsubstance) tendon pain typically occurs above the heel, within the meaty part of the tendon. Insertional tendon pain usually occurs right around the back of the heel bone and sometimes can feel like shooting, tingling, nerve-y pain; particularly when the foot is dorsiflexed (toes pulled up toward the sky). Often with achilles pain, in the earlier stages, symptoms tend to be worse early on during running and then afterwards; with many people experiencing a 'warm-up effect' where symptoms are minimal during activity. Naturally, there are many other issues that could be occurring if you're experiencing heel pain, so it's best to have professional medical assessment. That being said, let's dive a bit deeper.

Here are some quick signs

• Pain localized to the tendon or heel with morning stiffness (worse after getting out of bed but loosens up after walking around for a bit)

• Pain increases with rapid uphill or higher-speed running

• Thickening or crepitus (sounds 'creaky') at the tendon

Immediate actions

• Get it checked out! The issue could be a variety of things and you don't want to delay the proper treatment.

• For a sensitive tendon, we may need to reduce the overall load initially (shorten runs, reduce inclines speed) but avoid complete immobilization - this only weakens tendons further.

• Don't stretch it, often tendons get more irritated from stretching

• Use a heel wedge/lift in your shoe(s) to take some stress off of the area temporarily

• Temporary substitution (biking, swimming) for aerobic fitness

Simple self-tests

• Single-leg heel raise: on one leg, raise up onto tip toes, then slowly lower back down. Repeat as many reps as possible and compare on each side. Looking for pain or weakness.

• Single leg hop test: hop in place on one foot, if there's pain or poor elasticity (not springy) on one or both sides it could indicate a tendon issue

• Half kneeling ankle test: check your dorsiflexion range of motion in a half kneeling position. Here's a good example of that test. You may find that the symptomatic side is far more limited, which can be addressed with physical therapy.

Rehab overview

1. Pain management & load reduction — isometrics for pain control

   1. Initially it can be important to reduce load on the tendon to allow any acute inflammation to settle down. Ultimately, the structure of the tendon needs to be developed to allow it to function normally again. Isometric exercise can be a great starting point to reduce pain and to initiate tendon rebuilding. An isometric exercise is simply contracting and holding one position against resistance or and immovable object. This could be holding a 2 legged calf raise for 30-60 seconds, for example.

2. Strength phase — progressive heavy-slow resistance and eccentric loading 3×/week

   1. Once symptoms are well managed the training should progress toward heavier loading to really improve the tensile strength and elasticity of the tendon. Weighted calf raises (sitting or standing) are an important component of tendinopathy rehab. Developing a stiffer tendon will not only help to recover from tendinopathy but also improve running capabilities, particularly for trail runners who need their lower limb to constantly adapt to variable surfaces.

3. Function & return — plyometrics, graded hill/repeat sessions

   1. Ultimately it's important to train the tendon to withstand rapid loading again. Plyometric exercise (jumping/hopping/bounding etc.) is a key component of any successful tendon rehab plan in combination with continued resistance training.

General return-to-run criteria

• Pain ≤2/10 during and after runs

• Single-leg heel raise ≥25 reps with minimal pain

• Single-leg hop x30 seconds without pain

• At least 1.5x bodyweight seated calf raise

• >.5 reactive strength index (RSI) for each leg.

Prevention tips

• Gradual weekly mileage increases (≤10%)

• Routinely integrate strengthening exercise for calf and achilles

• Improve ability to share load between calf, hamstrings, quads and hips.

• Avoid drastic change in shoe type and terrain (gradually transition if you're going to make a change)

FAQs

• “How long does Achilles tendinopathy take to heal?”

  • Tendons take a long time to get stronger and stiffer. It can take weeks to months for a tendon to return to a more normal state. With patience and gradual progression, it is possible however.

• “Should I use a heel lift or eccentric exercises for Achilles pain?”

  • Heel lifts tend to be particularly helpful for insertional achilles pain. Eccentric exercises like the commonly used 'Alfredson protocol' can be useful initially, for mid-portion pain but may not be as useful for insertional symptoms.

If you're a trail runner dealing with heel pain, schedule a free consultation call to learn more about how to overcome your symptoms and run without pain again!