Why Does My Achilles Tendon Hurt When I Start Running or Get Out of Bed?
Why Does My Achilles Tendon Hurt When I Start Running or Get Out of Bed? A Physical Therapist Answers
By Nova Physical Therapy | North Hollywood, CA
You get out of bed in the morning and the first few steps feel stiff or painful behind your ankle.
After walking around for a while, it starts feeling better.
Then you go for a run.
The first several minutes are uncomfortable, but once you warm up, the pain decreases enough that you can keep going.
You may start wondering:
“If it gets better while I run, is it okay to keep running?”
“Why does my Achilles hurt most in the morning?”
“Do I need to stretch it?”
“Should I be doing eccentric heel drops?”
“Can shockwave therapy help?”
“Could my Achilles rupture?”
Pain and stiffness around the Achilles tendon can occur for several reasons. One possible presentation is Achilles tendinopathy, which commonly affects active adults and runners but can also occur in people who are not highly active. APTA
Symptoms alone, however, cannot establish a diagnosis.
A physical therapist can evaluate movement, ankle mobility, calf muscle performance, tendon-related functional limitations, walking and running tolerance, and other relevant findings while screening for presentations that warrant medical evaluation.
Learn more about Nova Physical Therapy's services at mynovapt.com/services/.
Patient Question
“My Achilles hurts when I first get out of bed and during the beginning of my runs, but sometimes it feels better after I warm up. Is it safe to keep running, and can physical therapy help?”
The Short Answer
Achilles pain that is noticeable during the first steps in the morning or at the beginning of activity can occur with Achilles tendinopathy, but that symptom pattern alone does not confirm the condition.
One of the most important questions is:
How much load can your Achilles currently tolerate?
The Achilles tendon is exposed to substantial forces during walking, running, jumping, hills, and faster running.
Symptoms can sometimes develop when training demand changes faster than the tendon and calf complex are prepared to tolerate.
The current APTA/JOSPT clinical practice guideline for midportion Achilles tendinopathy, revised in 2024, recommends tendon-loading exercise as a first-line treatment and specifically states that patients should exercise at loads as high as tolerated, with loading performed at least three times per week. Complete rest is not recommended for people with nonacute midportion Achilles tendinopathy; activity within pain tolerance may be continued while rehabilitation is performed. APTA
This does not mean everyone with Achilles pain should simply keep running.
Sudden sharp pain, a pop, substantial weakness, inability to push off, significant swelling, or difficulty walking can indicate a different and potentially more serious presentation requiring prompt medical evaluation.
What Is the Achilles Tendon?
The Achilles tendon connects the calf muscle complex to the heel bone.
It plays an important role when you:
walk
rise onto your toes
climb stairs
run
jump
and
push off the ground.
Running places substantially greater demand on the tendon than ordinary walking.
That is not inherently harmful.
Tendons are designed to tolerate load.
The challenge occurs when the demand being placed on the tendon exceeds its current capacity and adequate adaptation or recovery does not occur.
Why Does My Achilles Hurt in the Morning?
Morning stiffness is commonly reported with Achilles tendinopathy.
A patient may say:
“The first ten steps are the worst.”
After moving around, the ankle may feel more comfortable.
That symptom behavior can be clinically useful, but it does not tell us everything about the condition.
A physical therapist may ask whether morning symptoms are:
improving
staying the same
or
becoming progressively worse.
Changes in morning stiffness can also provide useful information about how the tendon is responding to recent activity and rehabilitation.
Why Does My Achilles Hurt at the Beginning of a Run but Then Feel Better?
Some people with Achilles tendon symptoms experience a warm-up phenomenon.
Pain or stiffness may be noticeable at the beginning of activity and then decrease as the person continues moving.
This can create a trap.
A runner may think:
“The pain disappeared, so the problem must be gone.”
But symptom reduction during a run does not necessarily mean the tendon tolerated the entire training session well.
A more useful question is:
What happens later that day and the next morning?
If a run feels manageable while you're doing it but produces substantially worse symptoms afterward or the following morning, the current running load may need to be reconsidered.
Is Achilles Tendinitis the Same as Achilles Tendinopathy?
The terms are often used interchangeably in everyday conversation, but tendinopathy is generally preferred for persistent tendon-related pain and dysfunction.
The older term tendinitis implies inflammation is the primary process.
Persistent tendon disorders are more complex than inflammation alone.
For patients, the terminology matters less than understanding this:
Persistent Achilles pain is not simply something that needs to be “rested until the inflammation disappears.”
Appropriate progressive loading is a major component of contemporary rehabilitation for midportion Achilles tendinopathy. APTA
Where Does Achilles Tendinopathy Hurt?
Location matters.
Two commonly discussed presentations are:
Midportion Achilles Tendinopathy
Symptoms are typically located in the tendon above its attachment to the heel.
Insertional Achilles Tendinopathy
Symptoms occur closer to where the Achilles tendon attaches to the heel bone.
These presentations should not automatically receive identical exercise programs.
For example, exercises that move the ankle into substantial dorsiflexion may create more compression at the tendon insertion and may need modification in someone with an insertional presentation.
The 2024 APTA/JOSPT guideline specifically addresses midportion Achilles tendinopathy, so its recommendations should not automatically be generalized to every Achilles disorder. APTA
Why Did My Achilles Start Hurting?
There is rarely one universal explanation.
A physical therapist may explore recent changes such as:
increased weekly running distance
more running days
speed training
hill training
jumping
a new sport
returning after a break
changes in footwear
or
changes in overall physical activity.
The question is not simply:
“What caused the tendon to become damaged?”
A more useful rehabilitation question is:
“What does this tendon currently need to tolerate, and how do we progressively rebuild that capacity?”
Can Hills Make Achilles Pain Worse?
They can increase demand on the calf-Achilles complex.
Uphill running generally requires greater propulsion, and hill training can represent a meaningful change in training intensity.
For a runner whose tendon is already sensitive, adding:
hills
speed work
and
higher mileage
at the same time can substantially change overall loading.
This does not mean hills are bad for the Achilles.
The goal is eventually to tolerate the activities the runner wants to perform.
The issue is progression.
Can Speed Work Aggravate the Achilles?
Potentially.
Running faster changes the demands placed on the lower extremity and Achilles tendon.
A runner may tolerate easy mileage but develop symptoms after adding:
intervals
sprints
track workouts
or
faster race-pace training.
This is why asking only:
“How many miles are you running?”
doesn't tell the entire story.
Ten easy miles and ten miles containing intense hill repeats or speed work are not the same training stimulus.
Is This Relevant for Los Angeles Marathon Training?
Yes.
The 2027 ASICS Los Angeles Marathon is scheduled for March 7, 2027, and organized local marathon-training programs are already underway. The Burbank/Encino Fleet Feet program, for example, began September 15, 2026. The McCourt Foundation
That makes October a particularly relevant time for runners to pay attention to early changes in:
morning Achilles stiffness
calf fatigue
running tolerance
and
recovery between training sessions.
The goal is not to make runners afraid of increasing mileage.
Training must progress if you are preparing for a marathon.
The goal is to build capacity progressively enough that your body can adapt to the increasing demands.
Should I Stop Running Completely?
Not automatically.
The 2024 APTA/JOSPT guideline specifically advises that complete rest is not indicated for people with nonacute midportion Achilles tendinopathy.
Patients may continue recreational activity within pain tolerance while participating in rehabilitation. APTA
However, that recommendation applies to an appropriately evaluated presentation.
It does not mean:
“Run through any amount of Achilles pain.”
Running may need to be temporarily:
shortened
slowed
reduced in frequency
or
modified to remove hills or speed work.
In other cases, temporarily stopping running may be appropriate.
The decision depends on the symptom behavior, functional findings, severity, and whether a more serious injury is suspected.
Should I Stretch My Achilles?
Stretching is not automatically required for every person with Achilles pain.
The 2024 clinical practice guideline states that calf stretching may be used for people with midportion Achilles tendinopathy who have limited ankle dorsiflexion with the knee flexed or extended. APTA
That is very different from saying:
“Everyone with Achilles pain needs aggressive stretching.”
If meaningful mobility restriction is present, stretching may be useful.
If it is not present, treatment priorities may be different.
Insertional symptoms may also require additional consideration because moving deeply into ankle dorsiflexion can increase compression at the tendon insertion.
Are Eccentric Heel Drops the Best Exercise?
Eccentric heel-lowering exercises became extremely popular for Achilles tendinopathy.
They can still be useful.
But they are not the only evidence-supported loading strategy.
The current clinical practice guideline recommends tendon-loading exercise rather than requiring one specific contraction type. APTA
A 2026 systematic review and meta-analysis of eccentric exercise similarly concluded that eccentric exercise can be a first-line option within a load-based program, but it was not clearly superior to other exercise approaches for pain relief. PubMed
Depending on the patient, loading may include:
isometric exercise
isotonic calf raises
eccentric loading
heavy resistance exercise
and eventually
faster or more elastic activities.
The important principle is progressive tendon loading—not loyalty to one famous exercise.
How Heavy Should Achilles Exercises Be?
This is where rehabilitation often becomes too easy.
The 2024 guideline recommends tendon-loading exercise with loads as high as tolerated, performed at least three times per week for midportion Achilles tendinopathy. APTA
That does not mean starting every patient with extremely heavy resistance.
It means the program should eventually provide enough stimulus to improve the capacity required for the person's goals.
A runner needs considerably more Achilles capacity than is required to walk from the couch to the kitchen.
Rehabilitation should reflect that difference.
Is Pain During Achilles Exercise Always Bad?
Not necessarily.
For an appropriately evaluated tendinopathy presentation, some discomfort during loading does not automatically mean tissue damage is occurring.
The patient's response should be monitored.
Important considerations include:
pain intensity
movement quality
symptoms after exercise
next-morning response
and
whether overall function is improving.
The goal is not to provoke as much pain as possible.
Nor is the goal necessarily to avoid every sensation.
Loading should be individualized and progressed according to tolerance and clinical response.
Do I Need to Strengthen My Soleus?
The calf complex includes both the gastrocnemius and soleus.
Because these muscles function differently depending partly on knee position, rehabilitation may include calf strengthening with both:
a relatively straight knee
and
a bent knee.
This can help develop calf capacity across different positions.
However, exercises should be selected based on the patient's presentation and goals rather than because one muscle is assumed to be the sole cause of symptoms.
When Do Hopping and Plyometrics Become Important?
Running is not a slow-strength exercise.
It involves repeated storage and release of energy through the lower extremity.
A runner may become strong enough to perform heavy calf raises but still lack the capacity required for:
hopping
faster running
hills
sprinting
or
sport.
Later rehabilitation may therefore include progressively faster and more elastic loading when appropriate.
The progression should reflect the activity the patient wants to return to.
Can Shockwave Therapy Help Achilles Tendinopathy?
This is an area where the evidence has changed meaningfully.
Shockwave therapy has been promoted for Achilles tendinopathy for years.
However, a May 2026 JOSPT systematic review and meta-analysis examined nine randomized controlled trials involving 557 participants with midportion or insertional Achilles tendinopathy.
The authors concluded that shockwave therapy did not provide a clinically meaningful benefit in pain and disabilityand should not currently be considered a routine treatment for either midportion or insertional Achilles tendinopathy. PubMed
For insertional Achilles tendinopathy specifically, shockwave showed no clinically meaningful benefit over sham treatment, with low-to-moderate certainty evidence.
For midportion tendinopathy, one trial favored shockwave over sham, but participant blinding was not successfully demonstrated.
The review also found no clear advantage of focused versus radial shockwave therapy. PubMed
This is important patient education.
Shockwave therapy should not be marketed as a guaranteed cure for Achilles tendinopathy.
Current evidence supports prioritizing active rehabilitation and progressive tendon loading rather than relying on shockwave as a routine passive treatment.
But Haven't Other Studies Found Benefits From Shockwave Therapy?
Yes, and this is why evidence-based practice requires looking beyond individual studies.
A newly published October 2026 systematic review and network meta-analysis evaluated shockwave therapy across multiple tendinopathies, not just the Achilles tendon. PubMed
Different tendons, shockwave protocols, comparators, and study designs can produce different conclusions.
Evidence supporting shockwave for one condition should not automatically be transferred to another.
For Achilles tendinopathy specifically, the 2026 JOSPT review is especially relevant because it focused directly on randomized trials involving midportion and insertional Achilles presentations.
The practical message is not:
“Shockwave never works.”
It is:
Current evidence does not support treating shockwave as routine first-line care for Achilles tendinopathy.
Can Physical Therapy Help?
Yes, when the presentation is appropriate for physical therapy.
The strongest contemporary rehabilitation emphasis for midportion Achilles tendinopathy is progressive tendon-loading exercise. APTA
Depending on the evaluation, physical therapy may address:
- Calf strength
- Calf endurance
- Ankle mobility
- Tendon-loading tolerance
- Walking tolerance
- Running tolerance
- Single-leg function
- Hopping and elastic loading
- Training progression
- Hill tolerance
- Speed tolerance
- Return to sport
- Patient education
Physical therapy can also help determine whether the symptoms appear consistent with a musculoskeletal presentation appropriate for rehabilitation or whether medical evaluation is warranted.
The goal is not simply:
“Make the Achilles stop hurting while you're resting.”
For a runner, the eventual goal may be:
“Build enough capacity for the Achilles to tolerate running again.”
Those are very different objectives.
What Does Research Say?
1. 2024 APTA/JOSPT Clinical Practice Guideline
The Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association published its revised clinical practice guideline for midportion Achilles tendinopathy in December 2024.
The guideline contains 28 recommendations addressing examination, outcome measures, and interventions.
Most importantly for rehabilitation, it recommends tendon-loading exercise as a first-line treatment, with loads as high as tolerated and exercise performed at least three times per week.
It also states that complete rest is not indicated for nonacute midportion Achilles tendinopathy and that patients may continue recreational activity within pain tolerance. APTA
2. 2026 Eccentric Exercise Meta-Analysis
A 2026 systematic review and meta-analysis found that eccentric exercise produced greater pain reduction than physical modalities in the included comparisons but produced pain outcomes comparable with other exercise approaches.
The authors concluded that eccentric exercise can serve as a first-line option within load-based rehabilitation, but it should not be considered an independently superior gold-standard exercise. PubMed
That supports a broader principle:
Tendons need appropriate progressive loading; they do not necessarily require one specific loading recipe.
3. May 2026 Shockwave Meta-Analysis
Korakakis and colleagues published a systematic review and meta-analysis in JOSPT involving nine randomized trials and 557 participants.
They found no clinically meaningful benefit of shockwave therapy for pain and disability across Achilles tendinopathy presentations and concluded that shockwave should not currently be considered routine treatment for either insertional or midportion Achilles tendinopathy. PubMed
4. October 2026 Shockwave Network Meta-Analysis
A broader systematic review and network meta-analysis published in October 2026 evaluated extracorporeal shockwave therapy across different tendinopathies.
This growing literature demonstrates why treatment claims need to be condition-specific.
Evidence from plantar heel pain, calcific shoulder tendinopathy, or another tendon condition cannot automatically establish effectiveness for Achilles tendinopathy. PubMed
What Happens During a Physical Therapy Evaluation?
At Nova Physical Therapy, an evaluation for Achilles-region pain may include, when appropriate:
- Detailed symptom history
- Exact location of symptoms
- Morning stiffness
- Walking tolerance
- Running history
- Recent mileage changes
- Running frequency
- Hill and speed training
- Ankle range of motion
- Calf muscle performance
- Single-leg heel-raise performance
- Functional strength
- Single-leg control
- Hopping when appropriate
- Running assessment when appropriate
- Footwear and training changes
- Screening for findings requiring medical referral
We may ask:
Where exactly does the pain occur?
How long are you stiff in the morning?
Does it improve after warming up?
What happens after your run?
How does it feel the following morning?
Did you recently increase mileage?
Did you add hills or speed work?
Can you perform a single-leg heel raise?
Can you walk normally?
Was there a sudden pop or sharp pain?
What are you trying to return to?
For one patient, the goal may be ordinary walking.
For another, it may be recreational basketball.
For another, it may be a 5K.
And for someone training locally this fall, it may be the 2027 Los Angeles Marathon.
The rehabilitation demands should reflect the goal.
When Should You Seek Medical Attention?
Not every painful Achilles tendon is a routine tendinopathy presentation.
Seek prompt medical evaluation if you experience:
- A sudden pop or snapping sensation
- Sudden severe pain in the Achilles region
- Significant new swelling or bruising
- Inability to push off normally while walking
- Marked difficulty walking
- Sudden substantial weakness
- Inability to rise onto the toes that is new after an injury
- Significant trauma
- Rapidly worsening symptoms
- Redness, warmth, fever, or other signs suggesting illness
- Significant calf swelling or other symptoms concerning for a vascular problem
An Achilles tendon rupture can occur suddenly and requires appropriate medical assessment.
Do not assume that every sudden Achilles injury is:
“just tendinitis.”
A physical therapist should refer when the examination raises concern for rupture or another condition requiring medical evaluation.
Why Patients Choose Nova Physical Therapy
We Care.
At Nova Physical Therapy, we don't believe every person with Achilles pain should automatically receive:
the same stretch
the same heel-drop program
the same machine-based treatment
or
instructions to stop running indefinitely.
One patient may say:
“It only hurts during the first mile.”
Another:
“My first steps every morning are painful.”
Another:
“I doubled my mileage and added hills.”
Another:
“I can walk normally, but I can't hop comfortably.”
Another:
“I felt a sudden pop and now I can't push off.”
Those presentations should not be treated as though they are identical.
Our approach emphasizes:
individualized physical therapy evaluation
evidence-informed rehabilitation
progressive tendon loading
calf strength and endurance
functional exercise
appropriate running progression
patient education
and
medical referral when findings warrant additional evaluation.
We want to know more than:
“Does your Achilles hurt?”
We want to understand:
What do you need your Achilles to do?
Walk around the neighborhood?
Work an eight-hour shift?
Hike?
Play basketball?
Run a 5K?
Or train for a marathon?
The rehabilitation program should progressively prepare you for the activities that matter to you.
That's part of what We Care means to us.
Frequently Asked Questions
Why does my Achilles hurt when I first get out of bed?
Morning stiffness and pain can occur with Achilles tendinopathy, but this symptom alone cannot establish the diagnosis.
Why does my Achilles hurt at the beginning of a run and then feel better?
Some tendon-related presentations demonstrate a warm-up phenomenon. Improvement during the run does not necessarily mean the tendon tolerated the entire training session well, so later and next-morning symptoms are also important.
Can I keep running with Achilles tendinopathy?
For appropriately evaluated nonacute midportion Achilles tendinopathy, the current clinical practice guideline does not recommend complete rest. Running or other activity may need modification according to symptoms and functional response.
Should I stretch my Achilles?
Stretching may be useful when clinically relevant ankle mobility limitations are present, but it is not automatically required for every patient.
Are eccentric heel drops the best treatment?
They are one useful loading strategy, but current evidence does not establish eccentric exercise as universally superior to other appropriately prescribed loading programs.
Should Achilles exercises be painful?
Some discomfort may be acceptable in certain tendon-loading programs, but exercise response should be individualized and monitored rather than intentionally provoking substantial pain.
How often should I strengthen my Achilles?
The 2024 clinical practice guideline recommends tendon-loading exercise at least three times per week for midportion Achilles tendinopathy, using loads as high as tolerated.
Can hills aggravate Achilles pain?
Hill running can increase calf-Achilles demand and may need temporary modification if it substantially aggravates symptoms.
Can speed training aggravate my Achilles?
It can increase tendon demand. Speed work may need modification during rehabilitation and can later be progressively reintroduced when appropriate.
Does shockwave therapy help Achilles tendinopathy?
A 2026 JOSPT meta-analysis found no clinically meaningful overall benefit and concluded that shockwave should not currently be considered routine treatment for midportion or insertional Achilles tendinopathy.
What's the difference between insertional and midportion Achilles tendinopathy?
Insertional symptoms occur near the tendon attachment to the heel, while midportion symptoms occur farther up the tendon. Rehabilitation considerations can differ.
When should I worry about Achilles pain?
A sudden pop, severe acute pain, substantial swelling or bruising, new inability to push off, or major weakness warrants prompt medical evaluation.
Schedule an Evaluation
If Achilles pain or stiffness is interfering with your ability to:
- Walk
- Run
- Climb stairs
- Exercise
- Hike
- Play sports
- Perform heel raises
- Increase your training
- Prepare for a race
an individualized physical therapy evaluation can help identify relevant physical and functional limitations and determine whether rehabilitation is appropriate.
For runners, the goal isn't necessarily to avoid running forever.
The goal is to understand current capacity, appropriately manage training demands, progressively rebuild strength and tendon-loading tolerance, and work toward the running demands that matter to you.
Learn more at https://mynovapt.com/services/.
Disclaimer
This article is intended for general educational purposes only. It does not constitute medical advice, medical diagnosis, imaging interpretation, individualized exercise prescription, treatment recommendations, or clearance to run or participate in sports.
Achilles pain, morning stiffness, swelling, weakness, or running-related symptoms cannot independently establish Achilles tendinopathy, Achilles tendon rupture, bursitis, bone injury, inflammatory disease, neurological involvement, vascular disease, or another medical condition.
Physical therapists in California evaluate movement, physical impairments, muscle performance, functional limitations, and activity restrictions within the California Physical Therapy Practice Act. Physical therapists do not diagnose disease.
Patients with sudden severe Achilles pain, a pop, significant new weakness, substantial swelling or bruising, inability to push off, significant trauma, or other concerning findings should receive appropriate medical evaluation.
Exercise, load modification, manual therapy, shockwave therapy, orthoses, or other interventions cannot guarantee pain relief, tendon healing, successful return to running, avoidance of surgery, or prevention of recurrence.
Individual results vary.
References
- Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira DS, Martin RL. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision – 2024. Journal of Orthopaedic & Sports Physical Therapy. 2024;54(12):CPG1-CPG32.
https://doi.org/10.2519/jospt.2024.0302 - American Physical Therapy Association. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision – 2024.
https://www.apta.org/patient-care/evidence-based-practice-resources/cpgs/achilles-pain-stiffness-and-muscle-power-deficits-midportion-achilles-tendinopathy-revision-2024-cpg - Korakakis V, Kotsifaki R, Sotiralis Y, Malliaras P. Shockwave Therapy for Midportion and Insertional Achilles Tendinopathy: A Nail in the Coffin? A Systematic Review With Meta-Analysis. Journal of Orthopaedic & Sports Physical Therapy. 2026;56(5):282-299.
https://doi.org/10.2519/jospt.2026.13985 - The Efficacy of Eccentric Exercise in the Treatment of Achilles Tendinopathy: A Systematic Review and Meta-Analysis. 2026. PubMed PMID: 42021217.
https://pubmed.ncbi.nlm.nih.gov/42021217/ - Guo NY, Wang SQ, Liu W, Mao ZM, Wang JQ, Xu BB. The Effect of Extracorporeal Shockwave Therapy in Tendinopathy: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.Orthopaedic Surgery. 2026;18(10):2060-2082.
https://doi.org/10.1111/os.70408 - American Physical Therapy Association. Achilles Tendinopathy Clinical Summary.
https://www.apta.org/patient-care/evidence-based-practice-resources/clinical-summaries/achilles-tendinopathy - Physical Therapy Board of California. Physical Therapy Practice Act.
https://www.ptbc.ca.gov/laws/pt_practice_act.shtml - The McCourt Foundation. 2027 ASICS Los Angeles Marathon. March 7, 2027.
https://www.mccourtfoundation.org/event/los-angeles-marathon/