Why Does My Achilles Tendon Hurt When I Walk or Run?

Why Does My Achilles Tendon Hurt When I Walk or Run? A Physical Therapist Answers

By Nova Physical Therapy | North Hollywood, CA

Patient Question

“Why does the back of my ankle hurt when I walk, run, climb stairs, or exercise, and could it be my Achilles tendon?”

The Short Answer

Pain around the Achilles tendon can occur for several reasons. One common musculoskeletal presentation is Achilles tendinopathy, which is generally characterized by localized tendon pain associated with activities that load the Achilles tendon.

Running, jumping, walking uphill, climbing stairs, and repeatedly pushing off the foot can all increase the physical demands placed on the Achilles tendon.

Symptoms may develop after a change in:

• Running distance
• Running speed
• Exercise frequency
• Sports participation
• Hill training
• Jumping activity
• Work demands
• Overall physical activity

However, pain near the back of the ankle does not automatically mean you have Achilles tendinopathy, and it does not tell us whether the tendon is “damaged.”

An individualized physical therapy evaluation can help determine whether the presentation is appropriate for physical therapy and identify relevant limitations in mobility, calf muscle performance, functional loading, walking, running, and other activities.

What Is the Achilles Tendon?

The Achilles tendon is the large tendon connecting the calf muscles to the heel bone.

It plays an important role when you:

• Walk
• Run
• Push off the ground
• Climb stairs
• Jump
• Land
• Stand on your toes
• Participate in sports

Every step requires the calf-Achilles complex to manage and transfer force.

Running and jumping substantially increase those demands.

The Achilles tendon is therefore designed to tolerate significant loading. Problems may occur when the demands being placed on the tendon exceed its current capacity.

What Is Achilles Tendinopathy?

Contemporary clinical guidelines use the term Achilles tendinopathy rather than automatically calling the condition “Achilles tendonitis.”

The 2024 Academy of Orthopaedic Physical Therapy clinical practice guideline defines tendinopathy around localized tendon pain associated with tendon-loading activities, avoiding the assumption that symptoms necessarily represent simple inflammation or degeneration. 

This distinction matters.

If every case is described as “inflammation,” patients may understandably believe that the tendon needs complete rest until inflammation disappears.

Current rehabilitation evidence supports a different approach for many patients with midportion Achilles tendinopathy: appropriately dosed tendon loading is a central component of treatment.

Where Does Achilles Tendinopathy Hurt?

Two commonly discussed regions are:

Midportion Achilles tendinopathy: symptoms generally occur several centimeters above where the tendon attaches to the heel.

Insertional Achilles tendinopathy: symptoms occur closer to the tendon's attachment at the heel bone.

These presentations are not necessarily managed identically.

The updated APTA/AOPT clinical practice guideline specifically focuses its recommendations on midportion Achilles tendinopathy, so evidence from that guideline should not automatically be generalized to every type of pain near the Achilles tendon. 

Why Did My Achilles Start Hurting?

Sometimes patients cannot identify one specific event.

Instead, symptoms may appear after changes in the amount or intensity of activity.

Examples include:

• Starting a running program
• Increasing weekly mileage
• Running faster
• Adding hills
• Returning to sports after inactivity
• Increasing pickleball or tennis frequency
• Starting jumping exercises
• Increasing gym activity
• Walking substantially more while traveling
• Changing work demands

The 2024 clinical practice guideline recognizes changes in loading environment—including activity intensity and duration—among factors relevant to Achilles tendinopathy. 

That does not mean exercise is harmful.

It means the body's capacity and the demands being placed on it should be considered together.

Why Is My Achilles Stiff When I First Get Up?

Some individuals with Achilles tendon symptoms report stiffness after periods of relative inactivity, including:

• First thing in the morning
• After sitting
• After driving
• After resting following exercise

Symptoms may change after several minutes of movement.

The pattern can provide useful information during a physical therapy examination, but morning stiffness by itself does not establish a diagnosis.

Why Does My Achilles Hurt When I Run?

Running repeatedly loads the Achilles tendon as the calf muscles help control and propel the body.

Symptoms may become noticeable during:

• Easy running
• Faster running
• Hills
• Sprinting
• Longer distances
• Running after increasing training volume

The presence of pain does not automatically tell us whether someone must completely stop running.

The physical therapist may consider the severity and behavior of symptoms, current training demands, functional capacity, and response after activity before recommending modifications.

Do I Need to Completely Rest My Achilles?

For many individuals with midportion Achilles tendinopathy, complete rest is not considered the primary rehabilitation strategy.

The updated guideline recommends continuing physical activity within pain tolerance rather than automatically prescribing complete rest. 

Activity may still need to be modified.

For example, a runner might temporarily adjust:

• Mileage
• Running speed
• Hills
• Frequency
• Jumping
• Sport participation

while progressively strengthening the calf-Achilles complex.

The appropriate modification is individual.

Should I Stretch My Achilles?

Not everyone with Achilles pain automatically needs stretching.

The 2024 guideline states that calf stretching may be used for patients with midportion Achilles tendinopathy who also demonstrate limited ankle dorsiflexion. 

That is an important distinction.

Stretching should address an identified impairment rather than simply being prescribed because the tendon hurts.

Some patients may need greater emphasis on strengthening and progressive loading instead.

Is Eccentric Exercise Still the Best Exercise?

You may have heard that Achilles rehabilitation requires eccentric heel drops.

Eccentric exercises can certainly be useful, but current evidence no longer suggests that rehabilitation must use only one specific contraction type.

The updated clinical practice guideline found that several types of tendon-loading exercise can improve pain and function, including:

• Eccentric loading
• Heavy-load exercise
• Slow resistance exercise
• Progressive loading
• Isometric exercise

The guideline therefore does not restrict clinicians to eccentric exercise alone. 

This is one of the most useful updates for patients because Achilles rehabilitation can be individualized rather than forcing everyone into exactly the same exercise protocol.

Can Physical Therapy Help Achilles Tendon Pain?

Yes. Exercise-based physical therapy has strong evidence for midportion Achilles tendinopathy.

The 2024 AOPT/APTA clinical practice guideline gives tendon-loading exercise its highest recommendation level and states that clinicians should use loading exercise, at loads as high as tolerated when appropriate, as a first-line intervention to improve function and decrease pain in individuals without presumed tendon-structure frailty. 

Depending on examination findings, physical therapy may include:

• Progressive calf strengthening
• Tendon-loading exercise
• Ankle mobility exercises when indicated
• Lower-extremity strengthening
• Balance or neuromuscular exercises when appropriate
• Walking progression
• Running progression
• Jumping progression when appropriate
• Activity modification
• Training-load education
• Patient education
• Home exercise programs
• Manual therapy when clinically indicated

Treatment should be individualized based on the patient's presentation and goals.

How Heavy Should Achilles Exercises Be?

The updated guideline recommends tendon-loading exercise with loads as high as tolerated for appropriate individuals with midportion Achilles tendinopathy and recommends performing loading exercise at least three times per week. 

That does not mean every patient should immediately perform heavy heel raises.

Loading may need to progress gradually based on:

• Symptoms
• Strength
• Exercise experience
• Age
• Medical history
• Current tendon capacity
• Functional demands

Someone beginning rehabilitation may require a different starting point from an experienced runner or athlete.

Does Pain During Exercise Mean I Am Damaging the Tendon?

Not necessarily.

Pain and tissue damage are not interchangeable concepts.

The updated guideline supports exercise at a tolerable intensity and recognizes that temporary symptom aggravation can occur during exercise-based Achilles rehabilitation. 

However, this does not mean all pain should simply be ignored.

A physical therapist can help monitor:

• Pain during exercise
• Symptoms afterward
• Next-day response
• Functional improvement
• Strength progression
• Changes in activity tolerance

These factors can help guide progression.

What About Shockwave Therapy for Achilles Tendon Pain?

Extracorporeal shockwave therapy has been studied for Achilles tendon disorders, but an important evidence distinction should be made.

The current APTA/AOPT Achilles clinical practice guideline specifically states that extracorporeal shockwave therapy was outside the scope of that guideline, along with pharmacological and surgical interventions. 

Therefore, the guideline's strong recommendation for tendon-loading exercise should not be interpreted as either recommending or rejecting shockwave therapy.

If shockwave therapy is considered for an individual patient, it should be evaluated separately based on the patient's specific presentation, contraindications, available evidence, professional scope, and clinical judgment.

It also should not automatically replace progressive rehabilitation of identified physical and functional impairments.

Do I Need an MRI or Ultrasound?

Not necessarily.

The clinical practice guideline indicates that imaging is generally not required to establish a typical presentation of midportion Achilles tendinopathy. Imaging may be considered when there is diagnostic uncertainty, delayed recovery, a negative change in symptoms, or when a procedure is being considered. 

An examination can assess:

• Symptom location
• Tendon-loading response
• Calf performance
• Mobility
• Functional limitations
• Walking or running tolerance

and determine whether additional medical evaluation may be appropriate.

Can I Keep Running With Achilles Pain?

Possibly, depending on the presentation.

Complete cessation of activity is not automatically necessary for midportion Achilles tendinopathy. 

Some runners may temporarily reduce training while continuing an appropriate amount of running.

Others may require a more significant modification.

Factors to consider include:

• Symptom severity
• Symptoms during running
• Response afterward
• Next-day symptoms
• Calf strength
• Running demands
• Current weekly mileage
• Recent changes in training

Return-to-running progression should therefore be individualized.

What Does Research Say?

The evidence for progressive loading in midportion Achilles tendinopathy is particularly strong.

The 2024 AOPT/APTA guideline reviewed contemporary evidence and concluded that tendon-loading exercise improves pain and function. Across studies, effective approaches included eccentric, heavy-load, slow-speed, progressive, and isometric loading. 

The guideline gives a Grade A recommendation for tendon-loading exercise as a first-line intervention in appropriate patients. 

It also recommends against complete rest and supports continuing activity within pain tolerance. 

This gives patients an important evidence-based message:

Achilles rehabilitation is generally not about avoiding all load. It is about developing the capacity to tolerate appropriate load.

The updated guideline is directly available through APTA's Achilles Tendinopathy Clinical Practice Guideline resource.

Why Is This Topic Especially Relevant in Los Angeles Right Now?

Running-related rehabilitation has timely local relevance.

A Burbank/Encino running program is already recruiting runners preparing for the 2027 Los Angeles Marathon and specifically includes biomechanics and injury-prevention education. 

USC's current 2026 sports physical therapy education also specifically lists Achilles tendinopathy, load management, and return-to-play decision making among upcoming lower-extremity athlete-care topics. 

For runners beginning a new training cycle, this is an appropriate time to pay attention to progressive training loads rather than waiting until symptoms substantially limit running.

What Happens During a Physical Therapy Evaluation?

At Nova Physical Therapy, an evaluation for Achilles-region symptoms may include:

• Medical history review
• Symptom history
• Activity and training history
• Ankle mobility assessment
• Calf muscle-performance assessment
• Single-leg heel-raise assessment when appropriate
• Lower-extremity strength assessment
• Balance assessment when relevant
• Walking assessment
• Running assessment when appropriate
• Functional movement assessment
• Tendon-loading tolerance
• Review of sport or occupational demands
• Activity limitation assessment
• Goal setting

The updated guideline specifically identifies measures such as single-leg heel-raise endurance and pain response during tendon-loading activities as relevant components of Achilles assessment. 

California physical therapists practice under the Physical Therapy Practice Act administered by the Physical Therapy Board of California. PTBC is responsible for regulating physical therapist and physical therapist assistant practice in California. 

When Should You Seek Medical Attention?

Not every episode of pain near the Achilles tendon represents tendinopathy.

Seek appropriate medical evaluation when symptoms involve:

• A sudden pop or snapping sensation
• Significant trauma
• Sudden inability to push off the foot
• Marked difficulty walking
• Rapidly developing swelling or bruising
• Significant weakness
• An open wound
• Fever or signs of infection
• New neurological symptoms
• Rapidly worsening symptoms

A sudden Achilles tendon rupture is different from a gradually developing tendinopathy and requires prompt medical assessment.

Persistent symptoms that do not respond as expected should also be reassessed.

Why Patients Choose Nova Physical Therapy

At Nova Physical Therapy, our mission is simple:

We Care.

Our goal is not simply to tell a runner to stop running or give every patient the same heel-drop program.

We want to understand what your Achilles tendon needs to tolerate in your life.

For one patient, that may mean comfortably walking around the neighborhood.

For another, it may mean returning to:

• Running
• Hiking
• Pickleball
• Tennis
• Basketball
• Soccer
• Gym training
• Recreational sports
• Work activities

Our treatment philosophy emphasizes:

• Evidence-based care
• Individualized treatment plans
• Patient education
• Progressive strengthening
• Appropriate tendon loading
• Functional outcomes
• Activity progression
• Running and sports rehabilitation when appropriate
• Long-term health and wellness

When appropriate, rehabilitation progressively builds the physical capacity required for the activities that matter to the patient.

Frequently Asked Questions

Why does my Achilles hurt when I first get out of bed?

Morning stiffness can occur with Achilles tendon conditions, including tendinopathy, but this symptom alone does not establish a diagnosis.

Is Achilles tendinopathy the same as Achilles tendonitis?

“Tendinopathy” is now commonly preferred because persistent Achilles pain cannot simply be assumed to represent inflammation. The current clinical guideline uses the term Achilles tendinopathy. 

Should I completely rest my Achilles?

For many appropriate patients with midportion Achilles tendinopathy, current guidelines discourage complete rest and support continued activity within pain tolerance. 

Are eccentric heel drops still recommended?

They may be useful, but they are not the only evidence-supported exercise. Several forms of progressive tendon loading can be effective. 

Can I run with Achilles tendinopathy?

Some individuals may continue running with appropriate modifications, while others may need greater temporary reduction. The decision should consider symptoms, functional capacity, training demands, and clinical findings.

Does Achilles pain mean my tendon is going to rupture?

No. Pain alone does not establish that a rupture is going to occur. Sudden trauma, a pop, marked weakness, or inability to push off requires prompt medical assessment.

Do I need an MRI for Achilles pain?

Not automatically. Imaging is generally not required for a typical clinical presentation of midportion Achilles tendinopathy, although it may be appropriate when the presentation is uncertain or recovery is not progressing as expected. 

Can physical therapy help Achilles tendinopathy?

Yes. Progressive tendon-loading exercise has strong clinical-practice-guideline support for appropriate patients with midportion Achilles tendinopathy. 

Does shockwave therapy help Achilles tendinopathy?

Shockwave therapy has been investigated separately, but the current APTA/AOPT Achilles guideline specifically excluded shockwave therapy from its scope. It should therefore be evaluated separately rather than presented as part of that guideline's recommendations. 

How long does Achilles tendinopathy take to improve?

Recovery varies. Symptom duration, physical capacity, activity demands, health factors, exercise progression, and individual response can all influence recovery. A specific timeline or outcome cannot be guaranteed.

Schedule an Evaluation

If pain around your Achilles tendon is affecting your ability to walk, run, climb stairs, exercise, work, or participate in sports, Nova Physical Therapy can help determine whether physical therapy is appropriate.

Our licensed physical therapists provide comprehensive evaluations and individualized rehabilitation programs focused on improving mobility, muscle performance, physical capacity, and function.

Contact Nova Physical Therapy today to schedule your comprehensive physical therapy evaluation.

Disclaimer

The information provided in this article is intended for educational and informational purposes only and should not be considered medical advice, diagnosis, or treatment. Reading this article does not establish a physical therapist-patient relationship with Nova Physical Therapy or any of its providers.

Pain around the Achilles tendon can have multiple causes. Morning stiffness, pain during running, tenderness, or pain with calf raises does not establish Achilles tendinopathy or any other specific diagnosis.

The clinical-practice-guideline recommendations discussed in this article primarily concern midportion Achilles tendinopathy and should not automatically be generalized to insertional Achilles symptoms, acute tendon rupture, or other causes of posterior ankle pain.

Treatment, exercise, activity modification, return-to-running recommendations, and other interventions should be individualized based on a licensed physical therapist's examination, clinical judgment, medical history, patient presentation, current evidence, applicable California laws and regulations, and collaboration with other healthcare professionals when appropriate.

Physical therapists screen patients and refer to physicians or other appropriate healthcare professionals when findings require additional medical evaluation.

If you experience significant trauma, a sudden pop, inability to push off the foot, marked weakness, rapidly developing swelling or bruising, or other concerning symptoms, seek appropriate medical attention.

Individual results may vary. Nova Physical Therapy does not guarantee specific outcomes, recovery times, or return-to-sport results from physical therapy, exercise, shockwave therapy, or any other healthcare intervention discussed in this article.

References

1. Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, 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. 
2. American Physical Therapy Association / Academy of Orthopaedic Physical Therapy — Achilles Tendinopathy Clinical Practice Guideline. 
3. Physical Therapy Board of California — Physical Therapy Practice Act. 
4. UCLA Health — Marathon Recovery Guidance. Published March 8, 2026. 
5. USC Division of Biokinesiology and Physical Therapy — 2026 Sports and Orthopaedic PT Education. 

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