Part of Achilles tendinopathy
Can I run with Achilles tendonitis? The rule that decides it
Warning signs, and when to get help
Can you run with Achilles tendonitis?
Yes for most people, though not for everybody. The guidelines are not neutral about it. The 2024 US clinical practice guideline advises, on moderate evidence, that complete rest is not indicated for midportion Achilles tendinopathy and that people should continue with their activities within their pain tolerance, alongside tendon loading at loads as high as tolerated (Chimenti and colleagues, 2024). The Dutch multidisciplinary guideline on Achilles tendinopathy tells patients with chronic symptoms that little or no improvement is expected in the short term from a wait-and-see approach, and its treatment recommendations start with progressive calf muscle strengthening exercises for at least 12 weeks (de Vos and colleagues, 2021).
A systematic review of 16 randomized trials in midportion tendinopathy found eccentric exercise had the most evidence of effectiveness, and that it beat a wait-and-see approach in both trials that compared them (Magnussen and colleagues, 2009). A tendon left alone gets weaker while you wait for it to stop hurting.
Silbernagel and colleagues (2007) put 38 people with Achilles tendinopathy on the same calf exercise program and then split them. One group also carried on running and jumping, guided by a pain rule, while the other stopped those activities for the first 6 weeks. At every follow-up the two groups had done equally well, and the researchers reported no negative effects from continuing. That trial is the direct evidence on running, all of it, and what it actually did matters.
Everybody in it was doing a loading program, which is the half that falls off when the study gets quoted as "running is fine". The group that kept running was not training freely either. They ran inside a rule and backed off when they broke it, so the permission comes attached to both conditions, and if you are running and doing nothing else for the tendon this trial is not about you. The Achilles tendinopathy program is the other half of the deal.
What rule tells you whether a run was too much?
What tells you is the first few minutes out of bed the next day, not the run itself, which is a poor judge of its own effect. In the pain monitoring model used in that trial, tendon pain during activity was allowed up to 5 out of 10. Pain afterward could also reach 5, as long as it was back to its usual level by the next morning. Pain and morning stiffness were not allowed to build from one week to the next (Silbernagel and colleagues, 2007).
Silbernagel's later clinical guide puts the emphasis on avoiding moderate or severe pain and symptoms that get worse over time (Silbernagel and colleagues, 2020). The pain monitoring model explains how physios use the same scale across tendon problems.
People get this reading wrong in ways we see every week:
- Judging by how the run felt. A tendon often behaves well mid run and complains hours later, so a comfortable run tells you very little.
- Running again before you have taken a morning reading. One run, one reading. Two runs in a row and you no longer know which one did what.
- Taking a painkiller before the run. That removes the measurement you came for.
Pain over 5 out of 10 during the run means the next one is shorter or easier. Pain that is still raised the next morning means the next run waits until the morning reading is back to baseline. Stiffness that is a little longer every week means the week as a whole is too much, even if no single run broke the rule. None of those three answers is stopping. Write the morning reading down somewhere, because week to week drift is invisible from memory.
One refinement from the same group helps here, because 5 out of 10 is the outer limit and not the target for every run. Silbernagel and colleagues (2020), whose paper reprints the pain monitoring model from the return to sport program Silbernagel and Crossley proposed in 2015, sort tendon loading activities into three bands and attach recovery days to each.
A light activity, their example being a 70 minute walk, sits at 1 to 2 out of 10 during and afterward and can be done daily. A medium one, their example being 30 minutes of jogging on a flat surface, sits at 2 to 3 during and 3 to 4 immediately afterward or the next day, with 2 recovery days before the next session of that kind. A hard one, running at 85 percent of your pre-injury speed for 20 minutes, sits at 4 to 5 during and 5 to 6 afterward, with 3 recovery days. The gaps are part of the dose. An easy jog every other day and a hard run every other day are not the same prescription.
When should you stop running completely?
A sudden pop or snap at the back of the ankle, or a leg that will not push off after one moment, is not a dose problem, and no pain score applies to it. That is a possible Achilles tendon rupture, it needs assessment the same day even if you can still walk, and the first line of the warning list on this page says exactly what to do. People do walk after a rupture, which is why the ability to walk is not a reason to wait.
If the tendon hurts walking to the kitchen, the problem is not your long run, and running more will not find the level. That is the quieter reason to stop for a while, and the one people talk themselves out of. Get the loading program started, let walking comfort settle, and bring running back from there.
Then there is a tendon that started hurting on a fluoroquinolone antibiotic, such as ciprofloxacin or levofloxacin, or in the months after a course. That line on the warning list below asks you to contact your doctor straight away and to hold off the calf exercises until you have been checked, which also means not running on it. The UK medicines regulator tells patients to stop the antibiotic at the first sign of tendon pain or swelling and to rest the painful area until they can see their doctor, and it says tendon damage can start within 48 hours of the first dose or appear months after the course has finished (MHRA, 2024). Everything else on this page assumes a tendon that is not suspected of having been weakened by a medicine, which is why this one goes to a doctor first.
Everything else on the warning list has its own timing, and those timings come ahead of any training decision.
What changes first: speed, hills or distance?
Most physios take hills out first, then fast running and track sessions, and bring them back last. That order is common practice rather than something trials have compared, so it is a sensible default and not evidence. Achilles pain when running sets out how to rebuild the training week around it, including the gaps between runs.
Runners almost always cut distance first, because distance is the number they can see, and they keep the fast group session because it is in the diary and their friends are there. That is the reverse of the order above, and it is what the clinic version of this looks like most weeks. If you are going to protect one thing, protect the easy flat running and give up the session you look forward to, which is the part nobody enjoys hearing.
Is running with insertional Achilles pain different?
Pain right at the back of the heel, on the bone, is the insertional kind, and bending the ankle up a long way presses the tendon against the heel bone. So the answer is still yes, with the difference sitting in what you avoid. The Kent Community Health NHS leaflet advises avoiding walking uphill or on inclines and sticking to flat ground, and the same thinking applies to a run. Note too that the 2024 US clinical practice guideline on Achilles tendinopathy states its own scope as the midportion (Chimenti and colleagues, 2024), so the strongest recommendations in this field were not written about pain at the heel bone.
If your pain is at the back of the heel (insertional), keep heel raises on a flat floor or at step level, and skip any exercise that lets the heel drop below a step until your physio says otherwise. Insertional or midportion Achilles tendinopathy covers how to tell the two apart and why the handling differs.
What has to be true before you add running back in?
Silbernagel and colleagues (2020) give two checks, and they put them as rules of thumb, not tests you pass. Before an athlete goes back to running and jumping, pain during daily walking should be minimal, which they put at 1 to 2 out of 10 on a 0 to 10 scale. The second is pain during single leg hopping: someone scoring above 2 out of 10 over 20 hops will struggle to start running while staying inside the pain monitoring limits. If you have already stopped running, do these before the first run back. They are readiness checks, not targets to chase.
Calf strength is treated the same way, as a deficit to close rather than one to run through, because reduced calf strength is one of the few risk factors for this problem you can actually change. It is also the part people skip, and the part that holds. Build the single leg heel raise and then the weighted calf raise, compare the sore side with the other one, and keep the strength work going 2 to 3 times a week once you are running again. Your physio will set the numbers. The return to running plan gives a walk and run structure for the build-up, and how long Achilles tendonitis lasts covers the timeframe the whole thing sits inside.
The hop check belongs with the last stage of the program, and the precautions that go with hopping apply here too. Jumping and hopping also load the joints, the bones and the pelvic floor. If you have osteoporosis or have had a fall in the past year, ask your physio before you do any hopping. If you have had a hip or knee replacement, get the go-ahead from your surgeon before you try hopping. Many surgeons advise against jumping and hopping after a joint replacement for good, not just for the first months, because each landing sends high impact through the new joint. If you are pregnant, have had a baby in the past year, or leak urine when you jump, cough or sneeze, check with your midwife or physio before you start this stage. Stop the hopping and speak to your physio if urine leaks while you are doing it, or if you feel pressure or heaviness low in your pelvis. After having a baby, postnatal guidance usually leaves jumping and hopping until at least 3 months after the birth, once a pelvic floor check shows you are ready. With a heart condition or high blood pressure, check with your doctor before you start.
When to see a physio or doctor
See a physio (physical therapist) or doctor if the pain is severe, stops you walking normally, keeps getting worse, or has not improved after a few weeks of looking after it yourself. Running decisions get a lot easier once someone has pinned down which part of the tendon is sore and how much strength the calf has lost, because both change the answer.
Book sooner if you have had an Achilles problem on either side before, or if you have taken a fluoroquinolone antibiotic recently. The Guy's and St Thomas' NHS leaflet advises relative rest, meaning you cut back the activities that load the tendon heavily and keep your fitness up in other ways, and a physio can tell you what that looks like for your week instead of in general. The warning signs below run to their own timings, and those come first.
Related exercise programs
Warning signs
Get emergency help now
- You felt a sudden pop or snap at the back of your ankle, it felt as if someone hit or kicked you in the calf, or walking or rising onto your toes on that leg suddenly became weak or difficult. Stop exercising and go to an urgent care center or emergency department the same day, even if you can still walk, as this can be a torn (ruptured) Achilles tendon. This page does not cover a rupture.
Get help now, day or night
- Your tendon pain or swelling started while you were taking a fluoroquinolone antibiotic, such as ciprofloxacin or levofloxacin, or in the months after a course. Contact your doctor straight away. The UK medicines regulator (MHRA) advises stopping the antibiotic at the first sign of tendon pain or swelling and talking to your doctor. Hold off the calf exercises until you have been checked.
Get help today
- A calf or thigh that is newly swollen or getting more swollen, warm, tender, red or darker than usual, has swollen veins that are sore to touch, or has a throbbing or cramping pain that does not fit your injury or condition, or that feels different from normal muscle soreness after exercise. This can be a sign of a blood clot (deep vein thrombosis), especially after surgery, an injury, time in a cast or boot, a long trip or a spell of being much less mobile than usual. Get medical advice the same day. If you are also short of breath or have chest pain, call emergency services.
- The tendon or heel is hot, red and swollen, or you have a fever or feel unwell. Get medical help the same day, and go to an emergency department if you feel very unwell. If you have a very high or very low temperature, shivering you cannot control, you are breathing very fast or finding it hard to breathe, you are confused or your speech is slurred, your skin, lips or tongue look blue, gray, pale or blotchy (on brown or black skin this can be easier to see on the palms of the hands or soles of the feet), or you have a rash that does not fade when you press it, call emergency services, as this can be sepsis.
- The pain started with a fall or a blow to the back of the ankle, and there is bruising or you cannot put weight on the foot. Get it checked the same day.
- The pain is there at night or at rest as well as with activity and keeps getting worse. If you are being treated for cancer now, contact your cancer team the same day.
Book an appointment
- Your heel or Achilles pain comes with back pain and stiffness that is worse in the morning and at night, or with painful, swollen joints elsewhere, or both heels became painful without an obvious reason. The same applies if you also have psoriasis, Crohn's disease or ulcerative colitis, or have had a red, painful, inflamed eye (iritis). This is not an emergency, but see your doctor in the next week or two, as it can be a sign of an inflammatory arthritis such as ankylosing spondylitis.
- You have numbness, tingling, burning or loss of feeling in the foot, often along the outer edge. Book an assessment with a doctor or physio in the next week or two. If it came on over hours or days, started after an injury, is spreading, or comes with weakness in the foot, get medical advice the same day.
- The pain is there at night or at rest as well as with activity and keeps getting worse. If you have had cancer, now or in the past, or are losing weight without trying, see your doctor sooner, within a day or two, and mention it. This applies even if the pain is not getting worse.
- The pain is there at night or at rest as well as with activity and keeps getting worse. See your doctor within a few days.
Common questions
Should I run with Achilles tendonitis or rest it?
Resting it completely is the one option the guidelines argue against. The Dutch multidisciplinary guideline tells patients with chronic Achilles tendinopathy that little or no improvement is expected in the short term from a wait-and-see approach, and puts progressive calf strengthening for at least 12 weeks at the front of non-surgical treatment (de Vos and colleagues, 2021). A systematic review of 16 randomized trials found eccentric exercise had the most evidence of effectiveness in midportion tendinopathy and beat a wait-and-see approach in the two trials that compared them (Magnussen and colleagues, 2009). That is not the same as permission to train as normal. The workable middle is a smaller amount of running alongside a calf strengthening program, with the next morning as your check. If you are running so much that the tendon is stiffer every week, you have the worst of both: the loading is going into running rather than into the strength work that changes the tendon.
Can I still run with mild Achilles tendonitis?
Usually yes. Mild is the easiest case to get right, because you have room to work with. Keep the pain inside the 5 out of 10 limit during and after the run, check it the next morning, and leave the fast sessions and hills out while it settles. The trap with mild symptoms is treating them as nothing: a tendon that is only slightly sore still tells you something about load, and the people who end up months into this are often the ones who ran through the mild stage unchanged. Mild also means you can lose it quickly, so start the strength work now.
How do I know if running made my Achilles worse?
By the first few minutes out of bed the next day, not by how the run felt. If the tendon is no stiffer and no sorer than it was yesterday morning, the run was within what it could take. If the stiff spell is clearly longer, or the tendon is sorer than its usual baseline, that run was too much. Two runs back to back without a morning reading in between is how people lose track of this. The honest version of the check needs one reading per run.
How long should I stop running for?
For most people the answer is not a block of weeks off. In the Swedish trial, the group that stopped running and jumping did so for 6 weeks, and they ended up no better off than the group that kept going inside the pain rule (Silbernagel and colleagues, 2007). So a pause is a tool for a tendon that hurts when you walk, not a treatment in itself. If walking normally is sore, pause running, get the calf loading going, and use walking comfort as the signal to start again. If something on the warning list on this page applies, stop and get it assessed rather than counting weeks.
Is it safe to run with insertional Achilles pain at the back of the heel?
It needs different handling, not a different answer. The Kent Community Health NHS leaflet on insertional tendinopathy advises avoiding walking uphill or on inclines and sticking to flat ground, because bending the ankle up a long way presses the tendon against the heel bone. Applied to running, that means flat routes, no hill sessions, and keeping a little heel in the shoe instead of switching to something flatter. The same pain rule still runs underneath it. Read insertional or midportion Achilles tendinopathy to work out which one you have.
Can I keep racing or doing speed work while my Achilles settles?
Speed work and racing are the parts most physios take out first, along with hills, and bring back last. That ordering is common practice rather than something trials have compared, so treat it as a sensible default and not a law. A race is a separate decision, because the pain rule cannot be applied halfway round one. If a race matters enough to run it sore, say so out loud to your physio and plan the weeks either side of it, instead of finding out afterward that the tendon has gone backward.
References
- de Vos RJ, van der Vlist AC, Zwerver J, Meuffels DE, Smithuis F, van Ingen R, van der Giesen F, Visser E, Balemans A, Pols M, Veen N, den Ouden M, Weir A. Dutch multidisciplinary guideline on Achilles tendinopathy. British Journal of Sports Medicine. 2021;55(20):1125-1134. https://doi.org/10.1136/bjsports-2020-103867
- Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clinical Journal of Sport Medicine. 2009;19(1):54-64. https://doi.org/10.1097/JSM.0b013e31818ef090
- 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 and Sports Physical Therapy. 2024;54(12):CPG1-CPG32. https://doi.org/10.2519/jospt.2024.0302
- Silbernagel KG, Thomee R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. American Journal of Sports Medicine. 2007;35(6):897-906. https://doi.org/10.1177/0363546506298279
- Silbernagel KG, Hanlon S, Sprague A. Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. Journal of Athletic Training. 2020;55(5):438-447. https://doi.org/10.4085/1062-6050-356-19
- Silbernagel KG, Crossley KM. A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation. Journal of Orthopaedic and Sports Physical Therapy. 2015;45(11):876-886. https://doi.org/10.2519/jospt.2015.5885
- Guy's and St Thomas' NHS Foundation Trust. Achilles tendinopathy. Patient information, resource number 4609/VER3. Last reviewed October 2024. https://www.guysandstthomas.nhs.uk/health-information/achilles-tendinopathy
- Kent Community Health NHS Foundation Trust. Achilles insertional tendinopathy. Patient leaflet 01271. Published 2 December 2024. https://www.kentcht.nhs.uk/leaflet/achilles-insertional-tendinopathy/
- Medicines and Healthcare products Regulatory Agency. Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate. Drug Safety Update. 22 January 2024. https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-must-now-only-be-prescribed-when-other-commonly-recommended-antibiotics-are-inappropriate
- NHS. Deep vein thrombosis (DVT). Page last reviewed 30 April 2026. https://www.nhs.uk/conditions/deep-vein-thrombosis-dvt/
- NHS. Symptoms: Ankylosing spondylitis. Page last reviewed 5 January 2023. https://www.nhs.uk/conditions/ankylosing-spondylitis/symptoms/
Written and checked by the PocketPhysio editorial team. Last updated 2026-10-16.
This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.