Marathon Season – Runners Ignoring Achilles Pain Until It’s Too Late.
If you’ve signed up for the marathon & there is a good chance you will feel Achilles tendon pain before race day arrives.
Research tracking runners over time reports up to 52% of runners will develop Achilles tendon pain over their running lifetime — and roughly 1 in 10 runners each season. This is compared to roughly 6% in people who don’t run.
So how does the injury present? – a runner feels a dull ache at the back of the ankle after a long run, decides it’s “just tight” and keeps training through it. That single decision is usually what turns a two week problem into a much longer one.
Why the warm up phenomenon is false reassurance.
It’s rarely a predictable progression – but for runners who think it will be ok because the pain warms up, are often shocked to find it does not stay that way for long.
It starts as the ache after a run + often some morning stiffness in the Achilles for the first few minutes of walking or after sitting for long periods. At this point pain at the start of a run or walk disappears once the tendon is loaded, warm & moving, then often returns afterward, usually within a few hours.
Easy to ignore.
Unfortunately, most runners find the pain after activity lengthens — soreness lasting several hours, sometimes into the next day, rather than resolving within the same day. This progresses to pain during activity – the warm-up effect stops working reliably – pain is now present throughout the run rather than easing off & starts affecting pace or gait.
Pain then becomes persistent — occurring with everyday loading on stairs, walking, after sitting & is present throughout active periods. This is when running generally has to stop.
Why does the Achilles Tendon fail?
The Achilles tendon transmits enormous load with every stride — several times body weight during running.
Tendons are constantly breaking down & rebuilding in response to load – a delicate balance between it’s ability to rebuild in response to load.
Tendinopathy develops when the rate of loading outpaces the tendon’s capacity to adapt. This is commonly due to an increase in training volume, intensity or load (could be extra load with poor footwear) rather than a single traumatic event.
Training for a marathon successfully is indeed a delicate balance between increasing volume and intensity & allowing the body to adapt.
It may not be a new injury.
Emeritus Professor Jill Cook and Professor Craig Purdam developed the widely used “continuum model” of tendinopathy. It describes three overlapping tendon states: reactive tendinopathy following a rapid increase in load, tendon disrepair (failed healing & remodelling) and degenerative tendinopathy with more established structural changes.
Importantly, these states are not always neatly separated. A tendon with longstanding degenerative changes can develop a reactive flare after a sudden increase in training load. This may feel like a new injury, but the underlying tendon may already have reduced capacity.
Why this time of year is the danger zone.
Running injuries are common during marathon preparation. Prospective research suggests that around 40% of recreational marathon runners may experience a running-related injury during a training block, although the figure varies considerably depending on how an injury is defined.
Achilles problems account for approximately one in ten running injuries.
Risk increases when the runner’s current training demands exceed their capacity.
Sudden increases in the length or intensity of individual runs, inadequate recovery & poorly tolerated changes in training load can all contribute. Strength training can improve muscular & tendon capacity, but there is not enough evidence to claim that running more than 50 km per week without strength training automatically multiplies injury risk.
Previous injury remains one of the clearest warning signs. Runners with a history of running-related injury have been found to be approximately twice as likely to experience another injury. Feeling better is therefore not always the same as having fully restored the strength, endurance and load tolerance required for marathon training.
Treatment – what the evidence says.
The good news is that most people with Achilles tendinopathy improve with well-structured conservative (no surgery required) management. Recovery can take several months and outcomes vary between individuals.
Tendons love load – progressive, deliberate & planned. The 2024 Clinical Practice Guideline from the Academy of Orthopaedic Physical Therapy recommends progressive tendon-loading exercise as the first-line treatment for midportion Achilles tendinopathy.
Loading may include eccentric, heavy-slow resistance, isometric and later faster or plyometric exercise, depending on the person’s symptoms, strength and activity goals. Complete rest is generally not recommended; activity should instead be modified and continued within an acceptable level of pain.
The key is applying enough load to stimulate adaptation, progressing it appropriately and restoring the strength, endurance and capacity required for running.
There is no single perfect sets & repetitions formula, which is why a generic stretching program or a sheet of heel raises will not help the tendon.
Achilles symptoms are generally easier to manage before they begin significantly limiting your running. Early assessment allows training loads to be adjusted, contributing factors to be identified and progressive rehabilitation to begin before strength and tendon capacity decline further.
Long-standing Achilles tendinopathy can still respond well to treatment, but recovery often requires patience and a structured return to running. Rehabilitation may need to address not only the painful tendon, but also calf strength, lower-limb function, training load and the physical demands of the runner’s sport.
Training through pain isn’t toughness — it’s usually the reason a two-week injury becomes a two-month one.
Our team of physiotherapists, podiatrists & exercise physiologists at The Sports Physio Clinic can assess your running gait, training load, tendon capacity and build you an evidence-based loading program to keep you training toward race day.
Book your assessment today. Book online here or call Narrabeen 99814099 | West Pymble 9418 2926
Prevalence of Achilles tendinopathy in physical exercise: a systematic review and meta-analysis — PMC9453689 (citing de Jonge et al.)
Lower Extremity Musculoskeletal Injuries Associated with Marathon Running — PMC12660524
HSS: Training Patterns Associated with Injuries in Marathon Runners — news.hss.edu
Midportion Achilles Tendinopathy: 2024 Clinical Practice Guidelines — Journal of Orthopaedic & Sports Physical Therapy, jospt.org/doi/10.2519/jospt.2024.0302
Eccentric exercise for mid-portion Achilles tendinopathy: systematic review and meta-analysis — PMC9878810
Recreational Runners With a History of Injury Are Twice as Likely to Sustain a Running-Related Injury — JOSPT 2021, jospt.org/doi/10.2519/jospt.2021.9673
The Effects of Early Physiotherapy Treatment on Musculoskeletal Injury Outcomes: A Narrative Review — PMC9602812 (evidence drawn from broader active/athletic populations)
Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009; revisited 2016
