Top 3 DON’Ts for Treating Running-Related Tendinopathies

Tendinopathies are among the most common injuries seen in runners. Overuse is a frequent issue, and you’ll often encounter runners at the later stages of tendinopathy, when it has already started limiting their mileage, rather than those in the early stages seeking proactive care. This becomes particularly challenging with endurance runners, as the toughest part is finding the right balance: keeping them running without compromising their recovery. Negotiation skills are key!

In his Practical guide on managing running-related injuries, physio Brad Beer shares expert tips for handling tendinopathies. Here, I’ve outlined a few key DON’Ts for managing these injuries, along with some common phrases you might hear from your runners.

If you’d like to see exactly how expert physio Brad Beer manages a range of injuries in runners, watch his full Practical HERE. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more here.

1 – DON’T stop running

“I don’t want to stop running and lose my progress”

Good news – most runners with tendinopathies don’t need to stop running completely, as doing so can reduce the tendon’s capacity and set them back when they try to resume. It’s important to start this conversation early, creating an environment where patients feel comfortable discussing their pain levels without fearing that all their miles will be taken away. Educating the patient about acceptable symptom levels is crucial, using the 24-hour recovery window as a guide. Additionally, helping them understand that pain doesn’t equal damage is vital, especially for stressed runners. Emphasising that staying within acceptable pain levels will support a faster recovery can motivate compliance, as a quicker return to their usual running load becomes a compelling incentive. Brad Beer shares how he educates his running patients in this clip from his Practical:

2 – DON’T underload

“But I do my 30 calf raises every day, why do my Achilles still hurt?”

Tendons like slow and heavy resistance. And contrary to long-held beliefs, Brad highlights that tendons don’t tend to have a particular preference on type of contraction (i.e., isometric, eccentric, concentric), but what they do need is heavy and slow load! So, for an endurance runner, hitting the gym is often integral to tendon recovery. In terms of Achilles tendinopathy, doing 30 body-weight calf raises every day may anecdotally help a little, but it is certainly not the most efficient way to get the calf musculature strong enough to withstand running load; particularly if your patient is doing them super quick to get them out of the way, this could actually be contributing to the Achilles overload, rather than mitigating it!

Getting your patient in the gym doing both seated and straight-leg calf raises at a heavy load, and ideally using a metronome, is the best way to increase the tissue tolerance that will ultimately allow them to increase their mileage. In the below snippet from his Practical, Brad demonstrates a seated bent-knee calf raise – an exercise he uses with every running-related injury, not just Achilles tendinopathy:

3 – DON’T demonise gait

“A physio once told me all my injuries are because I’m a heel-striker”

Brad dispels this theory, pointing out that, like many things physios have deemed “bad” (such as anterior pelvic tilt or lumbar flexion during lifting), heel-striking isn’t inherently bad. While the position of foot-strike may contribute to a higher likelihood of anterior or posterior injuries, there’s no need to drastically alter a runner’s gait based on this. He emphasises keeping gait analysis simple and not overwhelming the runner with a list of things they’re doing wrong. The goal isn’t to find what’s “wrong” but to identify areas that may be overworked. The three things you should focus on are:

• Hip dip
• Crossover gait
• Overstriding

Again, the presence of one or more of these factors doesn’t necessarily mean a change is needed; they should always be considered in the context of the patient. For instance, in a runner with long-term gluteal tendinopathy, a narrowing of the knee window (i.e., cross-over gait) can indicate overstriding, which may also contribute to a hip dip. In this case, it could be beneficial to cue the runner to increase their cadence and/or widen their base of support to reduce load on the gluteal tendons during recovery. However, this is primarily a short-term strategy to aid recovery. Watch Brad explain narrowing of the knee window in the video below, taken from his Practical:

Wrapping up

It’s likely that a runner will come to you with a long-term tendinopathy issue and express thoughts like one of the quotes above. In these cases, it’s important to address and correct any unhelpful beliefs or strategies they’ve developed before you can effectively apply your treatment. Education is key here, and staying updated with the latest evidence and expert advice is the best way to ensure your knowledge remains current and effective.

Get an in-depth insight into how expert physio Brad Beer manages a range of running-related injuries, watch his full Practical HERE.