Achilles Pain Holding You Back? Here’s What Runners Should Know | Find Your Stride | Edinburgh Podiatrist

Achilles tendinopathy remains one of the most stubborn injuries in the running community. Despite decades of research, clinicians and runners alike have struggled with inconsistent diagnostic approaches. The new Delphi consensus study led by Malliaras and colleagues (2025) attempts to clarify the current situation by establishing agreed-upon diagnostic domains, differential diagnoses, and red-flag conditions requiring medical attention.

Achilles tendinopathy remains one of the most stubborn injuries amongst runners.

What the Study Did Well

• Expert breadth: The panel included 52 experts from sports medicine, physiotherapy, orthopaedics, podiatry, and related fields, averaging 21 years of experience with Achilles tendon cases. This lends weight to the recommendations.

• Clear diagnostic core: Four domains emerged as essential to diagnosing Achilles tendinopathy:

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  1. Pain location

  2. Pain during activity

  3. Tests that provoke pain (e.g., calf raises, hopping)

  4. Palpation tenderness

     
     

• For both runners and clinicians, these are practical, easy-to-assess markers that don’t rely on costly imaging.

• Acknowledgment of complexity: The study highlights 15 possible differential diagnoses (e.g., plantaris tendinopathy, retrocalcaneal bursitis, calcaneal stress fracture) and six systemic conditions (e.g., inflammatory joint disease, metabolic syndrome, drug reactions) that can masquerade as Achilles pain. This is crucial for preventing misdiagnosis in runners who might otherwise be told to “just rest and stretch.”

• Pragmatic stance on imaging: Imaging (ultrasound, MRI) was deemed useful but not essential, aligning with the growing recognition that structural changes don’t always match symptoms. For everyday runners, this helps avoid unnecessary scans.

Limitations and Concerns

• Western bias: Nearly half the participants were from the UK and Australia, with minimal representation from Africa, Asia, or South America. Achilles injuries in recreational runners in these regions may present differently due to footwear, training loads, or healthcare access.

• No patient voice: The study deliberately excluded patients, focusing only on expert opinion. While understandable for diagnostic criteria, it misses lived experience insights—like how runners describe morning stiffness or activity-related pain, that could refine the language of diagnosis.

• Consensus ≠ evidence: A Delphi process gathers opinions rather than testing diagnostic accuracy. The “essential” domains are expert-agreed, not empirically validated against gold standards. Runners and coaches should remember this isn’t the final word, but a step towards consistency.

• Overlapping conditions: The grouping of “endocrine or hormonal disorders” separately from diabetes (itself an endocrine disorder) shows how even experts struggle with clear categorisation. For clinicians, this could create ambiguity.

Implications for Runners and Coaches

For athletes, the takeaway is refreshingly simple:

• Achilles tendinopathy is primarily a clinical diagnosis. If your pain is localised at the tendon, worsens with running or calf-loading, and is tender to touch, you likely fit the profile.

• Don’t panic about scan results, structural changes can appear in both injured and uninjured tendons.

• Be alert for symptoms that don’t fit the typical picture (night pain, swelling beyond the tendon, systemic issues), as these could indicate something more serious.

Bottom Line

This consensus paper is an important milestone. It provides a framework that can reduce confusion across clinics and research studies. But for the running world, it’s a starting point—not the final playbook. Diagnosis will always be part science, part art, especially in a condition as multifactorial as Achilles tendinopathy. Future research must validate these domains in real-world runner populations and broaden representation beyond Western experts.

Until then, runners should use these criteria as guideposts, but trust the nuance of an experienced clinician, because not every injured Achilles is the same.

Find Your Stride!