Rest Isn’t a Plan
Hey, if resting was a cure, I’d probably be out of a job.
Hi, my name is Dr. Daniel Zhu. I’m a physical therapist operating out of New York City, and I’m also the author of this Substack, The Sustainable Mile. Today I want to talk about a topic where rest comes into play and how it relates to returning to sport, in the context of a runner with Achilles pain.
Most times when a runner comes in to me, and they’re experiencing some form of Achilles discomfort, they tell me that they rested initially, waited for the pain to go away for their day-to-day activities, and then went back to running where they left off. And they ask me why they haven’t gotten better, because the pain usually comes back.
And here’s the truth. You fall into a trap of thinking that just because the pain goes away, the tissue is ready to handle load and stress again. What really has to happen is that you have to rebuild the tissue back up to a higher level of capacity by slowly and gradually returning to the activities you were doing. You can’t stop at 20 miles and then jump right back in once the pain stops without changing anything. The original cause might not even have gone away. Just because the tissue feels a little better with your day-to-day activities doesn’t mean it’s ready for a higher load.
So what you really have to do is work on progressively loading the area. While seeing a physical therapist or a medical professional will help guide you through these steps and choose the proper exercises and interventions, it also takes some patience and self-governance to slowly return to running fully and get yourself out of that negative feedback loop.
How long tendon healing actually takes
Tendon healing times have been shown to be more progressive, over a longer period of time, and to continue even past the 12-week mark.
In a study done by Danish researchers on 58 individuals with Achilles tendinopathy, their function and pain scores improved over the first 12 weeks of loading, and then continued to improve when they were checked again at a year.
What this means is that the Achilles will keep improving well past that initial 12-week mark. The process of healing takes longer than we expect it to.
Good pain and bad pain
Now for the functional piece of this. How does it relate to running, and how do you gauge the pain you feel when you run? How do you know whether it’s good pain or bad pain?
During the activity, anything sharp and sustained is what you want to avoid. If it feels like a sharp tear or a stabbing pain, that’s your signal to stop. A low-grade pain that’s more of a constant ache is usually okay, as long as it doesn’t get worse as you go, doesn’t linger once you stop, and isn’t sharp.
The next most important thing is how you feel the following day, in that 24 to 48 hour window after the run.
Ask yourself whether the discomfort feels worse than it did before, or about the same as your baseline before the activity. Compare it to how you felt the day before you ran. If it feels the same, that was a good dose. If it feels worse than it did the day before you ran, then most likely it was a little too much.
When rest actually is the answer
Now I’m going to go back on my word a little bit, given the title here. There is one exception, and that exception is a stress fracture.
Stress fractures are small fractures that aren’t significant enough to displace the bone, and often they don’t show up on an X-ray at all. Sometimes they can only be picked up on an MRI or something with more powerful imaging.
That being said, a stress fracture in the lower extremity usually requires some degree of offloading, and depending on the site, that can mean staying off the limb entirely for a while. This is the one instance where rest genuinely is the plan.
Even then, there are still ways to keep yourself healthy and strong while you’re offloaded. That’s another reason I’d recommend seeing a physical therapist or a trained medical professional, so the joints and muscles that are still available to you stay impairment-free, strong, and healthy. When you’re cleared to put weight back down on that area, you want to be ready to go.
The return to run program
As for the return to run program I have my patients do, it’s a walk-run, and I have them start with a one-to-one ratio of walking to running. That can be anywhere between one minute on and one minute off, depending on the severity of the symptoms.
Before you start: pain-free walking, and pain-free single-leg hopping. If hopping hurts, stay with the strength work.
Run every other day. Never two days in a row.
Every session runs about 30 minutes. Run every other day, never two days in a row.
Stage 1 — 1 minute run / 1 minute walk, 15 rounds
Stage 2 — 2 minutes run / 1 minute walk, 10 rounds
Stage 3 — 3 minutes run / 1 minute walk, 7 rounds
Stage 4 — 5 minutes run / 1 minute walk, 5 rounds
Stage 5 — 9 minutes run / 1 minute walk, 3 rounds
Stage 6 — 30 minutes continuous, easy
Advance when you’ve done a stage cleanly twice. Drop back a stage if it flares.
To advance: two clean sessions at a stage. Clean means the pain stayed low-grade, didn’t spike afterward, and the next morning was no worse than the one before.
To regress: a flare means drop back a stage and repeat it. Don’t push through, and don’t skip ahead to make up time.
Alongside all of it: progressive calf and Achilles loading. The walk-run gets you back to running. The strength work is the actual treatment, and it continues well past the point where you’re running continuously.
So the next time it hurts
Next time something hurts, resting it doesn’t mean you’re ready to go back to the sport or activity just yet.
Thanks for reading and listening. I’m the author of The Sustainable Mile, and if you’re dealing with this, the return to run structure above is where I’d start.
Reference
Beyer R, et al. Heavy Slow Resistance Versus Eccentric Training as
Treatment for Achilles Tendinopathy: A Randomized Controlled Trial.
Am J Sports Med. 2015;43(7):1704-1711.
[doi:10.1177/0363546515584760](https://doi.org/10.1177/0363546515584760)
Dr. Daniel Zhu is a Doctor of Physical Therapy and RRCA certified run coach in New York City. This is general education, not individual medical advice. If you’re dealing with a persistent injury, get evaluated by a licensed clinician.
