In this study, we examined how hill running affects the Achilles tendon, which is a common location for injuries in runners. Twenty females ran for 10 min on three randomly selected grades (-6%, 0%, +6%). Achilles tendon (AT) cross-sectional area (CSA) was imaged using Doppler ultrasound and peak vertical forces were analyzed using high-speed (240 Hz) videography. A metabolic cart and gas analyzer ensured a similar metabolic cost across grades. Data were analyzed using a forward selection regression. Results showed a decrease in AT CSA from pre-run to post-run (p = .0001). Peak vertical forces were different across grades (p = .0001) with the largest occurring during downhill running and smallest during uphill running. The results suggest that the Achilles tendon is affected by running and a decrease in CSA appears to be a normal response. The AT CSA does not differ between grade conditions when metabolic cost of running is matched, suggesting an adaptive effect of the AT. Coaches and athletes can use this knowledge to develop workout protocols that transition runners to downhill running and allow them to adapt to these greater forces.