You've felt it on your first steps out of bed, a stiffness, sometimes a sharp ache, right at the back of the heel or a few centimetres above it. Maybe it eases after a warm-up, only to return the next morning. If you've tried rest, stretching, or generic calf exercises without lasting improvement, there's a good chance the approach wasn't matched to your specific type of Achilles tendinopathy, and that distinction matters more than most people realise.
It's Not Just Inflammation
The first thing to understand is what Achilles tendinopathy actually is. It is not simply inflammation, and this matters because anti-inflammatory strategies alone rarely resolve it. Tendinopathy is a response to load exceeding the tendon's current capacity. The tendon's internal structure becomes disorganised, its ability to tolerate and transmit force is reduced, and pain emerges as a signal that demand is outstripping what the tissue can handle. This framing changes everything about how you approach treatment. You cannot rest your way to a stronger tendon. You need to load it, but load it intelligently.
Who Gets This?
Achilles tendinopathy is particularly common among runners, especially those who have increased their training volume or intensity too quickly. It also affects people returning to exercise after a period of inactivity, middle-aged recreational athletes whose tendon capacity has declined without a corresponding reduction in demand, and individuals whose calf complex is simply not strong enough relative to the loads they are placing on it. Affecting up to 52% of elite runners at some point in their careers, it is one of the most common overuse injuries in sport, and one of the most mismanaged.
Mid-Portion vs Insertional: A Critical Distinction
Not all Achilles tendinopathy is the same, and the location of your pain determines the approach to rehabilitation. Mid-portion tendinopathy affects the main body of the tendon, typically 2–6 cm above its attachment to the heel bone. This is the more common presentation. It responds well to progressive tensile loading, exercises that place the tendon under controlled tension through its range of motion. The classic heel drop off a step is appropriate here, as is heavy slow resistance calf training. Insertional tendinopathy affects the tendon right at its attachment to the calcaneus (heel bone). This is where the distinction becomes clinically critical: the tendon at its insertion is sensitive not just to tension but to compression, specifically the compression that occurs when the heel bone pushes against the tendon as the ankle moves into dorsiflexion. This means that the heel drop off a step, the exercise so often prescribed, can actively aggravate insertional tendinopathy by driving exactly the compressive load that is irritating the tendon. A 2025 randomised controlled trial demonstrated that a rehabilitation programme specifically designed to reduce tendon compression, limiting ankle dorsiflexion during exercises, eliminating calf stretching, and incorporating heel lifts, produced significantly better outcomes at both 12 and 24 weeks compared to a standard high-compression programme. Getting this distinction wrong does not just fail to help; it can make the condition worse.
Pain-Guided Loading: What It Means in Practice
One of the most important concepts in tendinopathy rehabilitation is pain-guided loading. Most patients arrive believing that any pain during exercise means stop. In tendinopathy, this is not quite right. A modest, acceptable level of discomfort during loading, typically up to a 3–4 out of 10 on a pain scale, is not a sign of damage. Tendons are not injured by appropriately dosed loading; they adapt to it. What matters is what happens in the 24 hours after a session: if pain has returned to baseline by the next day, the load was appropriate. If it has spiked and stayed elevated, the load was too much. This monitoring approach allows activity, including running, to continue through rehabilitation, rather than being abandoned entirely. Evidence consistently shows that complete rest is not indicated and typically worsens outcomes.
The Four Stages of Tendon Rehabilitation
Regardless of location, Achilles tendinopathy rehabilitation follows a logical progression: Stage 1, Isometric loading: Sustained holds that build tendon tolerance and provide pain relief without high tensile or compressive stress. Particularly useful in the early or reactive phase when the tendon is highly irritable. Stage 2, Isotonic loading (heavy slow resistance): Progressive strengthening through controlled movement, building calf strength and tendon capacity. This phase is the engine of recovery and is most commonly underdosed. Stage 3, Energy storage and release: Plyometric exercises, hopping, skipping, bounding, that train the tendon's capacity to rapidly absorb and release force. This is what running and sport actually require; training without it leaves the tendon underprepared. Stage 4, Sport-specific loading: Running progression, change of direction, and the demands of your specific sport, reintroduced systematically and guided by how the tendon responds.
How IP Physio Can Help
We begin by determining exactly where your tendon is symptomatic and what type of load is aggravating it, because the distinction between mid-portion and insertional changes the programme entirely. Common mistakes like prescribing heel drops off a step for insertional tendinopathy, or excessive rest for either type, are things we actively avoid. From there, we use objective calf strength testing to quantify where your capacity actually sits and build a staged loading programme that progresses in line with your tendon's response. We monitor how your tendon behaves between sessions, adjust accordingly, and, crucially, ensure the programme connects all the way through to your return to running or sport, not just to a point where you feel better at rest. If you've been dealing with persistent Achilles pain that hasn't responded to standard advice, we'd like to take a more systematic look at why, and what to do about it. Get in touch with us today.
References
- Cook JL, Purdam CR. Is compressive load a factor in the development of tendinopathy? Br J Sports Med. 2012;46(3):163–168.
- Pringels L, Capelleman R, Van den Abeele A, et al. Effectiveness of reducing tendon compression in the rehabilitation of insertional Achilles tendinopathy: a randomised clinical trial. Br J Sports Med. 2025;59(9):640–650.
- Chimenti RL, Neville C, Houck J, et al. Achilles pain, stiffness, and muscle power deficits: midportion Achilles tendinopathy revision 2024. J Orthop Sports Phys Ther. 2024;54(12):CPG1–CPG44.
- Martin RL, Chimenti R, Cuddeford T, et al. Achilles pain, stiffness, and muscle power deficits: midportion Achilles tendinopathy revision 2018. J Orthop Sports Phys Ther. 2018;48(5):A1–A38.
- Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007;35(6):897–906.
- Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes. Sports Med. 2013;43(4):267–286.
- Beyer R, Kongsgaard M, Hougs Kjær B, 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.