Insertional vs Midportion Achilles Tendinopathy: Why Location Changes Rehab

Two Locations, Different Loading Considerations

Midportion tendinopathy affects the main body of the tendon, typically 2–6 cm above where it attaches to the heel bone. It is the more common presentation. Pain and tenderness are felt in the cord of the tendon itself, and there is sometimes a thickened area you can feel between your finger and thumb.

Insertional tendinopathy affects the tendon where it attaches to the calcaneus (heel bone). Pain is felt at the very back of the heel, and it is often aggravated by positions that bend the foot up towards the shin, such as walking uphill, deep squats, or dropping the heel off a step.

The key difference

Midportion Achilles tendinopathy: the main rehabilitation goal is progressively increasing the tendon and calf complex's capacity to tolerate tensile and energy-storage loads.

Insertional Achilles tendinopathy: the same principle of progressive loading applies, but compression at the tendon insertion also needs to be considered. Deep dorsiflexion may therefore need to be modified, particularly when symptoms are irritable.

The two can coexist, and some people have symptoms in both areas.

Why Compression Matters at the Insertion

At the insertion, the Achilles tendon interfaces closely with the posterior calcaneus and surrounding structures. As the ankle moves into dorsiflexion, compression at the insertion can increase, adding to the tensile load experienced by the tendon. Compression has been proposed as a factor in the development and aggravation of insertional tendinopathy, although this comes from a conceptual model rather than trials showing that compression causes the condition.

This is why the classic heel drop off a step, where the heel sinks below the level of the step, needs more thought for insertional presentations. It takes the ankle into deeper dorsiflexion, which can increase compressive loading at the insertion.

What the 2025 Trial Found

In a 2025 randomised clinical trial involving sport-active adults with chronic insertional Achilles tendinopathy, a rehabilitation programme designed to reduce tendon compression produced better clinical outcomes than a higher-compression programme at 12 and 24 weeks. The programme included limiting ankle dorsiflexion, avoiding calf stretching and using heel lifts.

It is worth being clear about what this does and doesn't show:

• It shows that reducing compression can improve outcomes. It does not establish that a higher-compression exercise will automatically make insertional tendinopathy worse.
• Both groups still followed a progressive loading programme. Reducing compression was about how the tendon was loaded, not whether it was loaded.
• Because this was a relatively small trial (42 participants) of sport-active adults with chronic insertional symptoms, the findings should be applied alongside clinical assessment rather than treated as a universal rule for every case of insertional Achilles pain.

For an irritable insertional tendon, repeatedly loading the tendon into deep dorsiflexion may aggravate symptoms. This is why exercise selection and range of motion should be individualised rather than automatically prescribing heel drops from a step.

What This Means for Midportion Tendinopathy

For midportion tendinopathy, compression at the calcaneal insertion is less of a concern, and progressive calf loading through a fuller range is usually appropriate. This does not mean that every midportion case needs to be trained immediately through maximal dorsiflexion; range should still be progressed according to symptoms, capacity and the demands of the person's sport or activity.

Loading may include heel raises, heel drops and heavy slow resistance training depending on the individual's symptoms and capacity. Heavy slow resistance and eccentric training have produced similarly positive outcomes in chronic midportion Achilles tendinopathy, giving clinicians flexibility to choose exercises that suit the person's symptoms, preferences and goals.

For more on exercise choice, read Heel Drops, Heavy Slow Resistance or Isometrics: Is There a Best Achilles Exercise?.

Not All Back-of-Heel Pain Is Tendinopathy

Pain at the back of the heel can also come from a bursa between the tendon and the heel bone, a prominent posterior calcaneus (sometimes described as Haglund-type morphology), irritation of nearby nerves, or structures at the back of the ankle joint. In children and adolescents, heel pain has different common causes altogether.

Achilles tendinopathy is usually diagnosed clinically. Imaging is not routinely required in straightforward cases, but ultrasound or MRI may be useful when the diagnosis is uncertain, symptoms are atypical or not following the expected course, or another condition needs to be investigated. Structural changes can also appear in tendons that are not painful, so scan findings need to be interpreted alongside the clinical picture.

If your pain sits more under the heel than behind it, Is It Plantar Fasciitis? Other Causes of Heel Pain.

How We Assess This at IP Physio

We establish where your symptoms sit, what reproduces them, and how your tendon responds to tension and to positions of increased compression. That helps guide exercise selection, range of motion, load progression and, where appropriate, footwear or temporary heel-lift strategies. We then progress your programme using objective calf strength and capacity testing.

For the full picture, including pain-guided loading, imaging and how rehabilitation progresses, read Achilles Tendinopathy: Midportion vs Insertional, Symptoms & Rehab.