Part of Achilles tendinopathy
Insertional vs midportion Achilles tendinopathy: which do you have?
Warning signs, and when to get help
What is the difference between insertional and midportion Achilles tendinopathy?
The Achilles runs from the calf muscles down to the back of the heel bone (calcaneus). Midportion tendinopathy is pain in the cord itself, which Silbernagel and colleagues (2020) place 2 to 6 cm above the calcaneal insertion. Insertional tendinopathy is pain at the bottom end, where the tendon fans out onto the bone. Those two names are addresses on one tendon, nothing more. AAOS OrthoInfo describes the midportion type as more common in younger active people, especially runners, and the insertional type as frequently linked to tight calf muscles.
The words first, because they cause confusion on every other page you read. Silbernagel and colleagues (2020) explain that tendinitis is discouraged as a term because it implies inflammatory activity, which may or may not be present, and that tendinopathy is preferred: degeneration or failed healing from continuous overload without enough recovery. Tendinosis is an older word for the same degenerative picture, and AAOS OrthoInfo puts it more briefly: tendinitis, tendinosis and tendinopathy are common terms that essentially refer to the same problem. Tendonitis is the spelling most patients search for. All four are used for this problem, and none of them says anything about which end of the tendon hurts.
How do you tell which one you have?
Sit down with the leg relaxed and find the tender spot, not the general area. Run a fingertip down the back of the ankle until you hit the point that makes you wince, then notice what is under your finger. The cord of the tendon can be pinched between thumb and finger and squeezed from both sides, and it feels like a thick rope. The insertion cannot be pinched, because you are pressing on the hard back edge of the heel bone with a thin layer of tendon over it. Nothing you find this way is a diagnosis, and it is where a clinician starts too.
A rough measurement is what separates the two. Two to three adult finger widths above the top of the heel bone lands you in the 2 to 6 cm band that Silbernagel and colleagues (2020) describe for the midportion. Lower than that, on the bone itself, is the insertion.
Two other clues are worth collecting while you are down there. If what you notice during the day is the back of a shoe pressing on the spot, that points to the insertion, and AAOS OrthoInfo lists pain at the back of the heel when you wear shoes among the usual symptoms, where people with midportion pain rarely complain about the back of a shoe. Bending the ankle up a long way does the same job, by dropping the heel off a step or doing a deep calf stretch: that tends to be the move that provokes insertional pain and is often tolerated with midportion pain, and it is the single most useful thing you can tell a physio.
Swelling behaves differently at the two sites as well, the midportion often looking and feeling thickened along a stretch of the cord, the insertion sore and sometimes prominent at the very back of the heel instead.
One more answer is allowed, and plenty of people need it: both. AAOS OrthoInfo says plainly that the two types can occur separately or at the same time, and the two sites are only a few centimeters apart on the same tendon. If both spots are tender, work on the cautious assumption that the insertion is involved. The reason is not caution for its own sake: the restriction that goes with insertional pain, keeping the heel at step level or above, costs a midportion tendon almost nothing, while the full below-step version is the exercise OrthoInfo tells you not to do with insertional pain at all. The cheap mistake is the safe one to make.
Why does the treatment differ?
In the cord of the tendon the load is tension: the tendon is pulled along its length every time you push off, which is the loading a progressive strength program is designed to give it. At the insertion there is tension plus compression, so the two sites are being asked to cope with different things. Silbernagel and colleagues (2020) describe compressive forces on the tendon and the heel bone from footwear or from activities that place the ankle in a bent-up position, uphill running being their example, as possible contributors to pain there. The Kent Community Health NHS leaflet, written specifically for insertional tendinopathy, treats that pressure as a key factor and advises avoiding walking uphill or on inclines, sticking to flat ground, and avoiding flat shoes.
So the insertional version of this condition is not treated more gently, whatever you may have been told. It is treated with the compressing positions taken out and the loading left in. That distinction is where most of the conflicting advice online comes from: one set of pages is written about tension, the other about tension plus compression, and neither says which it is talking about.
What changes in the exercises for insertional pain
The bottom of the movement is the main change, and on paper it is a small one. If your pain is at the back of the heel (insertional), keep heel raises on a flat floor or at step level, and skip any exercise that lets the heel drop below a step until your physio says otherwise.
AAOS OrthoInfo states it as an instruction: heel drop exercises should be performed only for noninsertional Achilles tendinitis, and not if you have the insertional kind. The Dutch multidisciplinary guideline advises, for insertional Achilles tendinopathy, initially performing the exercises on a flat surface (de Vos and colleagues, 2021). Jonsson and colleagues (2008) built their program for insertional pain around exactly that: lowering to floor level and never below it. The Kent leaflet's own exercise is also done standing on a flat surface, rising onto the toes of both feet and lowering the heels back to the ground.
Our calf raises page is the flat-floor version, and the calf raise on a step page is the one where the heel position has to be set deliberately rather than by habit.
A lift can go under the heel during the exercise. Silbernagel and colleagues (2020) describe limiting how far the ankle bends up by placing a lift under the heel while doing heel raises, and give its thickness as 0.5 to 1 inch, which they convert to 1.3 to 2.5 cm. That is a lift used during the exercise, not a heel height for a shoe.
Deep calf stretches usually come out at first, because a stretch that pulls the ankle up hard is the same position as a below-step heel drop, with the same effect at the insertion.
What does not change is the rest of it: graded loading, done consistently, judged by the next morning. Heel drops explained covers the exercise itself, and shoes and heel lifts covers the footwear side, including the Kent leaflet's heel height figure and the silicone heel cushion.
What else sits at the back of the heel?
Several problems share a very small patch of heel, and they are easy to confuse because they all hurt in the same square inch. A Haglund deformity is a bony prominence on the upper back part of the heel bone (Choo and colleagues, 2020). Bone spurs often form at the back of the heel with insertional Achilles tendinitis (OrthoInfo). A retrocalcaneal bursa, a small fluid-filled cushion sitting between the tendon and the bone, can become irritated too, and the NHS lists bursitis among the causes of heel pain, with redness, swelling and a dull ache. Syed and Perera (2016) describe Haglund's syndrome as covering the deformity, insertional tendinopathy and bursitis together, which is the most useful thing to take from all of this: these are not competing diagnoses so much as neighbors, and more than one is often present.
What it means in practice is that you do not need to settle the question yourself, because the first steps are much the same: take the compression off the back of the heel, change what presses on it, and load the tendon in a way that does not squeeze it. For heel pain that may not be the Achilles at all, heel pain: Achilles, plantar fasciitis or bursitis sorts the three structures out, and heel pain in the morning covers the morning pattern and the other causes.
Heel pain in a child or teenager is usually a growth plate problem, not a tendinopathy, which is what Sever's disease covers, and it needs checking before any exercise program. Two sore heels with no training explanation, especially alongside back stiffness that is worse in the morning, belong with the inflammatory line on the warning list and with ankylosing spondylitis.
How good is the evidence for each?
For the midportion there is a clinical practice guideline. The 2024 revision states its own scope as midportion Achilles tendinopathy (Chimenti and colleagues, 2024), and it sits on top of randomized trials of loading programs. Its lead recommendation, on strong evidence, is tendon loading exercise with loads as high as tolerated as the first-line treatment, asked for at least 3 times a week, with complete rest advised against.
For the insertion there is much less. The central study, Jonsson and colleagues (2008), is a pilot of 27 people with 34 painful tendons and no comparison group: at about 4 months, 18 of the 27 were satisfied and back to their previous tendon-loading activity, which is 67 percent of the people and 23 of the 34 tendons. That is a promising signal and it is not proof, and the authors present it as a pilot. Alongside it sit the Dutch multidisciplinary guideline's advice to start the exercises on a flat surface for insertional pain (de Vos and colleagues, 2021), AAOS OrthoInfo's instruction not to use heel drops for insertional tendinitis, NHS patient leaflets and clinical practice. So the restriction itself is better supported than the program is.
Advice for insertional pain is therefore more cautious and more individual, which is a reasonable response to thin evidence, not a failure. If you have insertional pain and the internet seems to contradict itself, part of that is real: the strongest recommendations in this field were written about a different part of the same tendon.
The Kent leaflet advises against steroid injections for insertional pain, saying they may give temporary relief but are not a cure and could lead to tendon rupture. OrthoInfo says surgery is considered only if pain has not improved after 6 months of nonsurgical treatment. We do not describe operations on this page.
When to see a physio or doctor
See a physio (physical therapist) or doctor if the pain is severe, stops you walking normally, keeps getting worse, or has not improved after a few weeks of looking after it yourself. Sorting insertional from midportion is one of the quickest things an assessment does, and it is the decision everything else hangs on: get it wrong and the standard exercise advice is the thing making you sore.
For insertional pain that has not improved after three months of loading exercises, the Kent leaflet says an ultrasound scan should be considered, to rule out a more severe injury to the tendon. If you are months in and nothing has shifted, why Achilles pain is not getting better goes through the reasons that usually turn out to be behind it, starting with the one this page is about. The warning signs below each carry their own timing.
Related exercise programs
Warning signs
Get emergency help now
- You felt a sudden pop or snap at the back of your ankle, it felt as if someone hit or kicked you in the calf, or walking or rising onto your toes on that leg suddenly became weak or difficult. Stop exercising and go to an urgent care center or emergency department the same day, even if you can still walk, as this can be a torn (ruptured) Achilles tendon. This page does not cover a rupture.
Get help now, day or night
- Your tendon pain or swelling started while you were taking a fluoroquinolone antibiotic, such as ciprofloxacin or levofloxacin, or in the months after a course. Contact your doctor straight away. The UK medicines regulator (MHRA) advises stopping the antibiotic at the first sign of tendon pain or swelling and talking to your doctor. Hold off the calf exercises until you have been checked.
Get help today
- A calf or thigh that is newly swollen or getting more swollen, warm, tender, red or darker than usual, has swollen veins that are sore to touch, or has a throbbing or cramping pain that does not fit your injury or condition, or that feels different from normal muscle soreness after exercise. This can be a sign of a blood clot (deep vein thrombosis), especially after surgery, an injury, time in a cast or boot, a long trip or a spell of being much less mobile than usual. Get medical advice the same day. If you are also short of breath or have chest pain, call emergency services.
- The tendon or heel is hot, red and swollen, or you have a fever or feel unwell. Get medical help the same day, and go to an emergency department if you feel very unwell. If you have a very high or very low temperature, shivering you cannot control, you are breathing very fast or finding it hard to breathe, you are confused or your speech is slurred, your skin, lips or tongue look blue, gray, pale or blotchy (on brown or black skin this can be easier to see on the palms of the hands or soles of the feet), or you have a rash that does not fade when you press it, call emergency services, as this can be sepsis.
- The pain started with a fall or a blow to the back of the ankle, and there is bruising or you cannot put weight on the foot. Get it checked the same day.
- Heel pain in a child or teenager needs a doctor or physio to look at it before they start any exercises. See a doctor the same day, urgently, if your child is limping when they have not been playing sport, has pain in the hip, groin, thigh or knee as well as the heel, or has heel pain with a fever or seems unwell. If they cannot put weight on the leg, have a high temperature or seem very unwell, go to an emergency department. See a doctor within a day or two if pain wakes your child at night, pain at rest keeps getting worse, or there is a lump or swelling on the heel or ankle that keeps growing. Ask for an urgent appointment rather than the next routine one, and say what the pain does at night and whether a lump is getting bigger.
- The pain is there at night or at rest as well as with activity and keeps getting worse. If you are being treated for cancer now, contact your cancer team the same day.
Book an appointment
- Your heel or Achilles pain comes with back pain and stiffness that is worse in the morning and at night, or with painful, swollen joints elsewhere, or both heels became painful without an obvious reason. The same applies if you also have psoriasis, Crohn's disease or ulcerative colitis, or have had a red, painful, inflamed eye (iritis). This is not an emergency, but see your doctor in the next week or two, as it can be a sign of an inflammatory arthritis such as ankylosing spondylitis.
- You have numbness, tingling, burning or loss of feeling in the foot, often along the outer edge. Book an assessment with a doctor or physio in the next week or two. If it came on over hours or days, started after an injury, is spreading, or comes with weakness in the foot, get medical advice the same day.
- The pain is there at night or at rest as well as with activity and keeps getting worse. If you have had cancer, now or in the past, or are losing weight without trying, see your doctor sooner, within a day or two, and mention it. This applies even if the pain is not getting worse.
- The pain is there at night or at rest as well as with activity and keeps getting worse. See your doctor within a few days.
Common questions
How do I know if my Achilles pain is insertional or midportion?
Find the tender spot with one fingertip while you are sitting with the leg relaxed. If the sore part is the rope of tendon you can pinch between thumb and finger, two to three finger widths above the heel bone, that is the midportion, the area Silbernagel and colleagues (2020) describe as 2 to 6 cm above the insertion. If the tenderness is lower and you are pressing on hard bone, not squeezable cord, and the back of a shoe is what you notice most during the day, that is the insertion. If both spots are sore, say so to your clinician instead of picking one, because the cautious handling applies.
Why do heel drops hurt my insertional Achilles pain?
Because of where the bottom of the movement puts your ankle. Letting the heel sink below a step bends the ankle up a long way, and that presses the tendon against the back of the heel bone. Silbernagel and colleagues (2020) describe exactly that compression at the insertion from footwear or from activities that put the ankle in a bent-up position. The fix is not to abandon the exercise but to change where it stops: Jonsson and colleagues (2008) had people lower only to floor level and never below it. Heel drops explained has the detail.
Is insertional Achilles tendinopathy harder to treat?
It is less well studied, which is not quite the same thing, and it is the honest answer. The 2024 US clinical practice guideline for physical therapists states its scope as midportion Achilles tendinopathy (Chimenti and colleagues, 2024), so the strongest recommendations in the field were not written for the insertion. What we have for the insertion is one small study without a comparison group (Jonsson and colleagues, 2008), a line in the Dutch multidisciplinary guideline advising that the exercises for insertional pain are done on a flat surface at first (de Vos and colleagues, 2021), AAOS OrthoInfo's instruction not to do heel drops at all for insertional tendinitis, an NHS patient leaflet and clinical practice. One number comes from the study before that one. Fahlstrom and colleagues (2003) ran the standard 12 week eccentric program, the version that loads the ankle into full upward bend, in two groups at once. Among the midportion tendons, 90 of 101, which is 89 percent, ended up satisfactory with the person back at their pre-injury level. Among the insertional tendons, only 10 of 31, which is 32 percent, did. That gap is what prompted the flat-floor version Jonsson and colleagues went on to test. Clinicians do commonly find insertional pain slower to settle, and that is practice experience, not a measured comparison, so we are not going to put a figure on it.
What is a Haglund deformity?
A bony prominence on the upper back part of the heel bone (Choo and colleagues, 2020). It sits in the same small area as the tendon insertion and the bursa in front of the tendon, which is why one word often gets used for the whole region: Haglund's syndrome is described as covering the deformity, insertional tendinopathy and bursitis together (Syed and Perera, 2016). AAOS OrthoInfo also notes that bone spurs often form at the back of the heel with insertional Achilles tendinitis. In other words, more than one of these can be true in the same heel at the same time.
Is Achilles tendinopathy the same as Achilles tendonitis?
They are names for the same problem, and clinicians have moved away from one of them. Silbernagel and colleagues (2020) explain that tendinitis is discouraged because it implies inflammatory activity, which may or may not be present, and that tendinopathy is preferred, describing degeneration or failed healing from continuous overload without enough recovery. Tendinosis is an older word for the degenerative changes. Most patients search for tendonitis, so you will see all four words in use, and none of them tells you whether your pain is insertional or midportion.
Do I need a scan to tell which one I have?
No. The Guy's and St Thomas' NHS leaflet puts it directly: you do not need an X-ray or other scans to diagnose Achilles tendinopathy, and the diagnosis is usually confirmed from your history and an examination. Where the tenderness sits and what provokes it is how this is sorted out, in a few minutes, by hand. The Kent Community Health NHS leaflet does mention imaging, but for a different question: it says that for insertional pain, if loading exercises have not improved symptoms after three months, an ultrasound should be considered, to rule out more severe injury to the tendon. That is about a tendon that has not responded, not about making the initial distinction.
References
- Silbernagel KG, Hanlon S, Sprague A. Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. Journal of Athletic Training. 2020;55(5):438-447. https://doi.org/10.4085/1062-6050-356-19
- Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, Martin RL. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision - 2024. Journal of Orthopaedic and Sports Physical Therapy. 2024;54(12):CPG1-CPG32. https://doi.org/10.2519/jospt.2024.0302
- Jonsson P, Alfredson H, Sunding K, Fahlstrom M, Cook J. New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. British Journal of Sports Medicine. 2008;42(9):746-749. https://doi.org/10.1136/bjsm.2007.039545
- Fahlstrom M, Jonsson P, Lorentzon R, Alfredson H. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surgery, Sports Traumatology, Arthroscopy. 2003;11(5):327-333. https://doi.org/10.1007/s00167-003-0418-z
- de Vos RJ, van der Vlist AC, Zwerver J, Meuffels DE, Smithuis F, van Ingen R, van der Giesen F, Visser E, Balemans A, Pols M, Veen N, den Ouden M, Weir A. Dutch multidisciplinary guideline on Achilles tendinopathy. British Journal of Sports Medicine. 2021;55(20):1125-1134. https://doi.org/10.1136/bjsports-2020-103867
- Kent Community Health NHS Foundation Trust. Achilles insertional tendinopathy. Patient leaflet 01271. Published 2 December 2024. https://www.kentcht.nhs.uk/leaflet/achilles-insertional-tendinopathy/
- Guy's and St Thomas' NHS Foundation Trust. Achilles tendinopathy. Patient information, resource number 4609/VER3. Last reviewed October 2024. https://www.guysandstthomas.nhs.uk/health-information/achilles-tendinopathy
- American Academy of Orthopaedic Surgeons. Achilles tendinitis. OrthoInfo. https://www.orthoinfo.org/en/diseases--conditions/achilles-tendinitis/
- Choo YJ, Park CH, Chang MC. Rearfoot disorders and conservative treatment: a narrative review. Annals of Palliative Medicine. 2020;9(5):3546-3552. https://doi.org/10.21037/apm-20-446
- Syed TA, Perera A. A Proposed Staging Classification for Minimally Invasive Management of Haglund's Syndrome With Percutaneous and Endoscopic Surgery. Foot and Ankle Clinics. 2016;21(3):641-664. https://doi.org/10.1016/j.fcl.2016.04.004
- Medicines and Healthcare products Regulatory Agency. Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate. Drug Safety Update. 22 January 2024. https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-must-now-only-be-prescribed-when-other-commonly-recommended-antibiotics-are-inappropriate
- NHS. Deep vein thrombosis (DVT). Page last reviewed 30 April 2026. https://www.nhs.uk/conditions/deep-vein-thrombosis-dvt/
- NHS. Symptoms: Ankylosing spondylitis. Page last reviewed 5 January 2023. https://www.nhs.uk/conditions/ankylosing-spondylitis/symptoms/
Written and checked by the PocketPhysio editorial team. Last updated 2026-10-21.
This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.