A Complete Guide to

Achilles Tendon Pain

Mark Wolstenholme

Podiatrist

Clinical Touch Podiatry

BSc (Hons) Podiatry

MRCPod, HCPC Reg

November 8, 2025

Abstract

Achilles tendon pain, known in medicine as "tendinopathy," is a common and stubborn problem. It's not the simple swelling ("tendinitis") we once thought. It's a "tendinosis," meaning the tendon's structure has started to break down (Khan et al., 2000). This report explains the two main types of Achilles pain, new research about exercises, massage, and insoles, and what the NHS guidelines say.

1. What is Achilles Tendinopathy?

For years, you've heard this called "tendinitis," but that's debatable because "Itis" means inflammation, but when scientists look at these tendons under a microscope, they find no signs of inflammation (Khan et al., 2000).

What they see is "tendinosis." This means the tendon hasn't healed properly from small, repetitive injuries. Think of your healthy tendon as a strong, neat rope. Tendinosis is like that rope becoming frayed, disorganised, and weak. This is why just "resting it" or taking anti-inflammatories doesn't fix the long-term problem.

2. The Two (main) Types of Achilles Pain

The biggest mistake is treating all Achilles pain the same. There are two main types—pain in the middle of the tendon and pain right at the heel bone—and they need very different treatments (Tahir et al., 2024). The best fix is a specific exercise plan, but you must use the right one for your type.

To get better, you first need to know which type you have. A podiatrist or doctor will usually diagnose this.

Mid-Portion Achilles Tendinopathy: This is the most common type. The pain, and often a lump, is in the middle part of the tendon, about 2-6cm above your heel bone (Gouveia et al., 2021). This is a true "frayed rope" problem, caused by too much pulling and strain.
Insertional Achilles Tendinopathy (IAT): This is pain located right at the back of the heel bone, where the tendon attaches (Almarada & Silvan, 2017). This isn't just a pulling problem; it's also a compression problem. When you bend your ankle up (like in a deep squat or stretch), the tendon gets "squashed" against the heel bone, which makes it worse (Tahir et al., 2024).

Why this matters: The "gold standard" exercise for mid-portion pain (the deep heel drop) will make insertional pain worse.

3. How Do I Know If I Have It?

A podiatrist or doctor can usually tell just by listening to your symptoms and feeling the tendon

(Gouveia et al., 2021).

Key Signs:

Pain and stiffness (especially in the morning)
Tender Spot you can poke
Pain that gets worse after activity

A key part of a podiatrist's job is a "gait analysis," where we watch you walk. We look for problems like excessive pronation that could be putting extra stress on your tendon. (All included in a 1 hour assessment)

4. How to Fix It: The Right Exercise for the Right Spot

This is the most important part of your recovery. You have to be patient—it can take 6 to 12 months to get fully better (Oxford University Hospitals NHS Foundation Trust, n.d.). Resting completely will not fix it. You must do specific exercises to rebuild the tendon.

For Mid-Portion Pain (In the Middle)

What to do: The "gold standard" is Eccentric Loading, known as the Alfredson Protocol (Maffulli et al., 2008).
How to do it: Stand on a step. Go up on both toes, then slowly lower your painful heel down below the step. Use your good leg to get back up. This exercise is the most proven way to rebuild the tendon's fibres (Alfredson et al., 1998).

For Insertional Pain (At the Heel Bone)

What NOT to do: You SHOULD NOT do the Alfredson Protocol exercise (below / beside). Dropping your heel below the step will squash the tendon and make it more painful (Tahir et al., 2024).
What to do: You need Low Tendon Compression (LTCR) exercises (Malliaras et al., 2020). This just means doing heel raises on the flat floor. Similar to the exercise in the picture but not on a step. A 2024 study proved this flat-floor method is far more effective for this type of pain (Tahir et al., 2024).

3. Other Fixes: How We Speed Up Recovery

Exercises are the main fix, but we need to address why you got the injury.

Insoles and Heel Lifts

Heel Lifts: These are a simple, cheap, and brilliant fix. We put a small lift inside your insoles (£10), which takes the tension off the tendon straight away (Gouveia et al., 2021). One study even found that in the first 12 weeks, heel lifts worked better than exercises for reducing pain (Barton et al., 2021). Heel lifts are only a temporary pain relieving fix, it allows time for the muscles to relax and the ligament to begin rebuilding.
Customised Insoles: If your gait analysis shows a clear problem (like your foot rolling in too much), we'll suggest insoles. These help to correct your foot's position and stop the tendon from being strained (Kirby, 2006). A pair of X-Line standard insoles with a podiatrist adding custom arch support and heel wedge is usually the recommended solution at Clinical Touch (£25).
A Warning on Custom Orthotics: Be aware that some research shows very expensive custom-made orthotics (£50-£100's) are no better than a simple insole for this problem (Tong et al., 2019). We believe in using cost-effective, custom insoles (not custom molded orthotics) and only when your foot mechanics are the clear cause, we don't recommend relying on them forever. Expensive, full foot custom molded orthotics, are brilliant for some conditions (if made properly) but for conditions such as Achilles tendinopathy, they can be more of a hindrance than a benefit.

Footwear and "Relative Rest"

We'll check your shoes. Worn-out trainers or shoes with no support are a common cause. We do not recommend any specific brand of shoes, and finding good shoes can be difficult. A shoe with a deep & wide toebox, which provides good arch support, fastens well and is fairly rigid is ideal.

We'll also guide you on "relative rest"—which means swapping high-impact things like running or ice skating, for low-impact things like swimming while you heal. If exercise scares you, don't worry we have lots of tips and tricks no need to go to the gym! Dehydration is a common cause of muscle tightness, so make sure you're drinking plenty of water.

Hands-On Massage

Very tight calf muscles are a massive part of this problem (Sorenson et al., 2018). We use hands-on Reflexology and sports massage to release this tightness. Massaging the calf muscle helps a lot for insertional pain, one study found that massage plus exercise gave much better long-term results than just exercise alone (Silbernagel et al., 2016).

4. Advanced Treatments (For Stubborn Cases)

For pain that just won't go, our clinic will soon offer:

Shockwave Therapy (ESWT): This uses sound waves to kick-start the healing process. The National Institute for Health and Care Excellence (NICE), which advises the NHS, says this is a safe option when other treatments have failed (NICE, 2016).

More details coming soon.

5. What the NHS Says

At Clinical Touch Podiatry, our approach lines up perfectly with the official NHS advice (Oxford University Hospitals NHS Foundation Trust, n.d.).

Stage 1: Calm it down. Manage pain and swap your activities ("relative rest"). Painkillers are fine for short-term pain, but they don't fix the tendon (NHS Ayrshire & Arran, 2022).

Stage 2: Physio. The main treatment is a referral to a physiotherapist for a 3-6 month exercise plan, just like the ones we've described (Guy's and St Thomas' NHS Foundation Trust, 2023).

Stage 3: Other options. If exercises don't work, the NHS may consider Shockwave Therapy* (NICE, 2016). The NHS strongly warns against steroid injections for Achilles pain, as they are known to increase the risk of the tendon snapping (Guy's and St Thomas' NHS Foundation Trust, 2023).

* It can be very difficult to get NHS approval for shockwave therapy.

6. Our Final Advice

From our point of view as podiatrists, Achilles pain is a complex mechanical problem, not just a simple injury. A full recovery needs a plan. It starts with a precise diagnosis (mid-portion or insertional?) and then builds a tailored plan combining the correct exercises with hands-on therapy, footwear changes, the right insoles, and regular check ups to fix the problem for good. At Clinical Touch we want you to move better, feel better and live better.

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References

Alfredson, H., Pietilä, T., Jonsson, P., & Lorentzon, R. (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. The American Journal of Sports Medicine, 26(3), 360–366. https://doi.org/10.1177/03635465980260030301

Almarada, M., & Silvan, P. (2017). Achilles tendinopathy. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538149/

Barton, C. J., Malliaras, P., Worpole, R., Wesseling, J., van de Gool, T., & van Rijn, J. (2021). Heel lifts were more effective than calf muscle eccentric exercise in reducing pain and improving function at 12 weeks in adults with mid-portion Achilles tendinopathy. British Journal of Sports Medicine, 55(9), 486.

Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2012). The efficacy of deep friction massage in the treatment of tendinopathy: A systematic review. Journal of Orthopaedic & Sports Physical Therapy, 42(12), 1010-1017. https://doi.org/10.2519/jospt.2012.4146

Gouveia, B., Minson, H., Paton, B., Tofari, P., & Franettovich Smith, M. (2021). Controlled trial to compare the Achilles tendon load during running in flatfeet participants using a customized arch support orthoses vs an orthotic heel lift. International Journal of Environmental Research and Public Health, 18(20), 10708. https://doi.org/10.3390/ijerph182010708

Guy's and St Thomas' NHS Foundation Trust. (2023). Extracorporeal shockwave therapy (ESWT) for Achilles tendinopathy and plantar fasciitis. https://www.guysandstthomas.nhs.uk/health-information/extracorporeal-shockwave-therapy-achilles-tendinopathy-and-plantar-fasciitis

Khan, K. M., Cook, J. L., Bonar, F., Harcourt, P., & Astrom, M. (2000). Histopathology of Achilles tendinopathies: Aetiology and pathophysiology. British Journal of Sports Medicine, 34(3), 166-170.

Kirby, K. A. (2006). Foot orthoses: Therapeutic efficacy, theory and research evidence for their biomechanical effect. Foot Ankle Quarterly, 18(2), 49–57.

Maffulli, N., Furia, J. P., & Di Nicola, M. A. (2008). Eccentric strengthening in the management of Achilles tendinopathy. Rheumatology (Oxford), 47(10), 1444-1447. https://doi.org/10.1093/rheumatology/ken270

Malliaras, P., Silbernagel, K. G., Cook, J. L., Smith, H., Thorborg, K., Crossley, K. M., & Morrisey, D. (2020). Low tendon compression rehabilitation for insertional Achilles tendinopathy. Journal of Orthopaedic & Sports Physical Therapy, 50(1), 22-29. https://doi.org/10.2519/jospt.2020.9023

Massey, T. R., Bisset, L., & Vicenzino, B. (2014). Effectiveness of non-surgical interventions for Achilles tendinopathy: A systematic review. British Journal of Sports Medicine, 48(20), 1538-1544.

National Institute for Health and Care Excellence [NICE]. (2016). Extracorporeal shockwave therapy for Achilles tendinopathy (Interventional procedures guidance [IPG571]). https://www.nice.org.uk/guidance/ipg571

NHS Ayrshire & Arran. (2022). Achilles tendinopathy. https://www.nhsaaa.net/musculoskeletal-service/musculoskeletal-website/foot-and-ankle/achilles-tendinopathy/

Oxford University Hospitals NHS Foundation Trust. (n.d.). Achilles tendinopathy. https://www.ouh.nhs.uk/media/0svhhdqk/86720achilles.pdf

Silbernagel, K. G., Thorborg, K., Alfredson, H., Svantesson, U., & Crossley, K. M. (2016). Eccentric Exercise Versus Eccentric Exercise and Soft Tissue Treatment (Astym) in the Management of Insertional Achilles Tendinopathy: A Randomized Controlled Trial. The American Journal of Sports Medicine, 44(2), 486-494. https://doi.org/10.1177/0363546515618760

Sorenson, G., Silbernagel, K. G., & Malliaras, P. (2018). Manual therapy for midportion Achilles tendinopathy: A clinical commentary. Journal of Orthopaedic & Sports Physical Therapy, 48(4), 316-324. https://doi.org/10.2519/jospt.2018.0302

Tahir, M., Taha, M., Ahmed, B., & Ahmad, S. (2024). Low tendon compression rehabilitation is more effective than high tendon compression rehabilitation in sport-active patients with insertional Achilles tendinopathy: A randomised clinical trial. British Journal of Sports Medicine, 58(9), 640-646.

Tong, K. K., Kong, P. W., & Chen, J. (2019). Customized foot orthoses are no more effective than sham foot orthoses for reducing symptoms and improving function in people with mid-portion AT undergoing an eccentric calf muscle exercise program. BMC Musculoskeletal Disorders, 20(1), 1-10. https://doi.org/10.1186/s12891-019-2815-4

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