By Cian McMahon
If your Achilles hurts, one of the first things worth paying attention to is exactly where it hurts.
Pain through the middle of the Achilles tendon and pain right down where the tendon meets the heel can feel quite similar, but there is an important difference. Pain in the middle of the tendon is usually influenced mainly by tensile load — essentially, the pulling force created when your calf muscle contracts and tugs on the Achilles. Pain right at the heel, often called insertional Achilles pain, can involve that same pulling force, but there can also be compression of the tendon against the heel bone.
That difference matters. It can change how you modify your activity, which exercises you choose, how you perform them and even which shoes may be more comfortable.
Why does the location of Achilles pain matter?
Your Achilles tendon connects your calf muscles to your heel bone. Every time your calf contracts, it pulls through the Achilles.
That happens a lot more often than you might think. Walking, running, climbing stairs, jumping, exercising and pushing up onto your toes all require the calf and Achilles to work.
But the tendon isn’t loaded in exactly the same way along its entire length.
For practical purposes, it helps to think about two different locations:
- Mid-tendon Achilles pain: pain in the middle section of the Achilles, above the heel.
- Insertional Achilles pain: pain right down at the heel, where the Achilles attaches to the bone.
For mid-tendon pain, we’re particularly interested in how much pulling force is going through the tendon and how often that happens.
Once the pain is right at the heel, there’s another piece to consider: compression.
If the pain is in the middle of your Achilles
The Achilles is built to handle large forces. One of its main jobs is transferring force from your calf muscles through to your foot.
When your calf contracts, it pulls on the Achilles. We call this tensile loading or tensile strain, but you can think of it simply as the calf tugging on the tendon.
If the middle of your Achilles is painful and irritable, one thing we look at is how much of this loading you’re currently asking the tendon to tolerate.
And “load” isn’t just about how heavy something is.
It helps to break it down into three questions:
- How many times are you loading the tendon?
- How much strain is going through it each time?
- How quickly is that strain being applied?
Those three questions give us a few different ways to modify activity. You don’t necessarily have to stop everything that loads your Achilles.
How often are you loading it?
Walking and running involve loading and unloading the Achilles over and over again.
A single step isn’t much to think about. But a long walk or run involves hundreds or thousands of individual loading cycles.
So, if your Achilles has become irritable, reducing the total number of times you’re loading it may be one place to start.
In practice, this could mean temporarily reducing your running distance, cutting back on long walks or reducing repeated jumping and high-volume calf exercises.
The aim isn’t automatically to stop all activity. It’s to reduce the overall amount of loading to something the tendon is better able to tolerate at that point in time.
How much strain is going through the tendon each time?
We can also change the amount of strain going through the Achilles during each step.
This is one reason footwear can matter.
A heel riser slightly elevates the heel and may reduce the strain placed on the Achilles during activities such as walking.
A shoe with a higher heel-to-toe drop can have a similar effect. Heel-to-toe drop simply describes how much higher your heel sits compared with the front of your foot.
This doesn’t mean everyone with Achilles pain needs heel risers or a new pair of shoes. They’re simply two of the variables that can be adjusted when we’re trying to change the amount of strain going through the tendon.
How quickly are you loading it?
The third piece is speed.
Slowly pushing through your foot isn’t the same as pushing off quickly to sprint or jump. Your calf and Achilles are involved in both, but the tendon experiences the strain differently when force is applied quickly.
During a more painful or irritable period, it can therefore be useful to temporarily reduce faster calf contractions.
For example, that may mean taking faster or more explosive calf work out of your exercise program for a period while continuing with appropriately selected slower loading.
As the tendon becomes more tolerant of load, those demands can then be built back up appropriately.
What if the Achilles pain is right at the heel?
This is where the approach changes a little.
Your Achilles attaches directly onto the heel bone. When your ankle moves further into dorsiflexion — think of your knee travelling forwards over your toes while your heel stays down — the tendon at its attachment can experience more compression against the heel.
So, if your pain is right where the Achilles meets the heel, we’re thinking about two things:
How much pulling force is going through the tendon, and how much compression is occurring at the heel?
That second part is why simply treating every painful Achilles in exactly the same way can be unhelpful.
An exercise or position that may be appropriate for pain higher up the Achilles might unnecessarily increase compression if your pain is right at the tendon attachment.
What does Achilles compression actually look like?
An easy way to understand this is to stand with your foot flat on the ground and move your knee forwards over your toes.
As your knee moves forwards, your ankle moves further into dorsiflexion. At the heel, this changes the relationship between the Achilles tendon and the heel bone and can increase compression around the tendon attachment.
You’ll find this position in plenty of normal movements and exercises, including:
- deeper squats
- some calf stretches
- walking or running uphill
- calf exercises where your heel drops below the level of your forefoot.
None of these movements is automatically “bad” for your Achilles.
The question is whether repeatedly loading deeply into that position is appropriate while the tendon attachment is painful and irritable.
Sometimes a relatively small change in position allows you to continue exercising while reducing the amount of compression at the painful area.
A calf raise is a good example
Say you’re doing calf raises on the edge of a step.
At the top of the movement, you’re up on your toes. At the bottom, you might normally let your heel drop well below the level of the step.
That bottom position takes your ankle further into dorsiflexion.
If your pain is through the middle of the Achilles, that range may be incorporated into your exercise program when appropriate.
If your pain is right at the heel, however, dropping deeply off the step also increases compression around the Achilles attachment.
In that situation, the answer may not be to remove calf raises altogether. Changing how you perform the exercise can be more useful.
Reducing how far the heel drops and limiting the amount of dorsiflexion allows you to change the compression at the heel while still loading the calf and Achilles.
This is one of the problems with picking a generic “Achilles rehab program” online. Two people can both have Achilles pain but need quite different exercise positions because their pain is in different parts of the tendon.
Your shoes can make a difference too
Footwear is worth considering for both types of Achilles pain, although we’re not necessarily looking for the same thing.
For mid-tendon Achilles pain, a shoe that positions the heel slightly higher relative to the toes may reduce the strain experienced by the tendon with each step. A heel riser can sometimes be used for the same reason.
With insertional Achilles pain, we’re also interested in what’s happening right at the back of the heel. That means considering the position the shoe places your ankle in as well as how the shoe itself interacts with the painful area.
Rather than asking, “What’s the best shoe for Achilles pain?”, a more useful question is:
What are we trying to change with the shoe?
If we’re trying to reduce strain through the middle of the tendon, our footwear choices may be slightly different from someone whose main issue is compression and irritation right at the heel.
What can you change if the pain is in the middle of your Achilles?
For mid-Achilles pain, think about how often, how much and how quickly you’re loading it.
If your Achilles has become particularly irritable, you might temporarily reduce the amount of running or walking you’re doing rather than continuing with the same weekly volume.
Heel risers or shoes with a higher heel-to-toe drop may be another way of reducing the strain during each step.
If your exercise program contains a lot of fast or explosive calf work, slowing things down for a period can change how quickly strain is being applied.
These don’t have to be permanent changes. They’re ways of adjusting the demands on the tendon while you’re working towards building its capacity back up.
What can you change if the pain is right at the heel?
If your Achilles pain is right where the tendon meets the heel, pay particular attention to activities that push your ankle a long way into dorsiflexion.
That may mean temporarily changing how deeply you move your knee forwards over your toes during certain exercises.
If you’re doing calf raises from a step, for example, you might reduce how far your heel drops at the bottom rather than repeatedly lowering it well below the step.
Footwear may also need some thought, particularly if a shoe is irritating the back of the heel or putting the ankle into a position that isn’t currently comfortable.
Again, these changes aren’t about avoiding ankle movement forever. They’re about adjusting the amount of compression while the tendon is irritable and then progressing things appropriately from there.
What about stretching a sore Achilles?
Stretching is a good example of why the location of your pain matters.
Many calf stretches involve keeping your heel down while moving your knee or body forwards. That takes the ankle further into dorsiflexion.
If your pain is right at the Achilles attachment, that position can also increase compression of the tendon against the heel.
So rather than assuming a sore or “tight” Achilles needs to be stretched, it’s worth thinking about what that stretch is actually doing to the painful part of the tendon.
Stretching isn’t automatically good or bad for Achilles pain. The position, the location of your symptoms and what you’re trying to achieve all matter.
Do you need to completely rest your Achilles?
Not necessarily.
If your Achilles is irritated, reducing some of the activities that are aggravating it can be useful. But simply reducing activity and rebuilding the tendon and calf’s ability to handle load are two different things.
Your Achilles needs to tolerate load. It has to do that for everyday things such as walking and stairs, and considerably more if you want to run, jump, train or play sport.
So, while we may initially change some of the things that are irritating it, exercise also has a role in gradually rebuilding the capacity of the calf and Achilles.
The starting point depends on the person. It also depends on whether the pain is in the middle of the tendon or right at the heel.
When is it worth having your Achilles assessed?
If your Achilles or heel pain is persisting, keeps returning, or is starting to limit your walking, running, training or sport, an assessment can help work out what loads may be contributing to it.
At PhyxYou Physiotherapy in Port Macquarie, an Achilles assessment isn’t simply about identifying where it hurts. We also want to understand what you’re asking the tendon to do.
That means looking at things such as your current walking or running volume, the exercises you’re doing, which movements aggravate the pain, your footwear, and how much and how quickly you’re loading the tendon.
From there, activity, footwear and exercise can be adjusted to suit the location of your symptoms and what you’re trying to get back to.
So, what’s the difference between Achilles pain and heel pain?
If the pain is through the middle of your Achilles, we’re usually particularly interested in tensile loading — how often the calf is pulling on the tendon, how much strain it’s creating and how quickly that strain is being applied.
If the pain is right where the Achilles meets your heel, tensile load still matters, but compression against the heel bone becomes another consideration. That’s why exercise range, ankle position and footwear can need a slightly different approach.
If you’re not sure which type of loading is aggravating your Achilles, or you’re finding it difficult to return to walking, running or training without repeatedly stirring it up, book an assessment with PhyxYou Physiotherapy in Port Macquarie.We can assess what’s happening, look at how you’re currently loading the tendon and help you work out an appropriate plan for your activity and exercise.
