If your Achilles pain sits right where the tendon meets the back of your heel bone, it may not respond to the same exercises that help pain located a few inches higher up the tendon. That distinction, insertional versus mid portion Achilles tendinopathy, came up in a conversation at our 2026 Active Sports Therapy medical conference between Dr. Jason and Dr. Strasser, a sports orthopedic surgeon at Vanderbilt who also works with several professional teams here in Nashville.
Two Locations, Two Different Problems
Dr. Strasser was direct about which cases give him the most trouble. In his words, the insertional cases, where the tendon attaches into the heel bone, are the tricky ones to manage. Dr. Jason’s experience from the rehab side runs a little differently. The mid portion cases, higher up the tendon, are sometimes the ones that take more figuring out for our team. Same diagnosis on paper, different behavior depending on exactly where the pain sits, which is why getting the location right at the start changes the whole plan.
What Is Actually Happening Inside the Tendon
Achilles tendinopathy is not one clean injury. It is a collection of tiny tears in the tendon where scar tissue builds up over time. Some of that tissue develops poor blood flow, described in the conversation as ischemia from a microvascular problem in the area. What is lost along the way is type 1 collagen, the fiber that stores and releases energy efficiently when the tendon loads and unloads with each step. Without enough of it, the tendon does not spring back the way it should.
The approach Dr. Jason described is called stress shielding. Strengthen the healthy tendon around the injured section so it can carry more of the load, while working to calm the metabolic activity right at the site of injury itself. It is less about attacking the damaged tissue directly and more about changing what is being asked of it.
Why We Have to Unload Before We Load
Here is what makes the insertional cases harder to manage early on. A lot of the exercises that normally help build tendon capacity involve dorsiflexion, bending the ankle so the toes come up toward the shin. For a mid portion injury that is usually fine. For an insertional injury, that same motion compresses the exact spot where the tendon meets the heel bone, and compression on an already irritated attachment tends to make things worse before it gets better. So for a while, that range has to be avoided almost entirely.
The Seated Calf Raise Machine
The way we work around that in our office is with a seated calf raise machine set up to stop before neutral, so someone cannot move into the range that compresses the tendon. That lets us still put a heavy load through the tissue, which matters. The literature we pay attention to points to working around 70 percent of maximal contraction to get meaningful tendon adaptation. Once someone can tolerate that heavy, limited range work, we start layering in the eccentric portion of the movement, and from there we can finally start working back toward fuller dorsiflexion without setting off the same irritation.
When Surgery Becomes Part of the Conversation
Dr. Strasser was clear that most of his patients respond to conservative care first. In his own practice, he generally gives a course of conservative treatment around 12 weeks before considering surgery for these cases, and most people improve within that window without needing it. Occasionally someone does not respond, and for them surgery is the right next step. That is his call to make as the surgeon, and it reflects a conservative approach, operating only when it is genuinely the best option for that patient, not a timeline anyone else should expect for themselves.
Common Questions About Achilles Tendon Pain
Why does the location of my Achilles pain matter?
Pain right at the heel bone, called insertional tendinopathy, is affected by compression from ankle bending in a way that pain higher up the tendon is not. That changes which exercises help and which ones aggravate it early on.
Should I stretch a painful Achilles tendon?
Not necessarily, especially if the pain is at the insertion. Stretching often moves the ankle into the same compressive range that irritates that spot, which is why we assess where the pain sits before recommending a specific approach.
Does Achilles tendinopathy always need surgery?
No. Based on Dr. Strasser’s experience, most people respond to conservative care first, and surgery is reserved for the cases that do not improve with rehab over time.
What does treatment actually involve?
Getting an accurate read on where the pain sits, then a loading program built around that location, sometimes alongside modalities like shockwave therapy, progressing the range and intensity as the tendon tolerates it.
If Achilles pain has been sitting in one spot for weeks and is not settling down on its own, book a rehab evaluation with Active Sports Therapy and we will work out exactly where the problem is and what loading plan fits it.
Leave a Reply