Two runners walk into a clinic with "Achilles pain." Same tendon, same sport, same frustration. One hurts an inch or two above the heel bone. The other hurts right where the tendon attaches to the heel itself. If they both get handed the same rehab sheet, and they usually do, one of them is probably going to get worse.
Where your Achilles hurts changes what's irritating the tendon, which changes what rehab should look like. Getting this wrong is one of the most common reasons Achilles rehab stalls, and almost nobody tells you about it.
A note on terminology first: whether you were told you have Achilles tendinitis, tendonitis, or tendinosis, the question below still applies. Those names get thrown around interchangeably, and tendinopathy is the broader term most clinicians use now. What matters far more than the label is where on the tendon it hurts.
Find your spot
Press along your Achilles and find the sore spot. You'll usually land in one of two zones:
Mid-portion
- Pain roughly an inch or two above the heel bone, in the "rope" of the tendon
- Often a tender, sometimes thickened spot you can pinch
- Classically stiff and sore first thing in the morning, warms up with activity
- The more common of the two
Insertional
- Pain right at the back of the heel bone, where tendon meets bone
- May be aggravated by shoes pressing on the area
- Often flares with uphill walking, stairs, or anything stretching the ankle deeply
- Stubborn, and often worsened by the "standard" advice
Why the location matters: tension vs. compression
The difference comes down to tension versus compression. The mid-portion of the Achilles is mostly irritated by tensile load — too much pulling, too fast, too soon. Rehab for it is fairly forgiving: the tendon generally tolerates being loaded through a full range of motion, including a good stretch at the bottom.
The insertion is different. Where the tendon wraps onto the heel bone, deep ankle bend (dorsiflexion) doesn't just pull on the tendon, it also compresses it against the bone. If the insertion is already irritated, that compression keeps it that way.
What changes in practice
Without turning this into a treatment plan (that requires assessing an actual human), here's how the location shifts the strategy:
- Mid-portion: the tendon usually tolerates, and eventually benefits from, loading through a full range of motion (ROM). Progression is mostly about gradually increasing load and, later, speed.
- Insertional: early rehab typically stays in ranges that limit compression. Think loading with the heel level or elevated rather than dropped below a step. Deeper ranges are earned as the tendon settles. Even small things like avoiding aggressive calf stretching can matter.
- Both: need progressive loading over months, and both eventually need to restore the tendon's spring (the ability to store and release energy quickly) before running and jumping feel normal again. Skipping that last stage is one of the most common reasons rehab stalls.
Both types share the same finish line
One thing that doesn't change with location: tendons don't get better with rest alone, and they don't get better with light, unchanging exercise either. They adapt to progressively increasing demand. The final stage, which most home rehab never reaches, is restoring elastic, springy loading. A tendon that can handle slow heavy work but not fast bouncy work isn't finished, and that usually shows up the first week back at sport. It's also worth checking the floor underneath the problem: a weak foot quietly hands extra load to the tendon every single step.
Common questions
Can I have insertional and mid-portion Achilles pain at the same time?
Yes, it happens. When both zones are irritable, the compression-sensitive insertion usually sets the limits early on, so plans tend to get built around protecting that first and opening up range later.
Are heel drops off a step always wrong for insertional pain?
Not always, and not forever. The issue is specifically the deep drop below step level, which is where compression at the insertion is greatest, and that's mostly a problem while the insertion is irritable. Many people work back toward deeper ranges later, once symptoms have settled. It's the timing that catches people out, not the existence of the exercise.
What if the pain is underneath my heel rather than behind it?
That's more likely plantar fascia territory than Achilles. Classic plantar fascia pain is felt on the underside of the heel and is often at its worst with the first steps in the morning. Different structure, different plan, and worth getting identified properly rather than assumed.
How do I know for certain which type I have?
Location plus what aggravates it usually points strongly one way, which is what this guide is for. But “usually” isn't “always”, and a bursa, a bony prominence, or a neighbouring structure can muddy the picture. If you've been guessing for months without progress, an in-person assessment is worth more than another article.
Want a program that respects this difference?
The program I recommend handles both presentations and progresses all the way through to springy loading. Here's my full review, including who shouldn't buy it.
Read the DGR program review →This is educational content, not medical advice. I'm a licensed physical therapist, but nothing on this site is provided in that capacity, and reading it doesn't make me your physical therapist. I'm sharing education about conditions and rehab principles, not treating you. Always get clearance from your physician, physical therapist, or another qualified medical professional before starting any new exercise or rehab program. Heel pain has other causes too. If your pain is severe, sudden, or not behaving like anything above, get assessed. Read the full disclaimer.