Achilles pain: why the location matters

Achilles pain can interrupt walking, running and sport. Before choosing exercises or treatment, it helps to establish exactly where the symptoms arise. Pain where the tendon attaches to the heel may need a different rehabilitation approach from pain further up the tendon.

At Steps Podiatry & Gait in Inverness, we start by establishing a diagnosis. We then consider how you walk and, where relevant, run, before choosing interventions that fit your findings and goals.

Insertional or midportion Achilles pain?

Insertional Achilles tendinopathy affects the region where the tendon attaches to the heel bone, within approximately the lowest two centimetres. Midportion tendinopathy affects the tendon further above that attachment. Both can cause pain with loading and stiffness after rest. Nearby structures, including the bursae around the heel, may also contribute to symptoms. [1]

The distinction matters because bending the ankle deeply upwards can compress the tendon against the heel at its insertion. A heel-drop exercise below the edge of a step may therefore be unsuitable as a starting exercise for an irritable insertion. [3]

First, establish a diagnosis

Your specialist foot and ankle assessment explores the location and pattern of your pain, when symptoms began, changes in activity, footwear and previous treatment. We examine the painful region and nearby structures to establish what is most likely responsible.

Establishing a diagnosis provides the starting point for exploring the contributing functional factors and deciding which treatments are appropriate. Where further investigation is needed, we explain the next steps.

Diagnostic ultrasound: looking beyond the Achilles tendon

Pain at the back of the heel is not always caused by the Achilles tendon alone. At Steps, diagnostic ultrasound can help clarify which soft tissues are involved when the examination indicates that imaging would guide your care.

We can assess the tendon and its attachment alongside nearby structures. This helps distinguish Achilles tendinopathy from other possible causes, including retrocalcaneal bursitis (irritation of the small cushioning sac between the tendon and heel bone), superficial bursitis and changes in the tissues surrounding the tendon. Ultrasound can also help assess suspected tendon tears. These problems may coexist, so identifying the painful area accurately matters when planning rehabilitation. [4]

We interpret the scan alongside your history, examination and response to loading. A scan finding alone does not prove what is causing your pain. Ultrasound cannot exclude every cause of heel pain; suspected bone stress injury or other concerns may require different imaging or referral. [1,4]

Next, understand how you walk and run

Once we have a diagnosis, we look at the functional factors that may be contributing to your symptoms. Depending on your needs, this includes observing walking and running, assessing relevant joint movement and flexibility, checking strength and control, and considering your footwear and activity demands.

We bring these findings together with the examination and any ultrasound findings. A particular gait pattern does not automatically explain pain: the aim is to identify factors worth addressing in your individual case.

Then, build your treatment plan

Your plan follows the assessment findings. We explain what each intervention is intended to address and agree which combination is appropriate for you. This may include:

• Flexibility and movement work. Where the assessment identifies a relevant restriction, we select suitable movement exercises. The range matters: deep ankle bending or calf stretching may aggravate an irritable Achilles insertion, so these are not prescribed automatically. [3]
• Strength and tendon capacity. Where indicated, we choose strengthening exercises at an appropriate starting level and progress them according to your symptoms, function and goals. Progressive tendon loading remains an important part of Achilles tendinopathy care. [1,2]
• Gait retraining. Where walking or running assessment identifies a useful target, we may trial changes to your movement pattern and review their effect on symptoms and function.
• Footwear, orthotics or heel lifts. These may be considered where the assessment identifies a reason to alter support or how forces are distributed. We explain the intended role and review your response; they are not necessary for everyone.
• Activity adjustments. We discuss practical changes to walking, work or training so the plan fits your daily life and current tolerance.
• Shockwave therapy. This may be discussed as an additional option for persistent symptoms, taking account of the diagnosis and treatment already tried. We explain the uncertain benefit, alternatives and costs, and agree how any response will be reviewed.

The starting point and sequence depend on your findings. Follow-up lets us review the diagnosis, your response to each intervention and what needs to change as you return to your chosen activities.

Where does shockwave therapy fit?

Shockwave therapy is an additional treatment sometimes discussed for persistent Achilles tendinopathy. The 2021 guideline includes it among options to discuss when education, load management and exercise have not provided sufficient improvement after three months. [1]

At Steps, a discussion about shockwave starts with your diagnosis, the rehabilitation you have already tried and your goals. If it is selected after that discussion, we agree how to assess your response while continuing the appropriate exercise and load-management programme.

How does the evidence inform the plan?

Once Achilles tendinopathy has been identified, progressive tendon loading is an important component of care. The 2024 guideline for midportion Achilles tendinopathy recommends loading exercise as first-line treatment, with resistance progressed as tolerated. It also advises that complete rest is usually unnecessary: activity can continue within an agreed level of tolerance. These recommendations relate specifically to midportion symptoms. [2]

For insertional symptoms, a 2025 randomised trial involving 42 sport-active adults found better pain and function outcomes with rehabilitation that reduced tendon compression. The programme limited deep upward ankle movement during exercise, avoided calf stretching and included heel lifts. Both groups performed progressive loading; the difference was how compression was managed. [3]

These findings inform the exercise component of your plan, alongside the diagnosis, functional assessment and other interventions selected for you.

How do we judge progress?

We consider morning stiffness, pain during and after activity, calf performance and your ability to meet agreed goals. Your response between appointments helps guide progression. Returning to a comfortable walk and returning to repeated sprinting require different levels of capacity.

Explore sports injury assessment and rehabilitation at Steps, or book a specialist foot and ankle assessment for persistent Achilles symptoms.

Evidence behind this article

1. de Vos RJ et al. Dutch multidisciplinary guideline on Achilles tendinopathy. BJSM, 2021.
2. Chimenti RL et al. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision—2024. JOSPT, 2024.
3. Effectiveness of reducing tendon compression in the rehabilitation of insertional Achilles tendinopathy: a randomised clinical trial. BJSM, 2025.
4. A problem-based approach in musculoskeletal ultrasonography: heel pain in adults. Ultrasonography, 2022.

Evidence checked September 2026. This article concerns tendinopathy rehabilitation; suspected tendon rupture requires a different assessment and treatment pathway.