Achilles Tendinitis: Insertional vs Mid-Substance — Different Treatment
The treatment depends on WHERE on the Achilles you have pain. Mid-substance Achilles tendinopathy responds to eccentric heel-drop exercises (80% improvement at 12 weeks). Insertional Achilles tendinopathy needs different exercises — heel drops can MAKE IT WORSE. Don’t treat insertional with mid-substance protocols.
Insertional vs Mid-Substance: Critical Distinction
Mid-substance Achilles tendinopathy: Pain 2-6cm above the heel bone. Treatment: eccentric heel drops (Alfredson protocol) — 3 sets of 15, twice daily, 12 weeks. 80% improvement.
Insertional Achilles tendinopathy: Pain right where tendon attaches to heel bone. Treatment: heel LIFTS instead of heel drops. Modified eccentric exercises that don’t dorsiflex past neutral. Heel drops worsen insertional disease.
Why Achilles Tendinitis Develops
Tendinopathy from overload exceeding tissue capacity. Risk factors: runners (especially with sudden mileage increase), tight calves, age 30-60, fluoroquinolone antibiotics, hill running, switching to minimalist shoes too fast, dance.
Eccentric Heel Drop Protocol (Mid-Substance Only)
Setup: Stand on edge of stair, heels hanging off. Use both feet to rise on toes. Lift unaffected foot off step. Slowly lower affected heel below step level (eccentric phase) over 3 seconds. Use both feet to rise again. Repeat. Dosage: 3 sets of 15, twice daily, 12 weeks. Add a backpack with weight as you progress (1-5 kg increments). Some discomfort during exercise is OK; sharp pain means stop.
When Conservative Care Fails
If 3-6 months of proper eccentric protocol + shoe modification + activity reduction haven’t resolved: 1) Shockwave therapy (60-80% success), 2) PRP injection (65-80% success), 3) MLS laser (adjunctive), 4) Surgery (rare, last resort). Shockwave → | PRP →
Achilles Rupture vs Tendinitis
Tendinitis = chronic, develops over weeks. Rupture = sudden, “kicked from behind” feeling, often pop. Thompson test: squeeze calf — if foot doesn’t plantarflex, suspect rupture. Rupture is emergency. Tendinitis is not.
Frequently Asked Questions
How long does Achilles tendinitis take to heal?
12 weeks with proper eccentric protocol for mid-substance. 16-20+ weeks for insertional. Chronic cases can take 6-12 months.
Should I get a cortisone shot for Achilles tendinitis?
NO. Cortisone in or near Achilles tendon dramatically increases rupture risk.
Can I keep running with Achilles tendinitis?
Reduced mileage often OK if pain doesn’t worsen during run. Stop if pain >5/10 or worsening pattern.
Will a heel lift help?
Yes for insertional. Sometimes useful for mid-substance acutely.
When is Achilles surgery needed?
Rare. After 6-12 months of failed conservative care, or for acute rupture in select patients.
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Watch: Dr. Tom Biernacki Explains Achilles Tendinitis
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Frequently Asked Questions
When should I see a podiatrist?
If symptoms persist past 2 weeks, affect your normal activity, or are accompanied by red-flag symptoms (warmth, redness, swelling, inability to bear weight).
What does treatment cost?
Most diagnostic visits and conservative treatments are covered by Medicare and major insurers. Out-of-pocket costs vary by your specific plan.
How quickly can I get an appointment?
Most non-urgent cases see us within 5 business days. Urgent cases (sudden pain, possible fracture) typically same or next business day.