Achilles Tendinopathy: Why It Keeps Coming Back—and What Actually Works

Achilles pain is one of those injuries that feels simple but rarely is.People rest it, stretch it, strengthen it… and somehow it still lingers.

That’s because not all Achilles tendinopathy is the same, and treating it like one generic problem is usually why it fails.

Here’s how I break it down—and how I treat it differently in Birmingham.

Symptoms

Achilles tendinopathy commonly shows up as:

• Pain or stiffness in the Achilles, especially with the first steps in the morning

• Pain with running, jumping, sprinting, or hopping

• Tenderness to touch along the tendon

• Symptoms that worsen when the tendon is used like a spring (jump rope, box jumps, bounding)

• Pain that improves with warm-up… then returns later or the next day

Where the pain is located matters a lot.

Two Different Achilles Problems (That Get Treated the Same—but Shouldn’t)

1) Non-Insertional Achilles Tendinopathy

Pain is usually 2–3 cm above the heel bone, in the mid-portion of the tendon.

What’s Really Going On

Research using three-dimensional gait analysis has shown that many athletes with this condition fail to externally rotate the tibia during late mid-stance when walking or running.

In simple terms:

• The leg isn’t rotating correctly during push-off

• This overloads the Achilles in a repetitive, inefficient way

• This failure is often linked to poor tibialis posterior function (a key stabilizer of the foot and ankle)

So the tendon keeps taking stress it shouldn’t have to handle alone.

2) Insertional Achilles Tendinopathy

Pain is located right where the tendon attaches to the heel.

This type is:

• More stubborn

• More common in higher-arched (cavovarus) foot types

• Often driven by something called stress shielding

Here’s the key insight:The anterior (front) portion of the tendon—the part under less stress—is often the one that degenerates, not the heavily loaded posterior fibers.

That changes everything about how it should be loaded.

What Usually Failed

1) Generic eccentric heel drops

The classic protocol:

• Rise up with two feet

• Slowly lower with one foot

• Add weight with a backpack

This can help—but it often misses the real problem.

Common issues:

• Poor range of motion

• No control of rotation

• No differentiation between insertional vs non-insertional cases

For insertional cases, dropping the heel below stair level can actually make things worse.

2) Rest instead of re-loading

Tendons hate complete rest.They need graded, intelligent loading—not avoidance.

3) Ignoring spring mechanics

If hopping, jumping, or running still hurts the next day, the tendon hasn’t rebuilt its load tolerance—even if strength looks “fine” in the gym.

Why My Approach Is Different (Birmingham)

At Live Active: Spine & Sport in Birmingham, I treat Achilles tendinopathy as a movement and loading problem, not just a sore tendon.

For Non-Insertional Achilles Tendinopathy

I still use slow, heavy loading—but I fix the rotational deficit that standard protocols ignore.

That includes:

• Traditional slow-tempo heel raises (standing and seated)

• Closed-chain tibialis posterior loading to restore tibial external rotation

  • Arch raise / arch control drills using banded resistance

  • Emphasis on controlled lowering (eccentric control)

• Foot-to-leg coordination work so the Achilles stops compensating for poor mechanics

This combination dramatically improves outcomes compared to eccentrics alone.

For Insertional Achilles Tendinopathy

The goal is to load the damaged anterior fibers—not just hammer the tendon blindly.

That means:

• Heel raises performed on level ground

• No dropping the heel below horizontal

• Rising as high as possible onto the toes to selectively stress the anterior portion

• Slow, controlled eccentrics with symptom-guided progression

This approach has shown strong outcomes in published research and works far better than stair-drop protocols for insertional cases.

Pain Modulation & Tissue Support

To help people tolerate loading sooner and recover more consistently, I may also use:

• Soft tissue therapy to reduce excessive tone in the calf complex

• Dry needling to calm overactive tissue and improve load tolerance

• Class IV laser therapy to support pain reduction and tissue recovery

• Adjustments (often foot, ankle, or lower-chain related) when mechanics upstream are clearly contributing

These aren’t stand-alone fixes—they support the loading plan.

What Progress Looks Like

We track progress the right way:

• Re-testing hops and spring activities

• Monitoring next-day pain response

• Adjusting load—not guessing

• Gradually reintroducing plyometrics only when the tendon is ready

If pain worsens the next day → load was too highIf pain stays the same or improves → we progress

Simple. Objective. Effective.

Ready to Fix the Root Cause?

If you’re in Birmingham and dealing with stubborn Achilles pain—whether it’s mid-tendon or at the heel—I’ll help you figure out which type you have, why it keeps flaring, and exactly how to load it back to full capacity.

👉 [Book Your Achilles Evaluation in Birmingham]