The Best Exercise for Insertional Achilles Tendon Pain

 In Tendon Conditions
25

Achilles tendon pain is very common among runners and non-runners alike. It can affect people at any stage in life. There are two main categories of Achilles tendon pain and injury. They are:

  • Mid-portion Achilles tendon pain (pain in the middle of the Achilles)
  • Insertional Achilles tendon pain  (pain at the bottom of the Achilles tendon where it inserts into the heel)

achilles tendon regions

In the below video I demonstrate a key exercise that I prescribe to help people suffering from insertional Achilles tendon pain rehabilitate their injury.

Transcript (video)

Hi everyone, Brad here with a little physiotherapy tip of the week. This week’s tip has to do with sore Achilles tendons.

Your Achilles tendon spans the back of the calf and inserts down into the heel bone. There are two sorts of Achilles tendon problems, the first is an insertional Achilles problem, and the second is what we call a mid-portion Achilles problem.

Today we are actually going to talk about how to address the insertional Achilles problem. So the exercises as a physiotherapist I give for insertional Achilles tendon problem is very different from the exercise that I give for the problem being further up in what we call the mid-portion of the tendon.

You Can Run Pain Free Revised EditionLet’s talk about the exercise that is best for the soreness down low (at the insertion). We call these the isometric holds – so what we do is we come up on the toes and we hold that there for a period of time and then come back down. So, you come into a calf raise, holding, use a wall for balance and support, and then come back down. Now there is an ideal protocol to follow with this, and that is, to begin with, 10 lots of thirty-seconds. After a weak progress to 5 lots of 1 minute, and beyond that over subsequent weeks at your physios discretion move to 3 lots of 2 minutes, 2 lot of 3 minutes, and lastly 1 lot of 5 minutes.

This is a great conditioning exercise for the Achilles tendon, and it will start to get you moving in the right direction in getting you back running and doing the things that you love and enjoy. Over and out! Have a great week.

*end of transcription*

Avoid eccentric exercises for insertional Achilles tendon 

As a physiotherapist, I regularly see runners (and non-runners) performing tendon rehabilitation exercises that are not in their best interest. Often-times an eccentric exercise (where the heel drops below the horizontal-eg heel drops off a step) are being performed. The problem with eccentric exercises for insertional Achilles tendon pain and injuries is that the dropping down phase of the exercise (ie where heel drops below horizontal) will actually create tendon tension on the already sore Achilles tendon insertion. In cases where a patient engages me to assist them with their Achilles tendon rehabilitation, I will recommend that they immediately cease eccentric loading exercises and commence with just the isometric exercises as described above.

A note on calf strength

I also find that developing calf strength and endurance is also key in the rehabilitation of Achilles tendon injuries. Video below:

Prescription and Progressions

Commence with: 10 x 30s holds

Progress to: 5 x 1min holds, 3 x 2mins, 2 x 3mins, 1 x 5min hold.

For further help please refer to the below resources

  1. Listen to tendon expert physiotherapist and researcher Associate Professor Dr Peter Malliaras discuss the rehabilitation of tendon injuries on Episode 62 of The Physical Performance Show podcast HERE>>

Dr Peter Malliaras Dr Peter Malliaras Dr Peter Malliaras

2. If you would like to learn more about how to best rehabilitate your injury click through and read this post The 3 Stages of Achilles Tendinopathy Exercises HERE>>

Brad Beer physiotherapist gold coast

Brad Beer (APAM)

Physiotherapist, Author You CAN Run Pain Free!, Founder POGO Physio

pain free performance Gold Coast physio

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Showing 25 comments
  • Dan
    Reply

    Thanks for sharing this video, I appreciate the advice and I am in the process of giving isometrics a try. I have had trouble shaking this difficult injury. Do you recommend running during the 3-4 week period or taking the time off? Also would it be helpful to do the isometric holds with a weighted backpack on to increase the difficulty? Thanks again

    • Brad Beer
      Reply

      Hi Dan,

      Have you had any imaging done on your achilles tendon? Re running check out this post as a guide HERE>>

      Yes progressing the load with time will help to further condition the tendon.

      Regards Brad Beer

    • Himanshu Singh Parihar
      Reply

      Hey i m a sprinter , i am suffering from this type of tendonitis from half a year . i just finished the whole schedule of this exercises , now whats next ?
      I need to return back on track
      Plz reply asap

  • Paul Eaton
    Reply

    Hi Dan,

    Thanks for this helpful video. I’ve had a sore (back of) heel for a few months now. In the early days I also had a mild burning sensation at the sides of the heel from time to time. It was worse first thing in the morning or after sitting still for a while. I didn’t really have any pain when running. I reduced my running a lot to begin with and was just left with the sore heel. I’ve now stopped running for a month, but it hasn’t gone away. Can I start the exercises now or should I wait until the soreness has gone entirely? Thanks.

    • Brad Beer
      Reply

      Hi Paul,

      Thanks for your query-I recommend starting the exercises now-start with what you can tolerate in terms of holding duration eg 15s if necessary, and build up to 45s from there. Monitor the pain/stiffness the following morning getting out of bed.

      Regards Brad Beer

  • Tony Geraghty
    Reply

    Are calf stretches while healing from insertional achilles tendinitis acceptable to do?

    • Brad Beer
      Reply

      Hi Tony,

      Thanks for your question-stretching of insertional achilles tendinopathy.

      Typically it is best to avoid it for risk of irritating the tendon/bone interface through tensile/compressive forces.

      Are you getting on top of your injury?

      If you are yet to tune in-this podcast is a great resource on beating tendon pain

      https://www.pogophysio.com.au/blog/the-physical-performance-show-dr-peter-malliaras/

      Regards Brad Beer
      POGO

  • Dave
    Reply

    Thanks for putting together the information and videos. One question is the exercise you suggest done once a day every day and do you rest between each rep?
    Thanks

  • Chris
    Reply

    Hi, having been a marathoner I have recently changed focus and have been adding a lot of speedwork (under a coach), getting down to sub 4 min km reps, not too bad for an old bloke of 53! However I have developed the insertional issue after running a little too quickly up an incline. It tightened up almost straight away. It has eased somewhat and I am able to run for 40 mins without pain as such, but I do not have the full flexion back and it is still after sleep. I am doing single leg calf raises only, as often as I can, is this a good approach, keeping mobile?

    • Brad Beer
      Reply

      Hi Chris,

      Thanks for your question. Great work on the running!

      Re best approach- isometrics 5x45s holds for first few days> progressing to isotonic loading (see below link-loaded calf raises up and down), then finally energy storage exercises (hopping etc). It is important to consider what I call the 5 steps also (your running body, shoes, technique, training loads. and hip strength). If you want to read more plz refer to the 5 steps in ‘You CAN Run Pain Free!’.

      Also read this to ensure you get a streamlined return to your running + I suggest working with a good sports physio who has an interest in running.

      Regards,

      Brad Beer

      1. https://www.pogophysio.com.au/running-book/
      2. https://www.pogophysio.com.au/blog/the-3-key-stages-for-achilles-tendinopathy-exercises/

  • Lela Powell
    Reply

    Great article about “The Best Exercise for Insertional Achilles Tendon Pain”. Thanks for sharing!

  • Pierson
    Reply

    Should I be doing isometric holds for my insertional Achilles issue if my Achilles gets sore in the evenings (ie. after body has cooled down)? Or should I keep doing isometric holds in hopes that doing so will help the pain eventually go away??

    • Brad Beer
      Reply

      Hi Jack,

      Hi Pierson,

      Thank you for your comment/question. Yes these are still useful for calcific insertional tendinopathy. Just leave out the eccentric component (dropping off bit of wood in smith rack etc). The isometrics are key for initial pain reduction. Also suggest listening to Ep 62 of the podcast I host that I did with Dr Peter Malliaras on how to get on top of tendon pathology: HERE>> Episode 62 The Physical Performance Show to help guide you further. If you get stuck let me know-can offer SKYPE consults.

      All the best -Brad Beer

  • Pierson
    Reply

    Thanks Brad!

    Yes I’d be interested in SKYPE consults. Please send me the requisite about this.
    Pierson

    • Brad Beer
      Reply

      Thanks Pierson.

      I will have Matt Morby make contact with you via email.

      Regards Brad Beer

  • John
    Reply

    I’m glad I found this page. I’ve been ‘SLOWLY’ recovering from an Insertional Achilles Tendon injury, which I got from a repetitive jumping exercise at Taekwondo about 7 weeks ago. I’m going to start doing these ‘isometric holds’ and see how I progress. Can’t wait to get back to my Taekwondo class! (once I’m healed)
    Thank you for the advice.
    John.

    • Brad Beer
      Reply

      Hi John,

      I’m pleased you are getting back to your best.

      Be sure to tune into the Dr Peter Malliaras podcast for more insight into the treatment of tendon pathologies HERE>>

      Regards Brad Beer

  • Florin
    Reply

    Hi. Are the isometric holds recommended for enthesitis as I have been diagnosed with insertional enthesitis (not tendonitis, or is it the same thing?)?

    • Brad Beer
      Reply

      Hi Florin,

      Thank you for your question.

      Yes the isometric holds can be used for insertional achilles tendinopathy (ie rehabilitation of the enthesis).

      Be sure to tune into the Dr Peter Malliaras podcast for more insight into the treatment of tendon pathologies HERE>>

      Regards Brad Beer

  • Steve
    Reply

    I was shown a form of isometric where I rise my foot up on my toes then slowly over 3 seconds bring it back down to the floor. I do up to 25 of these per foot. once a week I use the smith machine to ad wait or a 50-65 lb kettle bell. I was told to do them in physical therapy but had trouble finding time with all the other things they were having me do being a runner. I finally decided to just get up and do all that stuff in the morning. What a difference the heel drops make after. I can go from a little sore and tight to nice and loose and comfortable.

    • Brad Beer
      Reply

      Hi Steve,

      Thanks for your comments.

      I’m pleased you have found an improvement in tendon function through loading.

      In addition to pain/symptom/stiffness reduction continue to load with heavy resistance work (seated and standing) calf combined with some progressive plyometric (hopping, jumping) as tolerated activity for best results.

      Brad Beer
      Sports & Exercise Physiotherapist

    • Brad Beer
      Reply

      Also Steve suggest tuning into this Expert Edition of the podcast feat. tendon researcher and physio Dr Peter Malliaras HERE>>

      Regards Brad Beer

  • Chris
    Reply

    Hi Brad, thanks for the great advice on this page. I have a really frustrating issue with the heel that doesn’t sound typical of the other complaints I’ve been reading. My pain is a very sharp and sudden pain at the back of the heel, about one inch from the ground (bottom of the insertion). It can happen when going up stairs, or even putting on my shoe when the toes flex back. It’s extremely painful, and once it “fires”, it becomes more sensitive to firing throughout the day unless I am very careful.

    Does this sound like Achilles tendinitis? I sometimes even feel a “bubbling” sensation in the area, and this usually means I am going to have a bad day. It’s been very stubborn to fix for over a year now…

    Any advice would be appreciated..

    • Brad Beer
      Reply

      Hi Chris,

      Thank you for your query.

      Your pain reads like insertional achilles tendinopathy: can give you the symptoms you have described.

      Also not uncommon for it to persist for 1yr + if an appropriate loading rehabilitation program has not yet been commenced.

      Take a listen to this Expert edition of the podcast HERE>> on tendon rehab

      I can assist you via SKYPE etc if you would like to explore this further.

      All the best

      Brad Beer
      Sports & Exercise Physiotherapist

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