Exercises for insertional Achilles tendonitis require a different approach
- Alison Gould
- 2 days ago
- 6 min read
Updated: 1 day ago
Choosing exercises for insertional Achilles tendonitis require a somewhat different approach than the standard rehab protocol for Achilles injuries. And now fresh research has confirmed what we've been saying for the last few years. Here's what to do differently and what to avoid altogether. Remember, if you need help with an Achilles injury, you're welcome to consult one of our team via video call.
In this article:
We've also made a video about this:
Some of the links in this article are to pages where you can buy products discussed or mentioned here. We might earn a small commission on sales at no extra cost to you.
What is insertional Achilles tendonitis?
The Achilles tendon attaches our calf muscles to our heel bone. So, it works whenever the calf muscles work, for example when we’re walking, running, jumping, or going up our toes.
Achilles tendonitis or tendinopathy can develop in three areas of your Achilles tendon:
High up in the tendon, where the tendon is attached to the calf muscles – this is not very common.
In the mid-portion of the tendon – the most common area for this type of injury.
Where the tendon inserts into the heel bone – the trickiest type to treat because it can be so easy to irritate it.
💡 High and midportion Achilles tendonitis are managed in a similar way, but insertional tendonitis requires a special rehab approach, as I shall explain below.
This advice also applies to Achilles tendinopathy, which just refers to a different stage of the same injury. We’ll be using the term insertional Achilles tendonitis throughout this article, but the exercise advice applies to both.
What the new research confirmed
For years now, we've been advocating that the most effective way to treat insertional Achilles tendonitis is to limit or avoid stretching the Achilles tendon into dorsiflexion during the initial recovery phase. Dorsiflexion is when your foot tilts so that your toes move closer to your shin (more about this below).
And this approach has now been validated by a group of researchers in Belgium who published their findings just two months ago (at the time of writing) in the British Journal of Sports Medicine.
They split 42 recreational and competitive sportspeople, all with insertional Achilles tendinopathy, into two groups.
One group was prescribed a standard Achilles rehab programme comprising stretches and exercises (including heel raises) that put the foot into dorsiflexion.
The second group was given a programme with exercises that limited dorsiflexion (e.g. heel raises only at floor level) and included calf massage instead of stretches. This group was also told about the importance of limiting dorsiflexion.
The researchers then tested their subjects for Achilles tendon pain and function at 12 weeks and again at 24 weeks into the programme. At both time points, the group whose programme limited dorsiflexion fared significantly better than the group on the standard rehab programme.
Why you DON’T want to stretch your Achilles tendon (too early)
Some medical practitioners tell patients with Achilles tendonitis to stretch their calf muscles and tendon.
Yes, one of the symptoms of Achilles tendonitis is a stiff feeling in the tendon and calf muscles, and many people will have a natural tendency to want to stretch these. However, this is not actual tissue stiffness, but rather the result of a build-up of fluid in the injured tendon.
Stretching the tendon might feel good in the moment, but often causes the sensitivity and pain to flare up later in the day.
Why does stretching irritate insertional tendonitis?
When our foot is in a dorsiflexed position (see picture below), it stretches the Achilles tendon and compresses it against the heel bone. This is fine when the tendon is not injured, and not much of a problem when you have tendonitis in the mid-portion of the tendon or higher up.
However, when you have insertional Achilles tendonitis, that compression against the heel bone can irritate an already painful tendon even further. It’s like prodding a bruise – it won’t make your injury worse, but it’s painful and it might not allow the pain to calm down anytime soon if you keep on doing it.
💡 So, the challenge with getting insertional Achilles tendonitis better is to (initially) avoid or adapt exercises and other activities that put your foot into dorsiflexion.
Also, be careful not to stretch your tendon inadvertently. Here is some advice on how to avoid this with specific activities:
👍 If you want to alleviate that stiff feeling, rather massage, use a massage gun, or foam-roll your calf muscles (not the injured part of the tendon itself).
Rehab exercises for insertional Achilles tendonitis
👉 Note that this advice is about the early stages of a rehab programme for insertional Achilles tendonitis. As your tendon gets better, you should be able to progress to the more “standard” Achilles rehab protocol, which would involve dorsiflexion.
Straight-leg heel raise exercises
The classic rehab exercise to strengthen an injured Achilles tendon back up to its pre-injury state is straight-leg heel raises (also called calf raises). You stand on a step, go up onto your toes, and then slowly lower yourself back down over the side of the step into dorsiflexion.
At Treat My Achilles, we usually tell our patients with insertional Achilles tendonitis to start their rehab with heel raises on the floor and not over the side of a step, so as not to go into that dorsiflexion stretch position.
And this is also the approach that the researchers found to be best in the study we mentioned earlier.
Bent-knee heel raises
We have two calf muscles in each leg: the gastrocnemius and the soleus. Heel raises with a straight knee, as commonly prescribed, work the gastrocnemius more, and heel raises with a bent knee work the soleus more.
Depending on your situation, you might have been prescribed bent-knee heel raises as part of your rehab programme.
As you can see, standing with a bent knee puts your foot into that dorsiflexed position that we want to avoid with insertional Achilles tendonitis.
👍 The solution is to do your bent-knee heel raises sitting down, with your feet somewhat forward, so that they are not in dorsiflexion.
Obviously, you’re not supporting your own bodyweight now, so you should put some weight on your knees to compensate for that – ask your physio how much weight and how to progress this.
Remember that there’s no one-size-fits-all exercise programme for Achilles tendonitis. So, the specifics of things like single-leg vs. double-leg heel raises, how many, and with what weight, as well as how to progress your exercises, should be prescribed by your physio, based on the capacity of your injured tendon, your activity goals, and how your tendon reacts to the rehab.
You can read more about variations on heel-raise exercises for Achilles rehab and how to progress them here.
Footwear
Using the correct footwear during your rehab exercises (and also as you go about your daily business) will help to reduce dorsiflexion and allow your pain to calm down more quickly.
Go for shoes where your heel is somewhat higher than the front of your foot (heel-to-toe drop). Most running shoes have somewhat of a heel-to-toe drop. The Brooks models below have a good heel-to-toe drop.
Here are our articles with more advice on everyday shoes and running shoes for Achilles tendonitis.
💡 You could also use heel-raising inserts in your shoes. The limited dorsiflexion group in the Belgian study started off with 12-millimetre inserts; the height was halved towards the end of their rehab programme, and finally they ditched the inserts.
The following heel-raising inserts on Amazon are height-adjustable:
How we can help
Need help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. All of us have a wealth of experience working with athletes across a broad variety of sports and ranging from recreationally active people to professional athletes. You can meet the team here.
About the Author
Alison Gould is a chartered physiotherapist and holds an MSc in Sports and Exercise Medicine. You can follow her on LinkedIn, Facebook, Instagram, and Twitter.