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Ankle Pain

Mid Portion Achilles Tendinopathy

Minute Read


Posted 1 year ago


Last updated: 16/01/2023


by James McCormack

Achilles Tendinopathy is one of the runners’ most common causes of ankle pain. There are two main types of Achilles Tendinopathy; mid-portion, which is in the middle of the Achilles Tendon and Insertional Tendinopathy, where the Achilles Tendon attaches to the heel bone. This article will discuss Mid Portion Achilles Tendinopathy and how to treat it.

Symptoms of Mid Portion Achilles Tendinopathy

One of the most common symptoms of Mid Portion Achilles Tendinoiapthy is stiff first thing in the morning when you get out of bed which eases within 5-10 minutes of walking. A similar pattern may be noticed when walking after a period of sitting.

Symptoms are typically slow and progressive rather than a sudden onset of pain that is more associated with an Achilles Tendon Tear. Pain is located in the middle of the Achilles Tendon, and patients describe their pain as a dull ache or burning sensation.

It is usual for Mid Portion Achilles Tendinopathy to be painful at the start of an exercise, warm-up and then the pain subsides. However, the pain usually is worse the morning after exercise.

Achilles Tendon Problems diagram


The most common cause of Mid Portion Achilles Tendinopathy is a sudden change in exercise levels. This can be a sudden increase in step count, running volume or speed. Introducing hill running or sprints also places large amounts of stress on the Achilles Tendon.

Other factors that can cause Mid Portion Achilles Tendinopathy are obesity, poor footwear, type II diabetes and prolonged steroid use.


A clinical assessment is the gold standard for diagnosing Mid Portion Achilles Tendinopathy. This will include a clinical interview and Physical Assessment to look at the loading capacity and strength of the Achilles Tendon. The therapist will squeeze the Achilles Tendon to locate the exact location of the pathology.

An MRI or Ultrasound may rule out other conditions like a tendon tear that can present with similar symptoms.

picture of Location of pain of mid portion achilles tendinopathy

Treatment for Mid Portion Achilles Tendinopathy

Physical Therapy is the best form of treatment for Mid Portion Achilles Tendinopathy. This will consist of strength training for the Achilles Tendon to increase the capacity of the Tendon for absorbing load. When someone has Mid Portion Achilles Tendinopathy, there is a change in the structure of some of the fibres within the tendon, which reduces their loading capability. For this reason, resting does not heal a Mid Portion of Achilles Tendinopathy, as once the affected fibres have changed in structure, they cannot return to their previous state with rest alone.

Strength training helps to grow more healthy fibres and can improve the capacity of some of the pathological fibres. It takes significantly longer to grow new tendon fibres than muscle hypertrophy, so rehabilitation for a Mid Portion of Achilles Tendinopathy takes up to 12 weeks.

A rehabilitation program is designed to overload the tendon. It should be carried out 3 times a week to allow the tendon to recover between sessions, and it is okay to have pain in your Achilles Tendon while you do the exercises, but this should subside within a couple of hours of the exercises. If the pain worsens the following morning, this is a sign of an overload the day before, and you should try fewer repetitions the following day.

In very painful cases of Mid Portion Achilles Tendinopathy, try the isometric exercises first before moving on to the double-leg calf raises and then progress onto the single-leg calf raises.

As we gather more information on Mid Portion Achilles Tendinopathy, we see that while there are many variations in strengthening programmes, any form of strength training helps. We have outlined and demonstrated a typical Mid Portion Achilles Tendinopathy rehabilitation protocol below:

Isometric Calf Raises

  • Sets: 4-5
  • Hold: 45 seconds

Progress onto Double Leg Soleus Raises and Double Leg Calf Raises off a Step

Soleus Raises off a Step

  • Sets: 3
  • Repetitions: 15

Calf Raises off a Step

  • Sets: 3
  • Repetitions: 15

Progress onto Single Leg Soleus Raises and Single Leg Calf Raises off a Step

Single Leg Soleus Raises off a Step

  • Sets: 3
  • Repetitions: 15

Single Leg Calf Raises off a Step

  • Sets: 3
  • Repetitions: 15

Physiotherapy with James McCormack

This is not medical advice. We recommend a consultation with a medical professional such as James McCormack. He offers Online Physiotherapy Appointments for £45.

Related Article: What are the different types of Achilles Tendon Pain 

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