Achilles pain at the bone, and why the usual exercises make it worse

We have a full guide to Achilles tendinopathy, and most of it holds here. This article exists because one version of the condition needs the standard exercise changed, and getting that wrong is the most common reason an Achilles plan stalls.

Where your finger lands

Run a finger down the back of the tendon until you reach the heel bone.

If the tender part is in the tendon itself, roughly two to six centimetres above the heel bone, that is midportion. If the tender part is right where the tendon meets the bone, at the back of the heel, that is insertional. Insertional pain is often worse on the sides of the attachment than in the middle of it, and the back of a stiff shoe pressing on that spot is frequently the thing that makes shoes the enemy.

The two behave differently enough that the plan is different, which is the whole reason this article is separate.

Why the position matters

A tendon is built to be pulled. At the point where a tendon wraps around a bone, it also gets pressed against it, and pressing is a different kind of load from pulling.

At the Achilles insertion, that compression happens when the ankle is pulled upward, which presses the tendon against the back of the heel bone. The further up your toes go, the harder it is pressed.

This is the same mechanism we describe in the gluteal tendon and the hamstring attachment. Three different tendons, one shared principle: at an attachment, position matters as much as load.

The exercise that helps one end and provokes the other

Heel drops off the edge of a step are the classic Achilles exercise, and they work by letting the heel sink below the level of the toes at the bottom.

That bottom position is exactly the position that compresses the insertion. So the standard exercise, done in the standard way, is a compression exercise for the part that is already being compressed. People do it conscientiously for six weeks, get worse, and conclude that their tendon does not respond to loading.

The fix is small. Do the same work on flat ground, so the heel stops level with the toes and never goes below. If that is still sore, put a small lift under the heel so the ankle sits in a little plantarflexion throughout. Same exercise, same progression, range stopped short of the provocative end.

What the treatment evidence says

Honestly: less than we would like, and less than exists for midportion.

Note what that does and does not say. It does not say exercise fails. It says that in the studies done specifically on this version of the condition, the strongest signal was for shockwave, with or without exercise alongside. Most of the loading evidence people quote for Achilles tendons was gathered on midportion cases, and transferring it here is an assumption rather than a finding.

Shoes, and the one that is doing it

A stiff heel counter pressing on a sore attachment will keep it sore no matter what else you do. Backless shoes at home, and a running shoe with a soft or low heel counter, remove a provocation that many people do not realise they have.

A small heel lift in everyday shoes does the same job as the modified exercise: it keeps the ankle out of the range where the tendon is squashed. It is a temporary measure while things settle, not a permanent fixture.

How much running you can keep

The same rule as the rest of our tendon work.

1During the run, it stays at five out of ten or below.

2By the next morning, it is back where it started.

Hills and speed both take the ankle further into the compressed range under load, so both come out first and go back in last. Flat, easy running is usually the last thing to be removed and the first to return.

When to get it looked at