Understanding Mid Portion Achilles Tendinopathy: Symptoms, Diagnosis, and Treatment

Dr. Martin Gonzalez
Jun 16
7 min read

Updated: Oct 26

You're just a few strides into your morning run when it hits. A sharp, stabbing pain right above your heel. Your Achilles feels like someone's taken a knife to it.

Sound familiar?

Maybe you've been dealing with that nagging ache that greets you every morning. You know the one, it makes rolling out of bed feel like you've aged decades overnight. If you're nodding along, you're likely dealing with mid-portion Achilles tendinopathy (MAT).

Over half of all Achilles problems (55%-65%) happen right in this sweet spot, roughly 2 to 6 centimeters above where your tendon meets your heel bone. Most people either ignore it completely or dive headfirst into random exercises they found on YouTube. Both approaches?

They'll backfire spectacularly.

But here's the good news.

Recent research has drastically changed how physical therapisits understand and treat this stubborn injury. This guide will walk you through a proven, step-by-step recovery process that actually works.

The Old School Approach That's Keeping You Injured

For decades, doctors called this "Achilles tendonitis." The prescription was simple: ice it, rest it, take some anti-inflammatory pills, and wait it out.

Turns out, that advice was dead wrong.

Advanced medical imaging revealed something interesting: there's no inflammation present in these injuries.

NONE!

Instead, researchers discovered something far more complex happening inside your tendon. We're talking about degeneration, where collagen fibers become disorganized, and poor healing responses.

Tendinopathy is primarily a degenerative condition caused by repetitive overloading. Your tendon isn't inflamed. It's breaking down from too much stress without enough recovery.

Why does this matter for your recovery? Because degenerative conditions get worse with complete rest. Your tendon needs progressive loading and strengthening to rebuild itself properly.

So those days of ice, rest, and hoping it goes away? They're history.

Not All Achilles Problems Are Created Equal

Before diving into the recovery protocol, you need to be sure you're dealing with mid-portion or insertional tendinopathy. The way you treat the injury could make things significantly worse.

Mid-Portion Achilles Tendinopathy (MAT):

Pain strikes 2-6 cm above your heel bone.
Usually triggered by overuse or sudden training increases.
Responds well to strength training.
Has better blood supply, making it more adaptable to healing.

Insertional Achilles Tendinopathy (IAT):

Pain occurs right at the heel bone attachment.
Gets aggravated by repetitive ankle dorsiflexion.
Heals much slower due to poor blood supply.
Less responsive to traditional exercise approaches.

If your pain sits higher up on the tendon, you're likely dealing with MAT—and this guide is for you.

The Honest Expectation About Recovery Time

Let’s address the truth that pisses off every patient: true recovery takes 6 months to a year. Sometimes longer. I know that's not what you wanted to hear. But here's why rushing the process backfires every single time.

Tendons have incredibly slow metabolisms. This is by design because the purpose of tendons is to tolerate load over a long period of time. This gives them an advantage for endurance activities (hello, marathon runners), but it means they heal at a snail's pace compared to muscles.

Full recovery means being completely pain-free for 9-12 months. Not just feeling better during easy activities, we're talking about zero pain during high-intensity training, jogging, and general competition.

The research is pretty clear on this: athletes who try to return too quickly have significantly higher reinjury rates compared to those who follow a structured, gradual progression program. Also, those who STOP performing their exercises after feeling improvement, get better, hit a plateau, and then their symptoms return because the tendon hasn't fully adapted.

The 4-Phase Recovery Protocol

Phase 1: Pain Management and Initial Loading (Weeks 1-2)

Your primary goal during this phase isn't to eliminate pain completely—it's to begin the healing process while managing symptoms.

Pain Guidelines:

Activity-related pain should stay below 5/10 on a pain scale.
Pain should return to baseline within 24 hours post-exercise.
Morning stiffness shouldn't worsen from day to day.

Exercise Protocol: Start with basic loading exercises to begin the strengthening process while managing pain levels.

Two-Legged Heel Raises (Floor):

Stand on both feet, rise up onto your toes.
Lower slowly and controlled.
3 sets of 10-15 repetitions, daily.
Focus on smooth, controlled movement.

One-Legged Heel Raises (Floor):

Perform single-leg heel raises on flat ground.
Use wall or chair for balance if needed.
3 sets of 10 repetitions, daily.
Progress only when you can complete all reps pain-free.

Single Leg Heel Raise w/ Arm Assist

Seated Heel Raises:

Sit in a chair, place weight on knees if tolerated.
Rise up onto toes, lower slowly.
3 sets of 10 repetitions, daily.
Excellent for early-stage loading with minimal stress.

Seated Heel Raise w/ Dumbbell

Phase 2: Progressive Strengthening (Weeks 2-6)

In this stage you move to more challenging exercises performed on the edge of a step. This forces your foot/ankle to go past neutral into dorsiflexion, allowing for greater range of motion, progressive loading, and stress to the achilles tendon.

Two-Legged Heel Raises (Step Edge):

Stand on the edge of a step with heels hanging off.
Rise up onto toes, lower slowly below step level.
3 sets of 15 repetitions, daily.

Building up load tolerance is the best way to manage tendon injuries

One-Legged Heel Raises (Step Edge):

Progress to single-leg step-edge heel raises.
Use opposite leg for balance only.
3 sets of 15 repetitions, daily.
Modification: These can be peformed on a leg press machine as well.

A leg press machine is a great alternative to improve stability and muscle control

Eccentric Heel Raises (Step Edge):

Rise up on both feet, lower slowly on affected leg only.
Take 3-4 seconds for the lowering phase.
3 sets of 15 repetitions, daily.
Promotes tendon remodeling and better mechanical properties.

Quick Rebounding Heel Raises:

Rapid, small-amplitude heel rises.
Focus on spring-like quality.
3 sets of 20 repetitions, daily.
Prepares tendon for more dynamic activities.

Phase 3: Heavy Strength Training (Weeks 6+)

This phase introduces heavy loading while maintaining daily exercise. You'll perform exercises daily with added weight 2-3 times per week.

Weighted Exercises (2-3x per week):

One-legged heel raises with added weight (backpack, dumbbells, weighted vest).
Eccentric heel raises with added weight.
Start with 5-10 lbs, progress gradually.
3 sets of 15 repetitions.

Daily Maintenance Exercises:

Continue sitting heel raises (3 × 15 reps).
Quick rebounding heel raises (3 × 20 reps).
Monitor pain levels using the pain-monitoring model.

Plyometric Introduction:

Begin basic jumping exercises.
Double-leg hops in place.
Progress to single-leg bounds.
Only when tolerated without pain increase.

Activity-Specific Training:

Gradual return to running/sport activities.
Start with short durations, low intensity.
Increase by 10% weekly if pain-free.

Phase 4: Maintenance and Full Return (3-6+ Months)

The final phase focuses on maintaining strength while returning to full activity levels.

Maintenance Program (2-3x per week):

One-legged heel raises with added weight (3 × 15 reps).
Eccentric heel raises with added weight (3 × 15 reps).
Sport-specific activities as tolerated.

Return-to-Sport Criteria:

Minimal symptoms during daily activities.
No morning stiffness most days.
No pain in distal tendon with heel raises.
Can participate in sport without difficulty.
Completed at least 3 months of progressive loading.

Long-term Maintenance:

Continue strengthening exercises 2-3 times weekly.
Don't abandon the program once symptoms resolve.
Gradual activity progression remains crucial.

The Pain-Monitoring Model

Research shows that using a pain-monitoring approach is more effective than rigid "no pain, no gain" or complete pain avoidance strategies. Although this method isn't perfect by any means, it's better than most approaches and I find it easy for patients to refer to in the clinic.

Pain Guidelines During Exercise:

0-2/10: Ideal, continue current program.
3-5/10: Acceptable, monitor closely.
6-10/10: Too high, reduce intensity or volume.
Pain should return to baseline within 24 hours.

Morning Stiffness Indicator:

Improving or stable: Continue program.
Worsening: Reduce exercise intensity.
Severe stiffness: Consider rest day or lighter exercises.

Common Mistakes That Sabotage Recovery

Mistake #1: The "Good Day" Trap. You feel great one morning and decide to test your limits. This almost always leads to setbacks. Stick to your program regardless of how you feel.

Mistake #2: Abandoning Strength Training Too Early. Many people stop their exercises once pain improves. Research shows you need to continue strengthening exercises 2-3 times weekly even after symptoms resolve.

Mistake #3: Using Outdated "No Pain, No Gain" Mentality. While complete pain avoidance is not recommended, pushing past your pain thresholds can delay healing. The pain-monitoring model allows for some discomfort (3-5/10) during exercises while ensuring you don't overdo it.

Mistake #4: Ignoring Sleep and Nutrition. Recovery happens during rest. Poor sleep and inadequate protein intake significantly slow tendon healing.

Mistake #5: Not Being Patient Enough. Surgery for MAT is rarely required. That being said, tendons can be stubborn. I strongly advise dedicating at least 3 months to a consistent exercise program before deciding if you see improvement.

When to Seek Professional Help

While this guide provides a solid foundation, certain situations require professional intervention:

Pain exceeds 7/10 during basic activities.
No improvement after 6-8 weeks of consistent exercise.
Sudden, severe pain increase.
Signs of complete tendon rupture (inability to stand on toes).

A qualified physiotherapist can provide manual therapy, assess your movement patterns, and modify your program based on your specific needs.

The Long Game: Preventing Future Issues

Once you've successfully navigated recovery, prevention becomes your priority:

Training Load Management:

Increase weekly mileage by no more than 10%.
Include rest days in your program.
Vary training intensities throughout the week.

Strength Maintenance:

Continue calf strengthening 2-3 times weekly.
Don't abandon exercises once symptoms resolve.
Progressive overload remains important long-term.

Biomechanical Considerations:

Address any underlying movement dysfunctions.
Consider footwear with a higher heel lift.
Maintain ankle and calf flexibility.

Your Recovery Starts Now

Mid-portion Achilles tendinopathy doesn't have to end your running career or keep you in pain indefinitely. But it is a stubborn condition that requires patience and consistent effort.

The protocol outlined here is based on current research and clinical experience. However, every individual responds differently. Listen to your body, track your progress, and don't be afraid to modify the program based on your symptoms.

Recovery might take longer than you'd like, but the alternative—chronic pain and repeated injuries—is far worse. Trust the process, stay consistent, and you'll come back stronger than before.

Schedule Your Free Consultation Today

I am currently accepting new clients and would love to offer you a free consultation call. This is a great opportunity to discuss your needs, explore how I can assist you, and answer any questions you may have.

References:

Silbernagel, K. G., & Crossley, K. M. (2015). A proposed return-to-sport program for patients with midportion Achilles tendinopathy: Rationale and implementation. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 876–886. https://doi.org/10.2519/jospt.2015.5885

Hanlon, S. L., Scattone Silva, R., Honick, B. J., & Silbernagel, K. G. (2023). Effect of Symptom Duration on Injury Severity and Recovery in Patients With Achilles Tendinopathy. Orthopaedic journal of sports medicine, 11(5), 23259671231164956. https://doi.org/10.1177/23259671231164956

Zeren PT LLC. (2019). Achilles tendinopathy: Things runners need to know. https://zerenpt.com