Understanding Mid Portion Achilles Tendinopathy: Symptoms, Diagnosis, and Treatment
- Dr. Martin Gonzalez
- Jun 16, 2025
- 10 min read
Updated: Jul 14
When it comes to any form of tendinopathy, proper education and setting reasonable expectations are two areas where I see a lot of physiotherapists fall short. Recent research supports the fact that the average timeline of healing can take 6 to 12 months, sometimes even longer.
Now, this isn't to say that you won't see improvement until then. It just means that rehabbing a tendon is a notoriously slow, and yes, a very frustrating process! If we are honest upfront about the commitment, patience, and dedication required to truly see significant changes, I think that would go a long way in tempering expectations and limiting potential disappointment down the line.
Okay, enough with the doom and gloom.
There is hope when it comes to managing mid-portion Achilles tendinopathy (MAT).
Let's dive in, shall we?
Over half of all Achilles problems (55% to 65%) happen right in the mid-portion, roughly 2 to 6 centimeters above where your tendon meets your heel bone. Most people either ignore it completely thinking it will "heal on its own," or they ice it for a couple of days and then jump right back into whatever activities they were doing.
Both approaches?
They'll backfire spectacularly and you likely won't see any progress. At all.
Recent research has drastically changed how physical therapists 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 minimal to 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 (flexing your foot towards your nose)
Heals 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. This particular guide is more appropriate for you.
Why Does Recovery Take So Long?
If medicine and exercises science is so advanced, compared to say 20-30 years ago, then why does it take so long still?
Let’s address the truth that pisses off every patient: true recovery takes 6 months to a year. Additionally, you need to be pain free for at least 9 months after recovery to be deemed truly "recovered". 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.
So how do we properly heal these injuries?
The 4-Phase Recovery Protocol
Remember, this is meant to be a general framework. Protocols are meant to be a roadmap and you probably won't fit perfecty nice and tidy into this exact timeline. Some of you will take longer, others less. There are too many factors that come into play; age, prior activity levels, injury history, weight and BMI, lifestyle factors (smoking, drinking, etc), that determine and have an impact on your response to pain.
To understand why we load the tendon in these phases, it helps to look at what's happening on a biological level. Think of a healthy tendon like a neatly braided, tightly pulled nylon rope. A tendinopathic tendon looks like someone took a wire brush to that rope.
It's a chaotic, frayed tangle of loose collagen strands.
The following phases act like a physical loom. By using mechanical tension (loading), we signal the cells to start a remodeling process, forcing those messy collagen strands to realign, heal, and braid themselves back into a strong, cohesive structure.
Nevertheless, I like to break this flexible roadmap into a simple 4 phase program:
Phase 1: Pain Management and Initial Loading (Weeks 1-4)
Your primary goal during this phase isn't to eliminate pain completely; it's to begin the healing process while managing symptoms. On a cellular level, early and gentle loading triggers a biological process called mechanotransduction. This simply means your cells turn mechanical stress into chemical signals that tell the body to kickstart a healthy tissue remodeling cycle. This wakes up the repair cells without tearing or over-stressing the fragile, chaotic collagen matrix.
Pain Guidelines:
Activity-related pain should stay below 4/10 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.
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.
Phase 2: Progressive Strengthening (Weeks 4-8)
In this stage, you move to more challenging exercises performed on the edge of a step. This forces your foot and ankle to go past neutral into dorsiflexion, allowing for greater range of motion, progressive loading, and structured stress to the Achilles tendon.
Biologically, combining a deeper stretch with a controlled muscle contraction acts as an alignment tool.
It applies intentional structural tension that coaxes those loose, tangled collagen threads to stop bunching up and instead organize themselves parallel to one another. This directly improves the mechanical properties, springiness, and total weight capacity of the 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.
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.
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 8+)
This phase introduces heavy loading while maintaining daily exercise. The initial cellular "braid" is now starting to take shape, but it is still thin and weak. To build a thick, strong rope capable of handling sport-level forces, you have to progress to heavy external weights 2 to 3 times per week. This heavy mechanical stimulus forces the tendon to increase its thickness and overall structural stiffness.
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 (3-9+ Months)
The final phase focuses on maintaining strength while returning to full activity levels. The collagen fibers are now highly organized and structurally tough. Our primary goal shifts to progressing power, explosiveness, and kinetic energy transfer while safely reintroducing high-velocity, sport-specific movements..
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:
Pain Levels | Description |
[0-2] Safe Zone | Ideal, safe to continue current and progress current program. |
[3-5] Caution Zone* | Acceptable discomfort. Monitor closely, do not panic. Pain should return to baseline levels < 24 hours. |
[6-10] Danger Zone | Too high. Scale back the intensity, load, or volume. |
Morning Stiffness Indicator*
If morning stiffness is improving or stable, continue the program. If it is steadily worsening day by day, reduce your exercise intensity. If you experience severe stiffness, consider an intentional rest day or lighter, pain-free movements.
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. True structural repair and tissue synthesis do not actually happen while you are moving; they happen almost entirely while you rest.
The Power of Deep Sleep: High-quality sleep is your body's peak window for human growth hormone (HGH) release. HGH is the primary chemical driver of cellular repair and muscle/tendon protein synthesis. Skimping on sleep directly robs your tendon of its optimal daily rebuilding window. Aim for 7- 9 hours a night, on average.
The Nutrition Part: Because tendons are constructed almost entirely from collagen proteins, you must give your body the raw materials it needs to repair frayed tissue. Aim for a high-quality daily protein target (around 0.7 to 1.0 grams per pound of body weight). Additionally, prioritize your Vitamin C intake. Vitamin C serves as a mandatory chemical co-factor that your body requires to structurally cross-link and weld those loose, new collagen strands into a tough, cohesive bundle. Without it, the structural integrity of the new tissue will fall short.
*Recommendation - add a collagen supplement to your diet as well.
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.
What Next?
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.
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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