How do you assess and start loading mid-portion Achilles tendinopathy?
Recognising mid-portion and insertional Achilles tendinopathy, ruling out rupture, and setting up progressive loading.
Subjective triage
- Pain in the Achilles tendon, often 2 to 6 cm above the heel (mid-portion) or at the heel (insertional).
- Morning stiffness or pain on first steps that eases with warming up.
- Often follows a change in running volume, speed, hills or footwear.
- Pain that settles during activity then returns later or the next morning.
- Ask about a sudden ‘kick’ to the back of the leg, which suggests rupture rather than tendinopathy.
Differential dilemma: vs achilles tendon rupture
| Feature | Achilles tendinopathy | Achilles tendon rupture |
|---|---|---|
| Onset | Gradual, linked to load changes | Sudden, often with a ‘kicked’ sensation or snap |
| Calf squeeze test | Normal plantarflexion | Reduced or absent plantarflexion (Simmonds' test positive) |
| Palpation | Tender, sometimes thickened tendon | May feel a gap in the tendon |
| Function | Can perform single-leg heel raises, often painful | Unable to perform a single-leg heel raise |
Red flags: recognise, screen, refer
Recognise
- Sudden onset with a snap or ‘kick’ (possible rupture)
- Calf swelling, warmth and tenderness (possible deep vein thrombosis)
- Recent fluoroquinolone antibiotic use
- Systemic or inflammatory features with several affected tendons
Screen
Perform the calf squeeze test on any acute presentation and ask about recent medication and inflammatory conditions.
Refer
Suspected rupture needs same-day assessment following local pathways. Suspected deep vein thrombosis needs same-day medical assessment.
The clinical reasoning chain
- 1
History
Gradual Achilles pain after adding hill sessions, stiff on first steps each morning.
- 2
Pattern
Load-linked onset with morning stiffness fits mid-portion tendinopathy rather than rupture.
- 3
Objective finding
Tenderness 4 cm above the heel, normal calf squeeze test, painful single-leg heel raises.
- 4
Diagnostic decision
Mid-portion Achilles tendinopathy: load management and progressive calf loading, with pain monitoring.
Structures to explore in 3D
In Physivo lessons, tap an anatomical term to focus the 3D model on it. These are the key structures for this presentation.
Mid-portion Achilles tendon
The area 2 to 6 cm above the heel, the most common site of tendinopathy.
Achilles insertion on the calcaneus
Site of insertional tendinopathy, sensitive to compression in dorsiflexion.
Gastrocnemius and soleus
The calf muscles that load the tendon and are the focus of rehab.
Retrocalcaneal bursa
Sits between the tendon and heel bone and can be irritated alongside insertional pain.
Quick diagnostic check
Quick reference FAQ
Should runners stop running with Achilles tendinopathy?
Not always. Many can keep running with adjusted volume, speed and hills if pain stays acceptable and settles by the next morning.
What is the main treatment?
Progressive calf and tendon loading exercise, such as heel raises progressed in load and speed, alongside education and load management.
How is insertional tendinopathy different?
Pain sits at the heel and is often provoked by dorsiflexion. Loading exercises are usually kept out of end-range dorsiflexion early on.