Almost everyone with Achilles pain is eventually told to do heel drops off a step. For about half of them that is exactly right. For the other half it is the reason they are not getting better.
Two problems, one tendon
Where the pain sits changes the treatment, and it is the first thing worth establishing.
| Mid-portion | Insertional | |
|---|---|---|
| Where it hurts | 2–6 cm above the heel bone, in the cord | Right at the back of the heel bone |
| Squeeze test | Tender pinching the tendon itself | Tender pressing on the bone junction |
| Worse with | Push-off, hills, speed work | Uphill running, stiff-backed shoes, stretching the calf |
| Heel drops below the step | Appropriate — the standard protocol | Often makes it worse |
| Better loading | Full-range eccentric heel drops | Heel raises kept to flat ground, no dorsiflexion |
| Outlook | Often much better by around 12 weeks | Traditionally slower |
That single difference explains a great deal of stalled progress. If heel drops have been making things worse rather than better, it is worth checking which type you have before concluding the exercise does not work.
What to do for each
Mid-portion. Full-range heel raises and slow lowers off the edge of a step, letting the heel drop below the toes. Both straight-legged and with a bent knee, so the deeper calf muscle gets loaded too. Slow, controlled, daily.
Insertional. The same idea, but keep the heel at or above floor level. No dropping below the step, and go easy on calf stretching, which compresses the same junction. A small heel lift in the shoe reduces that compression while it settles.
For both: some discomfort during loading is acceptable, provided it settles within twenty-four hours and is not worse the next morning. That morning check is the most reliable guide you have — more reliable than how the tendon feels during the exercise itself, which is often misleading in both directions.
A twelve-week shape
Tendon rehabilitation is dull and it is the treatment. This is roughly how a course runs, and what to watch at each stage.
| Weeks | What you are doing | What to watch |
|---|---|---|
| 1–2 | Settle the irritation; reduce hills and speed, keep walking | Morning stiffness starting to shorten |
| 2–6 | Daily loading, appropriate to your type | Discomfort during, settled within 24 hours |
| 6–10 | Add load rather than repetitions; reintroduce easy running | No increase in next-morning symptoms |
| 10–12 | Return to hills and speed, one variable at a time | The tendon tolerating a full week of it |
| Beyond | Keep two loading sessions a week going | Recurrence is common in people who stop |
What usually caused it
Almost always load, not damage. Tendinopathy is a tissue that has been asked for more than it was prepared for, which is a more hopeful framing than it sounds: capacity can be rebuilt.
- A jump in running volume — the classic is adding distance and hills in the same fortnight.
- New speed work after a period of steady miles.
- A change of shoe, particularly to a lower drop.
- Returning after a layoff at the volume you stopped at.
- Hill repeats, which load the insertion particularly hard.
Working out which applies matters, because unchanged load means it comes back. The American Orthopaedic Foot and Ankle Society publishes patient guidance on Achilles problems and when they need assessment.
Why “tendinitis” is the wrong word here too
The old name was Achilles tendinitis, implying inflammation. As with tennis elbow, tissue studies largely overturned that: what is found is a disorganised, degenerative tendon rather than an inflamed one.
The practical consequence is the same. Anti-inflammatory approaches target something that is largely not present, which is why rest, ice and tablets so often disappoint. Loading the tendon is what prompts it to reorganise, which is also why the treatment feels counterintuitive: you improve it by using it, carefully.
Where treatment fits
The same honest answer as tennis elbow, plantar fasciitis and gluteal tendinopathy: the loading programme is the treatment, and needling or hands-on work is there to make it tolerable.
Treatment concentrates on the calf complex rather than the tendon itself, because a tight, weak calf is doing most of the damage. Massage of the calf is often more useful here than work on the tendon, and direct pressure on an irritated insertion is usually counterproductive.
Say which type you have when you book, or describe where it hurts and we will work it out. It changes what we do.
A loading programme only works if it actually happens, and most of them quietly stop around week four — why rehab exercises get abandoned is about fixing that specifically.
If the trouble started with a rolled ankle rather than a gradual build-up, ankle sprain recovery is the more useful article — the rehabilitation differs, and the part that prevents a recurrence differs again.
When to see a doctor
Seek urgent assessment if you felt a sudden snap or a sensation of being kicked in the back of the ankle, or cannot push off at all — that can indicate a rupture. Also see a doctor for swelling with redness and warmth, pain that is constant including at rest, or Achilles pain while taking a fluoroquinolone antibiotic, which is associated with tendon problems.
Booking a session in Beverly
Acupuncture is $75 a session and massage is $45 for 30 minutes, $75 for 60 and $105 for 90, on our rates page. For a calf and Achilles, thirty focused minutes is often the sensible booking.
See also recovery work for active people, browse all our articles, or get in touch.
Frequently asked questions
Where exactly does it hurt?
That question decides the treatment. Pain two to six centimetres above the heel bone, in the cord of the tendon itself, is mid-portion. Pain right where the tendon meets the heel bone is insertional. They respond to different loading.
Why does the standard heel-drop exercise not always work?
Because dropping the heel below the step compresses the tendon against the heel bone. That is fine for mid-portion tendinopathy and unhelpful for insertional. One study avoiding dorsiflexion reported 67% satisfaction against roughly 30% in studies that worked into it.
How long does it take?
Months. Mid-portion cases often improve substantially within about twelve weeks of consistent loading. Insertional cases are traditionally slower. Tendons remodel on their own timescale and there is no shortcut.
Should I stop running?
Usually reduce rather than stop. Complete rest de-loads the tendon and it returns weaker. Cutting volume and hills, and keeping walking, is generally better tolerated than stopping altogether.
Does acupuncture help?
There is no strong condition-specific trial evidence. What applies is the general musculoskeletal pain literature, so treat it as a reasonable adjunct for pain while you do the loading work, not as a treatment for the tendon.
This article is general information, not medical advice. Acupuncture is intended to work alongside the care of your doctor, not to replace it. Please speak to a clinician about any new, severe or changing symptom.