Quick answer

Mid-substance Achilles tendinopathy causes load-related pain in the main body of the tendon, commonly around 2–7 cm above its insertion into the heel bone. It is distinct from insertional tendinopathy.

Article

Where the pain occurs

Patients usually point to a tender or thickened area above the back of the heel rather than directly at the tendon-bone attachment.

Typical clinical features

Pain with running, jumping, hills or calf raises, morning stiffness and reduced endurance are common. Diagnosis is primarily clinical; ultrasound or MRI may be useful when the presentation is atypical or progress is poor.

Why loading matters

The 2024 midportion Achilles clinical practice guideline supports tendon-loading exercise as a core intervention and advises that complete rest is generally not indicated in non-acute cases. Loading can be progressed according to irritability, strength and activity goals.

Key points

  • The location is typically proximal to the insertion.
  • Progressive loading is a first-line intervention.
  • Exercise can include more than eccentric heel drops; the program should progress toward the loads the patient needs.

Frequently Asked Questions

Is mid-substance tendinopathy the same as insertional disease?

No. They occur in different regions and have important management differences.

Do I need an MRI?

Not routinely. Imaging is most useful when the diagnosis is uncertain, symptoms are atypical or progress is not as expected.