Achilles Tendinopathy: Insertional vs. Non‑Insertional

Dr. Angela Walk
Jun 25, 2025
4 min read

Updated: Jul 20

he Achilles tendon—the strongest in the body—connects calf muscles to the heel, enabling walking, running, and jumping. When injured, it can become weak, thickened, and painful—a condition known as Achilles tendinopathy.

There are two primary types:

Non‑Insertional (mid‑portion): Located 2–7 cm above the heel.
Insertional: At the point where the tendon attaches to the heel

Insertional vs. Non‑Insertional Achilles Tendinopathy

Feature	Non‑Insertional	Insertional
Location	Mid‑tendon, 2–7 cm above heel	At tendon insertion on calcaneus
Typical Patients	Younger, more active (runners)	Any age, can be from calf tightness or heel deformities
Symptoms	Pain/stiffness mid‑tendon, swelling, worse with activity	Pain at heel insertion, bone bump (Haglund’s), morning stiffness
Best Conservative Strategy	Eccentric loading, progressive resistance	Modified eccentric exercises (no heel drops), slower transitions to loading
Bone Involvement	Rare calcification	Common – bone spurs often present

Natural Treatment Plan

Step 1: Transition to Functional Footwear

The first step is to transition out of footwear with an elevated heel.

Most conventional footwear has elevation of the heel. The industry standard is 8-12mm.

Long-term use of this type of footwear causes a chronic tightening of the calf muscle complex, and leads to many foot conditions, including AT.

A slow, gradual transition to zero drop footwear is ideal. This will place all the lower leg muscles back into their natural length-to-tension relationship.

Choose zero-drop, wide-toe, flexible shoes to restore natural calf‑tendon mechanics.

Take a look at my Approved Shoe List for the footwear that I approve and recommend for AT and other foot conditions.

Step 2: Remove Fascial Adhesions

With a repetitive strain, soft tissue adhesions develop, and must be removed to improve tensile strength and mobility.

Every 2 days, use a stainless steel tool on calves, tendon, and soleus to improve mobility and healing.

Step 3: Implement Progressive Loading

Progressive loading is one of the most effective rehabilitation principles we have.

It simply means you start with a level of exercise your tissues can tolerate, and then gradually increase the challenge as they become stronger.

This teaches your foot and achilles tendon how to handle load again. That's how real healing occurs.

One of my favorite ways to do this is with calf raises performed while your toes are slightly elevated. I designed a tool called the FasciaFlex Trainer specifically for this exercise. If you don't have the trainer, you can use a rolled up towel underneath your toes.

Now let me give you a quick science lesson because this part is incredibly important.

When your big toe bends upward into extension during walking, it tightens the plantar fascia, raises your arch, and transforms your foot into a stable lever so you can push off efficiently.

This process is called the windlass mechanism, and it's one of the most important functions of the foot and lower leg.

Unfortunately, in many people with achilles tendon issues, that mechanism becomes weak and inefficient.

There are 3 exercises below. Start with exercise number one and perform 2-3 set of 12-15 reps every other day. In 2 weeks, incorporate exercise number 2. In another 2 weeks, add exercise number 3.

Exercise 1. Calf Raises With A Ball Between Your Heels

We always begin with double-leg calf raises. Place your toes on the rolled towel or FasciaFlex Trainer.

Slowly rise onto the balls of both feet, pause briefly at the top, then lower under control. I recommend one to three sets of fifteen repetitions every other day.

Exercise 2. Eccentric Loading Calf Raises

After about two to three weeks, once that becomes comfortable, we move to eccentric calf raises. This is the classic "up on two, down on one" progression. Rise onto your toes using both feet. Then lift one foot off the ground and slowly lower yourself using only the affected leg. Again, perform one to three sets of fifteen repetitions every other day.

Exercise 3. Single Leg Calf Raises

Finally, when your strength and symptoms allow, progress to single-leg calf raises.

This is where your foot really begins to develop strength, resilience, and the capacity to tolerate everyday activities like walking, hiking, pickleball, and running without constantly becoming irritated.

The key is slow, controlled movement and gradually increasing the challenge over time. That's exactly how tendons, fascia, and muscles adapt.

That’s it. That’s how you use a progressive approach to strengthening your feet and lower leg.

This simple progression became one of the biggest reasons my patients started recovering faster and staying pain-free.

Exercise 4: Improve Ankle Dorsiflexion

Limited ankle dorsiflexion, the ability to bring your knee forward over your foot, can place excessive stress on the Achilles tendon during walking and running.

When the ankle doesn't have enough dorsiflexion, your heel often lifts off the ground earlier than it should during gait.

This early heel rise forces the Achilles tendon to absorb more load over and over again, increasing irritation and slowing recovery.

One of the best ways to improve ankle dorsiflexion is with kneeling ankle rocks.

Start in a half-kneeling position with your front foot flat on the floor. Keeping your heel down, slowly drive your knee forward over your toes until you feel a gentle stretch in the ankle. Return to the starting position and repeat in a slow, controlled manner.

As your ankle mobility improves, your walking mechanics become more efficient, reducing unnecessary strain on the Achilles tendon with every step.