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Common Causes of Calf Pain

John Miller Physiotherapist Erin Runge Physiotherapist
Article by John Miller & Erin Runge
Physiotherapist assessing a calf strain injury during a calf muscle examination

A calf assessment helps identify whether pain involves muscle, tendon, nerve or another cause.

Common causes of calf pain include muscle strain, Achilles tendon problems, muscle cramps, exercise-related pressure, referred nerve pain and circulation problems. Some causes improve with sensible activity changes and rehabilitation. Others need prompt medical assessment.

How the pain started provides an important clue. Sudden pain during sprinting may suggest a muscle injury. In contrast, pain that gradually increases with running, hills or walking may reflect tendon overload, reduced calf capacity or another lower-leg condition.

This guide compares common symptom patterns, warning signs and practical next steps. You can also explore the broader calf pain conditions guide.

Quick Guide to Calf Pain

The symptom pattern can help narrow the likely source, although it cannot confirm a diagnosis by itself.

Sharp pain during sprinting or jumping
May indicate a calf muscle strain or tear.

Morning stiffness near the heel
May indicate Achilles tendon irritation or tendinopathy.

A sudden pop and weak push-off
May indicate an Achilles tendon rupture.

Predictable tightness during exercise
May occur with chronic exertional compartment syndrome.

Burning, tingling or back-related pain
May indicate referred nerve pain.

Swelling, warmth or redness
Needs prompt medical assessment.

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What Structures Can Cause Calf Pain?

The calf contains several structures that help you walk, run, jump and push away from the ground. The main calf muscles are the gastrocnemius and soleus. These muscles connect with the Achilles tendon, which attaches to the heel bone.

Pain may also arise from nerves, blood vessels, the knee, the lower back or pressure inside the lower-leg muscle compartments. Therefore, calf pain does not always mean that the calf muscle itself is injured.

Sudden Causes of Calf Pain

Calf Strain or Tear

A calf strain or tear often causes sudden pain during sprinting, jumping, lunging or changing direction. Some people describe a sharp pull, tearing sensation or feeling like something struck the calf.

Common features include:

  • localised tenderness;
  • pain when walking or pushing off;
  • weakness during a calf raise;
  • swelling or bruising;
  • difficulty running or climbing stairs.

The severity can vary. A mild strain may allow walking with discomfort, while a larger tear can cause marked weakness, swelling and limping.

Achilles Tendon Rupture

An Achilles tendon rupture usually causes sudden pain at the back of the ankle or lower calf. People often report a popping sound or a feeling that someone kicked the back of the leg.

Walking may become difficult, and the injured leg may feel weak when pushing away from the ground. A suspected rupture needs prompt assessment because early diagnosis helps guide appropriate management.

Direct Impact or Contusion

A collision, fall or direct blow can bruise the calf muscles. Pain and swelling usually sit around the impact area. More severe trauma may also injure deeper tissues or, less commonly, contribute to acute compartment syndrome.

Gradual and Overuse Causes

Achilles Tendinopathy

Achilles tendinopathy can cause pain in the lower calf, along the tendon or close to the heel. Symptoms commonly build after increased running, hill training, jumping or a rapid change in activity.

Typical features include morning stiffness, tenderness, pain during calf raises and discomfort when starting exercise. Some people feel better after warming up, although symptoms may return during or after activity.

Calf Muscle Overload

The calf muscles can become painful when activity exceeds their current capacity. This may happen after increasing walking distance, running volume, hills, court sport or gym exercises too quickly.

Overload usually causes a gradual ache, tightness or fatigue rather than one clear moment of injury. Reduced calf strength, limited ankle movement, recent inactivity and a previous calf injury may contribute.

Muscle Cramps

Muscle cramps cause a sudden, involuntary and often painful tightening of the calf. Exercise-related cramps may occur with fatigue, unfamiliar loading, poor pacing or inadequate conditioning.

Hydration may play a role in some cases. However, recurrent cramps are not always caused by dehydration alone. Persistent or unexplained cramping deserves further assessment, especially when it occurs without exercise or alongside weakness, swelling or other symptoms.

Calf Pain During Exercise

Chronic Exertional Compartment Syndrome

Chronic exertional compartment syndrome can cause predictable tightness, pressure or cramping during running or repeated exercise. Symptoms often begin after a similar amount of activity and ease after stopping.

Some people also experience tingling, numbness or weakness. This pattern differs from a simple muscle strain because symptoms often recur at a repeatable exercise threshold.

Circulation-Related Walking Pain

Reduced blood flow can cause calf discomfort during walking. The pain may begin after a consistent walking distance and improve with rest. This pattern requires medical assessment, particularly in people with cardiovascular risk factors.

A physiotherapy assessment may help determine whether symptoms behave like a muscle, tendon or nerve problem. However, suspected circulation problems require medical investigation.

Referred Pain from the Back or Nerves

Not all calf pain starts in the calf. Irritation of a nerve in the lower back may refer symptoms into the back of the leg. This can occur with sciatica or another nerve-related condition.

Nerve-related calf symptoms may include:

  • burning or electric pain;
  • tingling or numbness;
  • pain extending from the back or buttock;
  • weakness in the ankle or foot;
  • symptoms affected by spinal position.

A thorough assessment helps distinguish referred nerve pain from a local calf muscle or tendon problem.

Other Possible Causes

Baker’s Cyst

A Baker’s cyst is a fluid-filled swelling behind the knee. If the cyst becomes irritated or leaks fluid down the leg, it may cause calf tightness, swelling or discomfort.

These symptoms can resemble other conditions, including a blood clot. Therefore, new or unexplained calf swelling should be medically assessed.

Stress Injury or Fracture

A stress injury of the tibia or another lower-leg bone can sometimes feel like calf or shin pain. Symptoms commonly worsen with repeated weight-bearing activity and may become more localised over time.

Persistent bone tenderness, night pain or increasing pain with walking or running needs further assessment.

Inflammation or Infection

Less commonly, calf pain may relate to infection or an inflammatory condition. Increasing redness, heat, swelling, fever or feeling generally unwell requires prompt medical care.

When Calf Pain Needs Urgent Medical Care

Seek urgent medical assessment if calf pain occurs with:

  • new one-sided swelling;
  • redness, warmth or unexplained tenderness;
  • chest pain or shortness of breath;
  • a cold, pale or discoloured foot;
  • severe pain after trauma;
  • rapidly increasing tightness or pressure;
  • progressive numbness or weakness;
  • fever or signs of infection.

These features may indicate a blood clot, circulation problem, acute compartment syndrome, infection or another condition that needs urgent medical investigation.

Could Calf Pain Be a Deep Vein Thrombosis?

A deep vein thrombosis, or DVT, is a blood clot within a deep vein. It may cause calf pain, swelling, warmth, tenderness or a change in skin colour. However, symptoms vary, and some people have few obvious signs.

Risk may increase after surgery, prolonged immobility, long-distance travel, serious illness or a previous clot. Pregnancy, some medications and certain medical conditions may also affect risk.

A suspected DVT is not suitable for routine self-treatment, exercise testing or massage. Seek prompt medical assessment. A doctor may arrange appropriate testing, commonly including vascular ultrasound.

Why Does My Calf Hurt When Walking?

Calf pain while walking may come from reduced muscle capacity, Achilles tendon irritation, a recovering strain, referred nerve pain or a circulation problem.

The timing of symptoms can help identify the next step:

  • Pain from the first few steps: may occur with an acute muscle injury or an irritable tendon.
  • Pain after increasing distance: may reflect reduced load tolerance.
  • Pain at a consistent distance that eases with rest: may require assessment for circulation or exertional pressure problems.
  • Pain with tingling or back symptoms: may indicate nerve involvement.

How Is Calf Pain Assessed?

A physiotherapist will ask how the pain started, where it sits and which activities aggravate it. The assessment may include walking, ankle movement, calf strength, balance, calf raises and tests of the knee, ankle and lower back.

The clinician will also check for swelling, bruising, weakness, altered sensation and warning signs that require medical referral.

Imaging is not necessary for every calf problem. Ultrasound or MRI may help clarify selected muscle and tendon injuries. Suspected blood clots, fractures, circulation problems or other medical conditions require the appropriate medical pathway.

How Physiotherapy May Help

Treatment depends on the cause rather than the symptom alone. A rehabilitation program may include:

  • temporary activity modification;
  • progressive calf strengthening;
  • ankle mobility exercises;
  • walking or running progression;
  • tendon or muscle loading;
  • balance and lower-limb control exercises;
  • return-to-sport planning.

The aim is to rebuild the calf’s capacity for daily activity, work or sport without progressing the load too quickly.

Calf pain single-leg calf raise rehabilitation

Progressive calf strengthening can rebuild walking, running and push-off capacity.

Reducing the Risk of Calf Pain

You may reduce the risk of recurrent calf pain by progressing activity gradually and maintaining calf strength.

Useful strategies include:

  • avoiding sudden increases in running or walking volume;
  • including both straight-knee and bent-knee calf exercises;
  • warming up before high-speed or jumping activity;
  • allowing enough recovery between demanding sessions;
  • reviewing footwear when symptoms follow a major footwear change;
  • addressing persistent ankle stiffness or calf weakness;
  • following a staged return after a previous injury.

People increasing their walking load may also find the walking injury guide helpful.

Related Calf and Leg Conditions

Explore the most relevant PhysioWorks guides.

Calf Pain FAQs

What is the most common cause of calf pain?

Muscle overload and calf strains are common causes, particularly after running, jumping, hills or a rapid increase in activity. However, the most likely cause depends on how the pain started, where it sits and whether there is swelling, weakness or nerve-related symptoms.

Why does my calf hurt after walking?

Calf pain after walking may come from reduced muscular capacity, Achilles tendon irritation, a recovering calf strain or a rapid increase in walking distance. Pain that predictably starts after a set distance and eases with rest also needs assessment for circulation or exertional pressure problems.

What should I do for a pulled calf muscle?

Reduce activities that cause sharp pain, keep the leg moving within a comfortable range and avoid returning to running or jumping too quickly. A staged strengthening program usually works better than prolonged complete rest. Seek assessment if walking is difficult, bruising is extensive or weakness is significant.

How can I prevent calf cramps?

Build exercise capacity gradually, manage fatigue and allow enough recovery between demanding sessions. Hydration may help in some situations, but repeated cramping is not always caused by dehydration. Seek advice if cramps are frequent, unexplained or occur alongside weakness, swelling or other symptoms.

When is calf pain serious?

Calf pain is more concerning when it occurs with one-sided swelling, warmth, redness, chest pain, shortness of breath, severe weakness, a cold or discoloured foot, fever or rapidly increasing pressure. These symptoms require urgent medical assessment.

What to Do Next

Seek urgent medical care when calf pain occurs with swelling, redness, warmth, breathing difficulty, severe weakness or another warning sign.

Otherwise, consider a physiotherapy assessment when calf pain keeps returning, affects walking or running, follows an injury, or does not improve as expected. Identifying whether the problem involves muscle, tendon, nerve or another structure helps guide an appropriate rehabilitation plan.

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References

  1. de Jonge S, et al. The tendon unit: biochemical, biomechanical, hormonal influences and pathophysiology in tendinopathy. Sports Med Open. 2021;7(1).
  2. Healthdirect Australia. Deep vein thrombosis. Accessed July 2026.

What Are the Most Common Running Injuries?

John Miller Physiotherapist Chelsea Gan Physiotherapist
Article by John Miller & Chelsea Gan
Runner with knee pain pointing to knee during physiotherapy assessment in clinic

Running injuries most often affect the knee, shin, Achilles tendon, calf, foot and hip. Many develop gradually when a recent running demand exceeds the capacity of a muscle, tendon, joint or bone.

Common pattern

Pain builds during a run, appears afterwards or feels worse the next morning.

Important clue

Symptoms often follow a change in distance, speed, hills, frequency, surface or recovery.

Seek assessment

Book earlier when pain changes your stride, causes limping or becomes sharp and localised.

Which running injuries are most common?

Running-related injuries can affect muscles, tendons, joints, bones and other supporting tissues. Some start suddenly, such as an ankle sprain or calf strain. However, many build over several runs as repeated loading exceeds the tissue’s current capacity.

The eight conditions below account for many of the knee, shin, calf, heel, foot and thigh symptoms reported by recreational runners.

Runner’s knee

Pain around or behind the kneecap. It commonly becomes noticeable during hills, stairs, squats or longer runs.

Shin splints

A broader area of exercise-related pain along the shin. Symptoms often follow a change in impact load or training volume.

Achilles tendinopathy

Pain and stiffness around the Achilles tendon. Morning stiffness and discomfort at the start of running are common features.

Plantar fasciopathy

Pain under the heel or arch. The first steps after rest may feel uncomfortable before symptoms ease with movement.

ITB syndrome

Pain around the outside of the knee. It may appear at a similar point during each run, particularly on hills.

Calf strain

A sudden or gradually worsening pain in the calf. Faster running, sprinting and hills can increase calf demand.

Hamstring injury

Pain at the back of the thigh or near the sitting bone. Symptoms may affect faster running, acceleration and longer strides.

Bone stress injury

Focal bone pain that may progress from running pain to discomfort with hopping, walking or normal daily activity.

Where do runners commonly feel pain?

Front or outside of the knee

Front-of-knee pain may relate to runner’s knee, also called patellofemoral pain. Symptoms often become noticeable during downhill running, stairs, squats or after sitting with the knee bent.

Pain on the outside of the knee may fit an iliotibial band presentation. However, several knee structures can cause pain in a similar area. The location alone does not confirm a diagnosis.

Along the shin

A broad area of tenderness along the inner shin often fits shin splints. By contrast, a small and sharply localised painful area raises more concern about a bone stress injury.

Shin pain warrants earlier assessment when hopping is painful, symptoms persist after exercise or discomfort begins affecting walking.

Behind the ankle or in the calf

Achilles tendinopathy commonly causes pain, stiffness or thickening around the tendon. Symptoms may feel worse during the first steps in the morning or when beginning a run.

A calf strain is more likely when pain starts suddenly during acceleration, hills or faster running. Significant weakness, swelling or difficulty pushing through the foot requires prompt assessment.

Under the heel or through the foot

Plantar fasciopathy often causes pain under the heel, particularly during the first few steps after getting out of bed or standing after rest.

Forefoot pain has several possible causes, including metatarsal overload, nerve irritation and bone stress. Persistent focal pain should not be managed simply by continuing to run through it.

At the hip, groin or back of the thigh

Hip and thigh symptoms may involve the gluteal tendons, hamstrings, hip joint or surrounding muscles. Proximal hamstring symptoms often sit close to the lower buttock and may become uncomfortable during faster running or prolonged sitting.

Groin pain has several possible sources. Assessment becomes more important when pain persists, affects walking or does not settle after a reasonable reduction in training.

Why do running injuries happen?

Running injuries rarely have one isolated cause. Instead, they usually reflect an interaction between recent training, previous injuries, recovery, health, tissue capacity and the demands of the runner’s chosen pace, terrain and distance.

Common contributing factors may include:

  • A longer individual run than your body has recently tolerated
  • Adding speed, hills and distance within the same training period
  • Returning quickly after illness, injury or a break from running
  • Insufficient recovery between demanding sessions
  • Reduced calf, thigh, hip or trunk capacity
  • A previous injury that has not regained full strength or running tolerance
  • A sudden change in shoes, running surface or training environment

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What are the early signs of a running injury?

An early running injury does not always begin with severe pain. Mild changes in comfort, stiffness or movement can appear before running becomes significantly limited.

During running

Pain starts earlier, becomes stronger or makes you shorten your stride.

After running

Soreness lasts longer than expected or increases later in the day.

The next morning

Stiffness, tenderness or pain is worse than your usual post-training response.

Other warning signs include swelling, reduced push-off strength, repeated pain at the same running distance and declining confidence in the affected leg.

Can you keep running with an injury?

Some runners can continue with a temporarily reduced load. Others need to pause running while the injury is assessed. The safest choice depends on the suspected tissue, symptom severity and how the condition responds during and after exercise.

Consider reducing or stopping the run when:

  • Pain continues to increase as you run
  • Your stride changes or you begin to limp
  • Symptoms remain clearly worse the following morning
  • You have sharp or highly localised bone pain
  • You lose strength, balance or confidence in the leg
  • Running causes increasing swelling

A minor symptom that remains mild, does not alter movement and settles promptly may allow a modified run. However, repeatedly testing an injury with the same aggravating session can delay recovery.

How are running injuries assessed?

A physiotherapy assessment usually begins by clarifying where symptoms started, how they respond to running and what changed before the problem developed.

Your assessment may include:

  1. Reviewing your recent training

    Your physiotherapist may compare distance, pace, hills, speed sessions, surfaces, footwear, recovery and recent interruptions to training.

  2. Examining the painful area

    Palpation, movement testing and relevant clinical tests help identify which tissues may be contributing.

  3. Checking strength and movement capacity

    Testing may include calf raises, hopping, squats, step tasks, hip strength or other movements matched to your symptoms.

  4. Reviewing your running where useful

    A running assessment can examine relevant movement patterns and how they interact with your current injury and training demands.

Imaging is not required for every running injury. However, a medical referral or imaging may be appropriate when the assessment suggests a fracture, significant tendon injury or another condition needing further investigation.

Physiotherapist guiding step-up exercise for lower limb strength and rehabilitation in clinic

How can physiotherapy help a running injury?

Physiotherapy aims to identify the likely injury, reduce aggravating load and rebuild the capacity needed for running. Your plan should reflect the affected tissue, your current symptoms and the type of running you want to resume.

Management may include:

  • Temporary changes to running distance, pace, hills or frequency
  • Progressive calf, knee, hamstring, hip or trunk strengthening
  • Mobility work when a relevant restriction affects function
  • Advice about footwear, surfaces and training structure
  • Movement or running retraining when it has a clear clinical purpose
  • A staged return-to-run program
  • Testing before faster running, hills or longer distances resume

Passive treatment may help some symptoms in the short term. However, rebuilding load tolerance and gradually returning to running usually remain central to rehabilitation.

Runners with recurring symptoms may also benefit from a dedicated running injury risk and performance assessment.

How can you reduce your risk of another running injury?

No strategy can prevent every injury. Even so, sensible progression and adequate recovery can reduce avoidable overload.

  1. Build one demand at a time

    Avoid making large increases in distance, speed and hills simultaneously.

  2. Watch individual long-run changes

    Compare a planned longer run with the longest distance you have completed recently, not only your weekly total.

  3. Keep regular strength work

    Calf, thigh, hamstring, hip and trunk exercises can support the physical demands of running.

  4. Respond early to warning signs

    Modify training when pain escalates, changes your stride or remains worse the following morning.

  5. Return gradually after a break

    Fitness can return faster than the load tolerance of bones, tendons and muscles after time away.

When should a runner book an assessment?

Consider booking a physiotherapy assessment when:

  • Pain is changing your running technique
  • You cannot progress training without another flare-up
  • Symptoms are worsening from one session to the next
  • Morning pain or stiffness is becoming more noticeable
  • Pain is sharply localised over a bone
  • You have swelling, weakness or difficulty walking
  • You are unsure how much running is currently safe

Earlier assessment is especially useful when a stress fracture, significant calf injury or Achilles tendon injury is possible.

Running injuries guide

Explore running-related conditions, treatment principles and return-to-running information.

Running assessment

Learn how strength, mobility, training and running movement may be assessed together.

Sports physiotherapy

Find out how sports physiotherapy can support injury rehabilitation and return to activity.

Common running injury FAQs

What is the most common running injury?

Knee pain, including runner’s knee or patellofemoral pain, is consistently among the most frequently reported running injuries. Shin splints, Achilles tendinopathy and plantar heel pain are also common.

Are most running injuries caused by overuse?

Many running injuries develop gradually through repeated loading rather than one traumatic event. However, “overuse” does not identify one cause. Training changes, recovery, previous injury, health and tissue capacity can all contribute.

What are the first signs of a running injury?

Early signs may include pain that begins sooner during a run, soreness that lasts longer afterwards, increasing morning stiffness or a subtle change in stride. Repeated symptoms at a similar distance also deserve attention.

Should I stop running when I have pain?

Stop or reduce running when pain escalates, changes your gait, causes swelling or remains clearly worse the following morning. Mild symptoms that settle promptly may allow modified activity, but the safe approach depends on the injury.

When is shin pain more serious?

Shin pain is more concerning when it is sharply localised, painful with hopping, present during walking or continuing after exercise. These features may indicate a bone stress injury and should be assessed promptly.

Can a running assessment prevent injuries?

A running assessment cannot guarantee injury prevention. It may identify useful changes to strength, training, recovery or movement when interpreted alongside your symptoms, injury history and running goals.

What causes knee pain when running?

Running-related knee pain may involve the patellofemoral joint, iliotibial band, patellar tendon or another structure. Training changes, reduced tissue capacity and a previous injury can contribute, so persistent pain should be assessed rather than diagnosed from location alone.

What should you do next?

Use the links above to compare your painful area with the most relevant condition guide. Meanwhile, reduce the running sessions that clearly aggravate your symptoms rather than repeatedly testing the same painful load.

Book an assessment when pain is changing your stride, limiting normal training or becoming more localised. A clear diagnosis and staged rehabilitation plan can help you return to running with appropriate progression.

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Select a PhysioWorks clinic to continue to live booking, an appointment request or reception assistance.

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View all clinic locations and phone numbers

Follow PhysioWorks

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References

  1. Correia CK, Machado JM, Dominski FH, de Castro MP, Fontana HB, Ruschel C. Risk factors for running-related injuries: an umbrella systematic review. Journal of Sport and Health Science. 2024;13(6):743–757. doi:10.1016/j.jshs.2024.04.011.
  2. Frandsen JSB, Hulme A, Nielsen RO, et al. How much running is too much? Identifying high-risk running sessions in a 5200-person cohort study. British Journal of Sports Medicine. 2025;59(17):1203–1211.
  3. Kakouris N, Yener N, Fong DTP. A systematic review of running-related musculoskeletal injuries in runners. Journal of Sport and Health Science. 2021;10(5):513–522. doi:10.1016/j.jshs.2021.04.001.

Achilles Enthesopathy vs Achilles Tendinopathy


John Miller Physiotherapist


Shane Armfield Physiotherapist

Article by
John Miller,
Shane Armfield
Physiotherapist assessing the Achilles tendon at the heel insertion
Achilles assessment considers the exact pain location, tendon response and nearby heel structures.

Achilles enthesopathy affects the Achilles tendon attachment at the heel, while mid-portion Achilles tendinopathy affects the tendon higher above the heel. This difference matters because insertional symptoms are often more sensitive to compression, particularly when the ankle moves into deeper dorsiflexion.

Both presentations can cause Achilles pain, morning stiffness and reduced tolerance for walking, running or sport. However, their early rehabilitation may need to start differently.

Insertional pain

Pain is focused at the Achilles attachment on the back of the heel.

Mid-portion pain

Pain is usually felt through the tendon body several centimetres above the heel.

Why it matters

Insertional symptoms may be aggravated by compression from deep ankle dorsiflexion, stretching or heel-drop exercises below step level.

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What Is the Difference Between Achilles Enthesopathy and Achilles Tendinopathy?

The main difference is where the symptoms occur.

The enthesis is the area where the Achilles tendon attaches to the calcaneus, or heel bone. Pain and tendon change in this region may be described as Achilles enthesopathy or insertional Achilles tendinopathy.

Mid-portion Achilles tendinopathy affects the tendon body higher above the heel, commonly around 2–6 cm from the insertion.

Insertional Achilles pain

Pain sits at the heel attachment. Compression between the tendon and heel bone can contribute to symptoms, particularly in deeper ankle dorsiflexion.

Mid-portion Achilles pain

Pain sits higher in the tendon body. Repeated tendon loading during running, hopping, jumping and push-off is commonly provocative.

Key Differences at a Glance

Achilles enthesopathy / insertional tendinopathy

Pain location: directly at the back of the heel where the Achilles attaches.

Common aggravators: hills, deep ankle bending, aggressive calf stretching, heel-drop exercises below step level and pressure from firm footwear.

Early rehabilitation: reduce excessive compression while maintaining appropriate tendon loading, then progressively restore strength and range.

Mid-portion Achilles tendinopathy

Pain location: usually several centimetres above the heel.

Common aggravators: running, jumping, hopping, repeated calf work, sprinting and hard push-off.

Early rehabilitation: progressive calf and Achilles loading matched to symptoms, strength and activity goals.

What Is Achilles Enthesopathy?

Achilles enthesopathy describes a problem involving the tendon attachment at the back of the heel. In clinical practice, symptomatic tendon change in this area often overlaps with the term insertional Achilles tendinopathy.

The insertion is exposed to both tendon tension and compression against the heel bone. Symptoms can therefore increase when the ankle moves into deeper dorsiflexion, such as during uphill walking, deep calf stretching or calf raises performed with the heel dropping below a step.

Some people also have irritation of the bursa between the Achilles tendon and heel or a nearby bony prominence. This is one reason retrocalcaneal bursitis can feel similar to insertional Achilles tendon pain.

What Is Mid-Portion Achilles Tendinopathy?

Achilles tendinopathy can also affect the tendon body above the heel. This is called mid-portion Achilles tendinopathy.

Symptoms commonly include local tendon pain, morning stiffness, tenderness and reduced tolerance for running, jumping, hills, stairs or repeated calf loading. The tendon may also feel thicker than the other side.

A training increase, return to sport, extra hill work, faster running, increased jumping or reduced calf capacity can contribute when the tendon is exposed to more load than it currently tolerates.

What Symptoms Help Tell Them Apart?

The exact location of pain often provides the clearest clue.

  • Insertional pain: tenderness is directly at or very close to the heel attachment.
  • Mid-portion pain: tenderness usually sits several centimetres above the heel.
  • Morning stiffness: may occur with either presentation.
  • Running and hopping pain: may occur with either presentation as tendon load rises.
  • Deep ankle dorsiflexion pain: is particularly relevant when insertional compression contributes.
  • Tendon thickening: may occur, but its presence does not determine pain severity on its own.

Broader heel pain and calf pain can come from several structures, so pain location alone does not confirm the diagnosis.

How Are Achilles Enthesopathy and Tendinopathy Assessed?

A physiotherapist will usually combine your symptom history with an examination of the Achilles tendon and surrounding structures.

Assessment may include:

  • the exact location and behaviour of your pain
  • Achilles and heel tenderness
  • ankle movement and symptom response to dorsiflexion
  • single-leg calf raise strength and endurance
  • walking, stair, hopping or running tolerance
  • recent changes in training, work or activity load
  • footwear and heel-counter pressure
  • comparison with the other side where useful

Ultrasound or MRI may help when symptoms remain unclear, behave unusually or fail to improve as expected. Imaging is not always necessary because tendon changes seen on scans do not always match a person's symptoms.

What Else Can Cause Pain at the Back of the Heel?

Not all posterior heel pain is Achilles tendinopathy. Other possibilities include retrocalcaneal bursitis, calf injury, bone or joint problems, referred pain and inflammatory conditions.

A sudden injury also raises concern for an Achilles tendon rupture.

Achilles tendon palpation and calf squeeze assessment for suspected rupture
A sudden loss of Achilles function requires assessment for a possible tendon rupture.

Why Does Compression Matter for Insertional Achilles Pain?

When the ankle bends upwards, the Achilles insertion can be compressed against the heel bone. That compression is particularly relevant in insertional Achilles tendinopathy.

A 2025 randomised clinical trial compared rehabilitation with lower versus higher Achilles tendon compression. The lower-compression program limited dorsiflexion during exercise, avoided calf stretching and used heel lifts. It produced greater improvements in Achilles symptoms and function over 12 and 24 weeks.

This does not mean the tendon should avoid loading. Instead, it supports choosing an appropriate starting range and gradually increasing tendon demand as symptoms and capacity improve.

Should You Stretch Insertional Achilles Tendinopathy?

Aggressive calf stretching is often unhelpful during an irritable insertional presentation because deeper dorsiflexion can increase compression at the tendon attachment.

Similarly, traditional heel-drop exercises performed with the heel descending below a step may not be the best starting exercise for an irritable Achilles insertion.

Early strengthening can instead begin through a more comfortable ankle range. More dorsiflexion can be reintroduced progressively when appropriate.

Mid-portion Achilles tendinopathy may tolerate a broader movement range, although exercise selection should still reflect pain, strength and individual response.

How Is Achilles Enthesopathy Treated?

Insertional Achilles rehabilitation usually aims to maintain useful activity while reducing the most provocative compression and rebuilding tendon capacity.

A rehabilitation plan may include:

  • temporarily reducing steep hills, jumping or other provocative loads
  • adjusting shoes that press directly on the painful heel
  • avoiding aggressive calf stretching during an irritable stage
  • calf strengthening that initially avoids excessive dorsiflexion
  • temporary heel elevation when clinically appropriate
  • progressive restoration of calf strength and endurance
  • gradual return to walking, running, jumping or sport demands

A temporary heel lift may reduce insertional compression for some people. However, footwear, comfort, movement and individual response should be considered rather than assuming heel lifts suit everyone.

How Is Mid-Portion Achilles Tendinopathy Treated?

Progressive tendon loading is a central part of treatment for mid-portion Achilles tendinopathy. The exercise program may use controlled calf raises followed by progressively heavier, faster or more functional loading as tendon capacity improves.

The aim is not simply to make pain disappear during exercise. Rehabilitation should rebuild the strength and load tolerance needed for the person's walking, work, running or sport demands.

For a more detailed rehabilitation pathway, see our main Achilles tendinopathy treatment and recovery guide.

Can You Keep Walking or Running?

Complete rest is not usually required for Achilles tendinopathy. Many people can remain active while temporarily modifying the activities that cause the largest symptom flare.

For runners, this may mean reducing hills, speed, distance, jumping or weekly frequency for a period rather than stopping all running automatically.

Pay attention to how the tendon responds during activity and later that day or the following morning. Increasing pain, limping or a persistent next-day flare may indicate that the current dose is too high.

When Should You See a Physiotherapist?

Consider a physiotherapy assessment when Achilles or heel pain is affecting walking, stairs, work, exercise, running or sport, particularly when symptoms persist or keep returning.

An assessment can help distinguish insertional Achilles symptoms from mid-portion tendinopathy, retrocalcaneal bursitis, an Achilles rupture or another source of heel pain.

Achilles Tendinopathy

Detailed information about Achilles symptoms, progressive loading and rehabilitation.

Achilles Tendon Rupture

Recognise warning signs of a sudden Achilles tear and the importance of early assessment.

Heel Pain

Compare common causes of pain under, behind and around the heel.

Calf Pain

Explore muscle, tendon, nerve and other causes of lower-calf symptoms.

Tendinopathy

Understand tendon overload, reduced load tolerance and progressive rehabilitation.

Achilles Enthesopathy vs Achilles Tendinopathy FAQs

Is Achilles enthesopathy the same as insertional Achilles tendinopathy?

The terms overlap considerably. Achilles enthesopathy describes involvement of the tendon attachment or enthesis at the heel. Insertional Achilles tendinopathy describes symptomatic Achilles tendon pathology in the same insertional region. The exact diagnosis may depend on the clinical presentation and whether nearby structures are also involved.

Where does insertional Achilles tendinopathy hurt?

Insertional Achilles tendinopathy usually causes pain directly at the back of the heel where the Achilles tendon attaches to the calcaneus. Pressure from footwear, hills and deeper ankle dorsiflexion may aggravate symptoms.

How is mid-portion Achilles tendinopathy different?

Mid-portion Achilles tendinopathy usually causes pain several centimetres above the heel rather than directly at the tendon attachment. Repeated running, hopping, jumping and calf loading commonly provoke symptoms.

Should you stretch insertional Achilles tendinopathy?

Aggressive calf stretching may aggravate an irritable Achilles insertion because deeper ankle dorsiflexion increases tendon compression against the heel. Rehabilitation may initially use strengthening through a shallower range before gradually restoring more dorsiflexion.

Can heel lifts help insertional Achilles pain?

A temporary heel lift may help some people by reducing ankle dorsiflexion and compression at the Achilles insertion. It is not necessary for everyone, so footwear, comfort and response should guide its use.

Can you keep running with Achilles tendinopathy?

Many people can continue some running with suitable load modification. Distance, speed, hills and frequency may need temporary adjustment. Increasing pain, limping or a persistent next-day flare can indicate that the current running load is too high.

What to Do Next

If pain at the back of your heel is affecting walking, running, work or sport, identifying the exact pain location is a useful first step. A physiotherapist can assess whether your symptoms fit insertional Achilles tendinopathy, mid-portion Achilles tendinopathy, bursitis, rupture or another cause and then match rehabilitation to your presentation.

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References

  1. Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, Martin RL. Achilles pain, stiffness, and muscle power deficits: midportion Achilles tendinopathy revision – 2024. J Orthop Sports Phys Ther. 2024;54(12):CPG1–CPG32. doi:10.2519/jospt.2024.0302.
  2. Pringels L, Capelleman R, Van den Abeele A, Burssens A, Planckaert G, Wezenbeek E, Vanden Bossche L. Effectiveness of reducing tendon compression in the rehabilitation of insertional Achilles tendinopathy: a randomised clinical trial. Br J Sports Med. 2025;59(9):640–650. doi:10.1136/bjsports-2024-109138.
  3. Paantjens MA, Helmhout PH, Backx FJG, van Etten-Jamaludin FS, Bakker EWP. Extracorporeal shockwave therapy for mid-portion and insertional Achilles tendinopathy: a systematic review of randomized controlled trials. Sports Med Open. 2022;8(1):68. doi:10.1186/s40798-022-00456-5.