Insertional vs midportion Achilles tendinopathy: why the difference decides your treatment
Not all Achilles tendon pain is the same problem, and treating it as if it were is why so many cases drag on. Where your tendon hurts changes what works: pain in the middle of the tendon responds well to the classic heel-drop programmes, while pain right at the heel bone often gets worse with exactly those exercises. If your Achilles has not improved despite months of effort, there is a good chance the plan was built for the wrong type. At The London PRP Clinic by The Wellness, the first job at consultation is working out which Achilles problem you actually have.
Key points
Midportion tendinopathy affects the tendon body, a few centimetres above the heel; insertional tendinopathy affects the attachment at the heel bone.
Deep heel drops off a step help midportion problems but often aggravate insertional ones, because of compression at the attachment.
Insertional cases need modified loading that avoids deep dorsiflexion, and typically take longer to settle.
PRP can support repair in both types when a properly targeted loading programme has plateaued.
A bony prominence or pump bump at the heel suggests insertional disease, sometimes with a Haglund deformity.
Joint and tendon PRP at The London PRP Clinic by The Wellness starts from £750 per treatment area.
Midportion Achilles tendinopathy
This is the classic runner's Achilles: pain and often thickening in the middle of the tendon, two to six centimetres above the heel. It stiffens overnight, aches at the start of a run, warms up, and complains again the next morning. The midportion tendon has the best evidence base of the two types: progressive loading programmes, including eccentric heel drops and heavy slow resistance work, help the majority of people over about twelve weeks. When a midportion tendon has genuinely plateaued on a well-run programme, PRP has its strongest supporting evidence here, alongside honest acknowledgement that one major placebo-controlled trial found no advantage, which we discuss openly.
Insertional Achilles tendinopathy
Insertional disease is pain right where the tendon meets the heel bone, sometimes with a visible or palpable bony bump. It behaves differently for a mechanical reason: when the ankle bends deeply, as in a heel drop off a step, the tendon compresses against the bone, and that compression is part of the problem. This is why the standard heel-drop programme, so useful higher up the tendon, frequently makes insertional pain worse. Insertional cases need a modified programme that loads the tendon within a flatter ankle range, progress more slowly, and respond less predictably. When a bony prominence (sometimes called a Haglund deformity) or calcification inside the tendon is involved, imaging helps plan treatment, and stubborn cases have a wider range of opinions, from shockwave to, occasionally, surgery.
Which one do you have?
The location of the worst pain is the first clue: a few centimetres up the tendon suggests midportion; right at the bone suggests insertional. Morning stiffness at the attachment, pain with deep ankle bending, and a tender bony bump all point insertional. Examination, and often an ultrasound or MRI, settles it. Getting this right matters because the loading programme, the injection target, and the realistic timeline all differ, and it is the first thing your doctor establishes at consultation.
Where PRP fits for each type
For midportion tendinopathy that has plateaued on proper loading, PRP offers a reasonable next step with a favourable safety profile, as covered in our article on PRP versus steroid for Achilles pain. For insertional disease, the evidence is thinner and expectations should be more cautious: the compression element means loading modification does most of the work, and PRP is considered case by case, often alongside shockwave, when progress has stalled. What we will never do is sell an injection as a substitute for the programme: both types are won or lost on loading, and the written plan you leave with reflects that.
What treatment involves
Your consultation includes history, examination, review or arrangement of imaging, and a clear statement of which type you have and what that means. If PRP is suitable, a small blood sample is taken, processed, and injected into the target tissue under guidance in a single visit of around 45 minutes, with a written reloading plan over six to twelve weeks. Many cases need one or two sessions. You may also find our guides to Achilles and patellar tendinopathy and marathon training injuries useful.
What it costs
At The London PRP Clinic by The Wellness, joint and tendon PRP starts from £750 per treatment area, confirmed before any treatment begins. Consultations are £59 by phone for 15 minutes, £150 by video and £220 in person at our Marylebone clinic. If the verdict is that your Achilles needs a different route, including a surgical opinion for advanced insertional disease, we say so and you pay only for the consultation.
Why people choose The London PRP Clinic by The Wellness
We are a doctor-led PRP clinic: every case is assessed and injected by a GMC-registered doctor, the diagnosis comes before any talk of treatment, and the evidence is presented as it is, not as we would like it to be. Read more about PRP for runners and athletes.
To discuss your Achilles, call 020 3951 3429, message us on WhatsApp, or book a consultation.
Frequently asked questions
What is the difference between midportion and insertional Achilles tendinopathy?
Midportion tendinopathy affects the body of the tendon a few centimetres above the heel and responds well to classic heel-drop loading. Insertional tendinopathy affects the attachment at the heel bone, where deep ankle bending compresses the tendon, so it needs a modified programme and often takes longer to settle.
Why did heel drops make my Achilles worse?
The most likely reason is that your problem is insertional. Dropping the heel below step level compresses the tendon against the heel bone, which aggravates insertional disease even though the same exercise helps midportion tendinopathy. The fix is usually a modified loading range, not more effort.
Does PRP work for insertional Achilles tendinopathy?
The evidence is thinner than for midportion disease. Insertional cases are treated primarily with modified loading and sometimes shockwave, with PRP considered case by case when progress has stalled, and expectations set cautiously. Advanced cases with large bony changes occasionally need a surgical opinion.
What is the bump on the back of my heel?
A bony prominence at the tendon attachment is often called a Haglund deformity, sometimes with calcification inside the tendon. It commonly travels with insertional tendinopathy and is assessed with examination and imaging, which together guide whether loading, shockwave, PRP or a surgical opinion fits best.
How long does Achilles tendinopathy take to heal?
Midportion cases typically improve over about twelve weeks of proper loading. Insertional cases usually take longer, often three to six months, and need more patience with the programme. Plateaued chronic cases take as long as they take, which is why an honest timeline at the start matters.
How much does PRP for Achilles tendinopathy cost in London?
At The London PRP Clinic by The Wellness, joint and tendon PRP starts from £750 per treatment area. Consultations are £59 by phone for 15 minutes, £150 by video and £220 in person.
References
Insertional and midportion Achilles tendinopathy: why location changes management. British Journal of Sports Medicine. 2023.
Loading programmes for Achilles tendinopathy: current concepts and evidence. American Journal of Sports Medicine. 2023.
This article is for information and does not replace personal medical advice. All treatments at The London PRP Clinic by The Wellness are performed by GMC-registered doctors. Written and medically reviewed by The Wellness Team. Last updated October 2026.