Shoe inserts for Achilles tendonitis

Heel-raising Achilles tendon inserts for your shoe can help to relieve Achilles pain. However, these heel cups for Achilles tendonitis will not heal your tendon. This article explains how to use heel inserts alongside the correct rehab approach for your tendon to once again be able to cope with your daily life and sports activities. Remember, if you need more help with an Achilles injury, you're welcome to consult one of our team via video call.

The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in our articles.

In this article:

1. Shoe inserts for insertional Achilles tendonitis

2. Shoe inserts for mid-portion Achilles tendonitis

3. A shoe insert is not enough to rehab your Achilles tendonitis

4. How we can help

We also made a video about this:

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First of all, it's important to pinpoint where your pain is. Most Achilles tendinopathies occur in one of two places: It’s either an insertional or a mid-portion Achilles tendinopathy.

The insertional Achilles tendinopathy is found in the lower part of the back of your heel, where (as the name suggests) the tendon inserts into the calcaneus or heel bone. The mid-portion tendinopathy is somewhat higher up, between the heel bone and the bottom of your calf muscles.

Shoe inserts for insertional Achilles tendonitis

If you have an insertional Achilles tendinopathy, using a heel cup – particularly at the beginning, when it's quite painful to walk or put your foot flat onto the floor – can help to reduce the pain by reducing the compressive force in the tendon.

Compressive forces (when the Achilles tendon is closer to the heel bone) is what typically irritates an insertional Achilles tendinopathy.

There are two forces. One is compression, and one is when the tendon contracts, typically when you go up on your toes. The compressive force can be found when you stretch it by putting your foot into dorsiflexion, i.e. bending your toes upwards towards your knee, for example when you do a typical calf stretch. During walking, our calf muscles contract while the ankle is in a dorsiflexed position, which also increases the compression between the Achilles and the heel bone.

Ankle dorsiflexion increases the compression between the lower portion of the Achilles tendon and the heel bone.

When you stretch the tendon like this, it comes closer to the heel bone into which it is attached, and if you have tendonitis, it has the same effect as prodding a bruise – not very pleasant! A shoe insert that raises your heel so that it is higher than the ball of your foot shortens the tendon, which means that it doesn’t compress so much, which removes or reduces the pain caused by the compressive force.

So, in the case of insertional Achilles tendinopathy, a shoe insert can be very useful for managing the pain.

These inserts can be gel inserts, harder inserts, and/or adjustable inserts.

Shoe inserts for mid-portion Achilles tendonitis

Heel-raising shoe inserts can also help to reduce your pain if you have mid-portion Achilles tendinopathy. Injured tendons often don’t like being stretched, and if your Achilles is extremely sensitive right at the beginning of treatment, a heel lift can help to take a bit of the stretch away and give it some help to calm down.

But mid-portion Achilles tendonitis is usually less sensitive, so we don’t prescribe heel-lift inserts as often as for insertional tendonitis. This is because the middle part of the tendon isn’t compressed against the heel bone when it is stretched.

A shoe insert is not enough to rehab your Achilles tendonitis

A recent research paper claims that heel-raising shoe inserts are superior to eccentric calf exercises when it comes to treating Achilles tendinopathies. However, there are a few issues with how the researchers conducted their study, which means that these results should be interpreted with caution.

Eccentric calf exercises, where you typically stand on the edge of a step and slowly drop your heels over the edge, stretching the calf muscles and Achilles tendons, and then go back up again is one of the most-prescribed exercises for Achilles tendinopathy.

Eccentric heel lift exercises over a step increase the compression forces on the Achilles tendon.

The researchers took two groups of people with Achilles tendinopathy. One group got heel-raising shoe inserts and the other group did the eccentric calf exercises. After a few weeks, the group with the shoe inserts reported better symptoms (i.e. less pain) than the group who did the exercises.

In the short term, this is not surprising. In the early stages of an Achilles tendinopathy, shoe inserts will calm the pain down, as explained above. Putting your tendon in a stretch position by going over the side of a step (especially without a shoe insert) creates more stretch and compression, and will aggravate your pain.

Also, the researchers prescribed the Alfredson eccentric exercise programme, which we know can aggravate Achilles pain because it consists of a high volume of exercises off a step and doesn’t really allow for recovery between sessions. The programme wasn’t really individualised either, and patients were instructed to train through pain and only stop a session if the pain became “disabling”. Working into such high pain levels is bound to make an injured tendon more sensitive.

The study also did not look at the longer-term outcomes. People who only use shoe inserts to calm their Achilles pain down while they rest up and then, after a while, go right back to doing their daily activities and sports will likely find that their pain returns after a few weeks.

In our experience, the patients who did the exercises would probably have been better off in the long run. This is because shoe inserts, while they are useful for managing the pain, do nothing to restore the strength your tendon lost due to your injury.

Without rehabbing the symptomatic tendon back to its original robust state or even stronger, Achilles tendinopathy patients who start their usual activities risk re-injuring their tendons.

This is why strength exercises are so important.

The type and intensity of the exercises we prescribe to our patients will depend on their symptoms, how strong they are already, and what their goals are in terms of daily activities and sports. We always individualise it to the patient. We also favour programmes that allow the tendon to fully recover between training sessions.

If there's a compression element to your pain, we wouldn't pick those drop-off-a-step type movements; we may modify or change that. And fortunately, in real life, as opposed to in the experiment, we can recommend shoe inserts where appropriate in addition to doing what is necessary to get your tendon robust enough to cope with the demands of your daily life and sports.

In summary, heel-lifting inserts can be a useful adjunct to your rehab but should always be used in combination with a strength training plan. To be effective, your rehab plan should be adapted to suit your specific case and should not be causing your symptoms to increase.

How we can help

Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

About the Author

Alison Gould is a chartered physiotherapist and holds an MSc in Sports and Exercise Medicine. You can follow her on LinkedIn, Facebook, Instagram, and Twitter.

References:

1. Rabusin CL, Menz HB, McClelland JA, et al. Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (HEALTHY): a randomised trial. British Journal of Sports Medicine 2021;55:486-492.