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Ankle Pain

Insertional Achilles Tendonitis

Minute Read


Posted 10 months ago


Last updated: 03/12/2022


by James McCormack

Achilles Tendon Insertion

The Achilles Tendon attaches to the calf muscle (origin) and the heel bone (insertion). There are two main types of Achilles Tendonitis; mid-portion Achilles Tendonitis is in the middle of the Achilles Tendon, while Insertional Achilles Tendonitis is the lower aspect of the tendon as it attaches to the heel bone (Calcaneus). As the tendon attaches to the heel bone, it wraps around the curve of the calcaneus, attaching to the bottom of the heel. If there is pain or tenderness on the very back of the Achilles Tendon, it is referred to as an Achilles Enthesopathy.

The Achilles Tendon is the largest in the human body. Its function, along with the calf muscle, is to lift the heel off the floor and is therefore used for most weight-bearing activities. It absorbs large amounts of force on impact activities such as hopping, running, and jumping. This article will cover the symptoms, treatment, and recovery of Insertional Achilles Tendonitis.

Insertional Achilles Tendonitis Symptoms

In acute episodes of Insertional Achilles Tendonitis, there is swelling and pain around the back of the heel bone. It is common to get this on one side only, but it is not entirely atypical to have pain in both feet. Pain may be constant with use and ease with rest. Sharper pain is common with activities such as hopping and running.

Insertional Achilles Tendonitis is commonly seen alongside subcutaneous bursitis, and in these instances, there may be a visible bump of swelling at the back heel.

In sub-acute cases, there may be stiffness at the back and underside of the heel first thing in the morning. It is common to ease within 30-45 minutes after getting out of bed. It may be tender at the start of exercise, such as a run and improve as it warms up. It may be sore again within an hour after the activity.

In chronic cases, it is common for there to be constant pain with all weight-bearing activities and worse on exertion.

Similar Conditions:

Posterior Ankle Impingement

This provides pain at the back of the ankle that can be the result of an extra bone such as an Os-Trigonum or a bony growth on the heel bone called a Stiedas process. This is common in dancers and exacerbated by terminal Plantarflexion.

Calcaneus Stress Fracture

A stress fracture of the heel bone can occur as a result of a repetitive overload of the heel bone. This is common in runners and an x-ray or an MRI can be required for diagnosis.

Retrocalcaneal Bursitis

A bursa is a sac of fluid at the back of the heel bone. Its primary function is to act as a cushion between the heel and the tendon. If it becomes irritated through overuse it can become swollen and painful.

Insertional Achilles Tendonitis Causes

A biomechanical overload is one of the key causes of Insertional Achilles Tendonitis. It is often the result of compression on the tendon where it attaches to the heel bone and an altered gait due to high pain levels can place additional pressure on this area.

Sudden changes in use such as increased volume or speed of walking or running can lead to insertional tendon pain. Changes in footwear especially the heel height of the stack of a trainer can suddenly change where the direction of force goes through the tendon.

A Haglund’s deformity or bone spur is often described as a cause of Insertional Achilles Tendonitis but there is rarely the cases. It is usually coincidental that this heel spur is present alongside the pain. Calcification of the tendon as it is attached to the bone can cause acute episodes of Insertional Achilles Tendonitis but this is rare.

Systemic conditions such as inflammatory arthritis, steroids, and some forms of antibiotics are other known causes.

Picture diagram of baglunds deformity, bursitis and insertional achilles tendonitis

Insertional Achilles Tendonitis Diagnosis

Clinical tests by a Physical Therapist such as the Achilles Tendon pinch test is an effective form of clinical diagnosis while a Thompson Test may be carried out to rule out an Achilles Tendon Rupture.

An ultrasound is a cost-effective imaging tool for diagnosing Insertional Achilles Tendonitis while a more expensive method is an MRI which is the most accurate type of scan for Insertional Achilles Tendonitis.

Insertional Achilles Tendonitis Treatment

Home Treatment for Insertional Achilles Tendonitis

  • Ice the tendon for pain relief
  • Anti inflammatories such as ibuprofen
  • Rest
  • Non-impact activity
  • Where a heeled shoe or place a heal raise inside stability running shoes
  • Night splints
  • Massage gun or foam roller to the calf muscle

Picture of a Stability Running Shoe

Physical Therapy for Insertional Achilles Tendonitis

Physical Therapy is the most effective form of treatment for Insertional Achilles Tendonitis. Depending on the stage of Insertional Achilles Tendonitis, treatment may differ but lets have a look at some of the treatments available.

Short Term Pain Relief

Pain relief is important in the acute stages as it prevents secondary compensation injuries. This can come in the form of acupuncture, dry needling and massage.

Load Modification

Whether you have had an onset of pain from running or just from walking, altering the volume of these activities is important. Strength training is the best form of rehabilitation but if your pain levels are too high to do this due to high activity levels then it is very difficult to make progress. Reducing your step count and keeping it consistent is helpful. Keeping the running pace and distance consistent can be helpful as well as keeping 24-48hours rest between runs to allow the tendon time to recover.

Strengthening Exercises

Strength training is the best form of treatment for any form of tendonitis. The difference between Mid-portion Achilles Tendonitis and Insertional Achilles tendonitis rehabilitation is that for insertional tendonitis all forms of calf raises are from the ground upwards. Dropping below a step or neutral can lead to compression on the Achilles Tendon, leading to further irritation.

Heavy Slow Resistance training on a leg press or using weights at home can show significant improvements in function and pain relief.

Insoles or Orthotics

The best inserts for Insertional Achilles Tendonitis are custom insoles that are formulated by foot specialists. They typically have a heel raise that shortens the Achilles Tendon alongside some medial arch support of the foot. Gait analysis is normally carried out, followed by a 3D and Dynamic foot scan to determine the level of support required.


Steroidal injections are generally to be avoided for this condition as there is moderate evidence to suggest it can weaken the tendon over time. A walking boot is generally preferred to offload the tendon before recommencing Physical Therapy.

Shockwave Therapy

There is moderate level evidence that Shockwave Therapy can be used as a primary form of treatment for Insertional Achilles Tendonitis and we recommend using it alongside strengthening exercises.


In rare cases, surgery may be necessary for Insertional Achilles Tendonitis where it hasn’t responded after 3 months of appropriate Physical Therapy. This can be in the form of debridement of the tendon and a Haglund’s deformity my be shaved if present. Physical Therapy is carried out for 6-12 weeks to ensure an optimal surgery recovery.

Physiotherapy with James McCormack

This is not medical advice and we recommend a consultation with a medical professional such as James McCormack to achieve a diagnosis. He offers Online Physiotherapy Appointments for £45.

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