After my recent piece on insertional achilles tendinopathy I approached fellow Physio and tendinophile Seth O'Neill for his take on the condition. I expected a few extra lines for the article and instead he sent me virtually a whole blog! Seth is Physiotherapy Lecturer at Leicester and Coventry Universities and is currently researching achilles tendinopathy. You can follow Seth on Twitter via @Seth0Neill and visit his website. We've teamed up to put together some additional information to compliment our previous article on this topic.


Firstly is it Insertional Achilles Tendinopathy?

Accurate diagnosis is important in these cases. For example many of the exercises for mid-portion achilles tendinopathy will aggravate an insertional one if mis-diagnosed. It's also important to rule out pain from the superficial or deep retrocalcaneal bursa, Tibialis Posterior tendinopathy and posterior ankle impingement. This isn't easy to do and is one of many reasons why it's important to see a physio to help manage these conditions.

Insertional achilles tendinopathy is diagnosed with a history of symptoms during tendon loading activities (movements into dorsiflexion) and pain at insertion of achilles rather than mid tendon. Mid-portion achilles tendinopathy usually presents with pain 2-7cm above the heel bone. Achilles stretch and load reproduce symptoms insertional achilles tendinopathy and US or MRI can be used to exclude other pathology if needed.

Differential diagnosis – i.e. what else can it be?

There are several other structures that can cause pain around the achilles and heel area;

One thing to consider is the bursa, a fluid filled sac that is usually well innervated and therefore capable of producing pain. Involvement of the bursa often occurs with tendinopathy as it commonly sits between the tendon and its attachment. The bursa responds to excessive load by swelling in size and can become very painful. Often this is termed 'bursitis', with the suffix 'itis' suggesting inflammation but there is some debate as to the role of inflammation in bursa pathology.

Picture source

The Superficial Calcaneal Bursa will cause pain over the insertion of tendon if you pinch the skin (over the calcaneus). This bursa may be effected by footwear especially heel counters that compress this zone. Otherwise loading may not alter this that much. Onset will match this eg compression.

The Retrocalcaneal Bursa is anterior to tendon (see picture above) so is often involved with tendinopathy but will cause pain if you pinch anterior to the tendon. Compression of bursa will always hurt and give a clue to source of symptoms but MRI or US are more accurate and can confirm the diagnosis;

Picture source Hirji et al. (2011)

Tibialis Posterior tendinopathy is another potential diagnosis. Pain will occur under similar loading circumstances to achilles tendinopathy including early morning pain but symptoms are usually more medial and are directly behind the medial malleolus (bone on the inside of the ankle). Pain will be reproduced with palpation of the tendon of tibialis posterior and not on achilles. For more information see our article on Tibialis Posterior Tendinopathy.

Posterior ankle impingement can also be a cause of pain in the heel area. It is diagnosed by applying overpressure to ankle plantarflexion as this compresses the posterior joint line. In non-physio terms this means moving the ankle joint down (as if pointing your toes) and applying extra pressure at the end of the range. The impingement is often bony and can be caused by an additional bony growth known Os trigonum (although it can also be synovial impingement). It's more common in activities that require a lot of plantarflexion such as ballet dancers who walk on their toes as demonstrated brilliantly in this excellent blog. Kristen, the author of the blog, posted her X-rays and MRI scan which tell the story well;

Pain from posterio impingement is usually associated with excess active plantarflexion (as demonstrated above) rather than dorsiflexion and tendon loading activities. Tendon palpation will be pain free.

Tendon compression

Research by Cook and Purdam (2012) has highlighted the role of compression in insertional tendinopathy. The achilles is compressed against the heel bone (calcaneum) in dorsiflexion (upward movement of the ankle);

Activities that involve dorsiflexion of the ankle such as walking uphill, squatting, lunging etc. are likely to aggravate insertional achilles tendinopathy.

Managing pain

Reducing pain has been discussed in the previous blog but there are a few points to add;

  • Regarding Pain and the reactive stage you could add fish oils/omega 3’s and green tea, for those that like that sort of thing!
  • I’d point out the taping is useful for pain but will not change the pathology, to make it clear hard work and strengthening is the only successful avenue. In my clinical experience those who adhere get 100% return to sport and a large shift on VISA A (the achilles tendon outcome measure). This isn't based on research but rather findings in clinic.
  • A heel raise can help but may need to be huge – around 40-60mm. This is often ok for women, not as suitable for a man, but dress shoes with a heel are better than nothing. You may not need any heel raise unless it's particularly severe and desperately needs to settle.
  • I also ensure people don’t sit in dorsiflexion when they have insertional issues and often mid tendon too, this seems to be a regular observation and patients report benefit.

Thoughts on exercise

If the person is able to then start normal concentric exs with eccentric bias straight away, I personally find I don’t really need to use isometric except for the shoulder. I do however make it clear patients can start with 5 reps or so and aim to build to 15reps. Start with one set and build up to 3. This allows us to start in the reactive phase and it seems to get good results.

Using the additional weight is crucial to full recovery and to get back to normal distances, slow and steady for first month and then introduce faster sport specific work and lots of endurance.

If someone can't run 1-2 miles without a flair up then avoid running until strength has improved. if they can use in conjunction with strength work but run 3 times per week max, unless already running regularly.

Rest days are key.

Bony bits!

Some people can have a exostosis (bony growth) on the heel like a haglund deformity and this can often be triggered by new footwear or increased wearing of these footwear especially if they have high or hard heel counters (the bit that encloses the heel). Try changing footwear to something with a lower or more cushioned heel counter. Comfort is key – make sure it doesn't aggravate symptoms.


Closing thoughts: insertional achilles tendinopathy has symptoms that can come from a number of other sources – see a Physio to ensure accurate diagnosis and treatment. Load management and exercise selection form the key treatments for this condition – for more information on this see our previous article. As ever on RunningPhysio if in doubt, get checked out!



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