Achilles & Heel
Insertional Achilles Tendinopathy
About Your Condition
Insertional Achilles tendinopathy is degeneration of the Achilles tendon where it attaches to the heel bone (calcaneus). It can occur alone or alongside Haglund's deformity — a bony prominence at the back of the heel that rubs against the tendon insertion and against shoe heel counters, contributing to irritation and pain.
Symptoms are felt directly at the back of the heel — pain and swelling at the insertion, stiffness with the first steps in the morning or after rest, and aggravation from uphill walking, stairs, and firm or tightly fitting heeled footwear.
Non-Operative Management
Non-operative management centres on graduated tendon loading and reducing mechanical irritation at the insertion — the loading pattern differs from non-insertional disease, so it's worth being specific about technique.
Loading Rehabilitation
- Progressive tendon loading is performed on flat ground rather than off the edge of a step — loading the tendon into a stretched, dorsiflexed position (as used for non-insertional disease) aggravates insertional pathology rather than helping it.
- A structured heavy, slow-resistance or eccentric-concentric loading program, guided by a physiotherapist, is the mainstay of treatment and should be progressed gradually as symptoms allow.
Footwear and Heel Lifts
- A heel lift reduces stretch and impingement at the insertion during walking.
- Avoid rigid, low-backed, or tightly fitting heel counters that press directly on the back of the heel; a soft or open-backed shoe reduces direct irritation.
Activity Modification
- Reducing hill work, stairs, and running load during a symptomatic flare allows the tendon to settle.
- Low-impact cross-training — swimming, cycling — maintains fitness without loading the insertion.
Injections
- Cortisone injections are not recommended for Achilles tendinopathy — they can weaken the tendon and increase the risk of rupture, and are generally avoided in Dr Hogan's practice.
When to Consider Surgery
Surgery is considered when symptoms significantly limit your daily activities despite an adequate trial of non-operative treatment, typically over six months.
Two surgical options are available. Haglund resection and Achilles reconstruction is the traditional open approach, detaching and reattaching the tendon, and is suited to more extensive disease. A Zadek osteotomy is a minimally invasive percutaneous option that addresses the Haglund's deformity and relieves insertional impingement without detaching the tendon, offering a faster recovery in appropriately selected patients — the choice depends on the extent of tendon degeneration and is made jointly with Dr Hogan.