What Is Insertional Achilles Tendinitis?

The Achilles tendon is the largest tendon in the body. Insertional Achilles tendinitis is caused by damage to the Achilles tendon fibers where the tendon inserts onto the heel bone. It may be associated with inflammation of a bursa or tendon sheath in the same area. 


Most patients report a gradual onset of pain and swelling at the back of the heel bone without a specific injury. At first, the pain may only be noticeable after activity, but it can get worse over time. The pain increases with jumping or running and especially with sports requiring short bursts of these activities. Patients experience tenderness over the back of the heel bone and the bone often becomes enlarged, which causes even more problems with shoes. It is often painful to stretch the tendon and pull the foot up. 


Insertional Achilles tendinitis primarily is caused by damage to the tendon over time. The average patient is in their 40s. Decreased flexibility in upward motion of the ankle is common and is a focus of physical therapy-based treatment.

Certain medical conditions are associated with increased risk for insertional tendinopathies in general. These conditions include psoriasis and Reiter's syndrome, spondyloarthropathy (generalized inflammation of joints), gout, familial hyperlipidemia, sarcoidosis, and diffuse idiopathic skeletal hyperostosis as well as the use of medications such as steroids and fluoroquinolone antibiotics. 


Your foot and ankle orthopaedic surgeon will perform a clinical exam to determine if you have insertional Achilles tendinosis. They may order X-rays to look for calcium deposits within the tendon at its insertion into the heel. These deposits are present approximately 60% of the time and may be associated with a lower success rate for non-surgical treatment. X-rays also may reveal a Haglund's deformity.

MRIs may be used to determine the extent of tendon degeneration as well as other factors such as bursitis, which may contribute to heel pain.


Non-surgical Treatment

Non-surgical treatments options include nonsteroidal anti-inflammatory drugs, heel lifts, and switching to shoes that do not put pressure over this area. Exercise-based treatments such as physical therapy are an effective first-line treatment for the majority of patients.

Other options that may help include night splints, arch supports, or the use of a cast or brace. Nitroglycerin patches also may be of benefit to increase the blood supply to this area.  

Surgical Treatment

Surgery may be recommended if there is no improvement after several months of non-surgical treatment. During the procedure, your surgeon will make an incision over the back of the heel and remove the diseased portion of the tendon. A small amount of bone is removed from the back of the heel bone to create a healthy area for the tendon to attach. Your surgeon will then reattach the tendon using special bone anchors that allow the tendon to be fixed to the bone.

Several different approaches and techniques, including endoscopy, may be used. There is no clear consensus regarding which technique is best. In older patients or those in whom more than 50% of the tendon is removed, one of the other tendons at the back of the ankle usually is transferred to the heel bone to assist the Achilles tendon with strength as well as provide a better blood supply to this area.


After surgery, you will be put into a cast or removable cast boot. If the tendon was not fully detached from the heel, the doctor may allow you walk around in the boot for 6-8 weeks and work on motion exercises with physical therapy.

If the tendon was totally detached or another tendon was used in the repair, a cast or boot may be used for 2-3 months. For the first six weeks, may be limited from placing weight on the foot, but in the second six weeks you can walk in the cast or boot. 

After the cast or boot comes off, you can wear shoes with a small heel lift and begin physical therapy. The length of time needed to return to full activities and sports is determined by the strength of the repair and the speed of recovery with physical therapy. Full recovery can take 6 months or longer in some cases.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Complications with this surgery specifically can include residual pain, weakness or tightness, or rupture of the repair. 

Would a cortisone injection help? 

Cortisone injections are not recommended to treat these types of problems of the Achilles tendon because they can weaken the tendon, leading to possible rupture.

After surgery, can I return to all the activities I want to do?

Yes. After the appropriate repair, physical therapy, and healing time, the goal is for you to be able to return to activities you want to do. Residual pain may limit but not prevent you from doing some activities.

If I don't remove the bone spur, will my Achilles tendon keep tearing?

Although they can look pointed and sharp, bone spurs or calcifications at the tendon attachment are not really the cause of the tendon damage, but more of an effect of the damage to the tendon. Patients who are successfully treated without surgery will still have bone spurs on X-rays but will no longer have pain. If you do end up having surgery for this problem, however, the bone spur will be removed in the process most of the time.


Contributors/Reviewers: Sudheer Reddy, MD; David Lee, MD

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