Insertional Achilles Tendinopathy – Diagnosis and Management

Diagnosis

Insertional Achilles tendinopathy is the most likely diagnosis for an adult presenting with posterior‑superior heel pain, mild swelling, erythema, and warmth at the Achilles insertion site. 1

Pain localized to the posterior‑superior heel corresponds anatomically to the Achilles tendon insertion on the calcaneus. 1
The condition typically has an insidious onset of chronic posterior heel pain and swelling in middle‑aged adults. 1

Examination reveals central or global tenderness at the Achilles insertion, often with palpable medial and lateral prominence. 1
Pain is worsened by increased activity and pressure from footwear. 1
Pain relief when walking barefoot helps differentiate insertional Achilles tendinopathy from plantar fasciitis. [1][2]

Weight‑bearing radiographs commonly show spurring or erosion at the Achilles insertion, supporting insertional tendinopathy. 1
Radiographs may also demonstrate a prominent posterior‑superior calcaneus (Haglund’s deformity). [1][2]
Radiographs are useful to exclude calcaneal stress fractures or other bony pathology. 2
If radiographs are negative and symptoms persist beyond one week, MRI without contrast or ultrasound can confirm tendon pathology and detect associated bursitis. 2

Haglund’s deformity with bursitis is more frequent in younger adults (20‑30 years) and presents with lateral tenderness and a visible posterior‑lateral calcaneal prominence. [1][3]

Corticosteroid injections should never be placed near or into the Achilles tendon insertion because of a high risk of tendon rupture. [1][4]
When injection therapy is indicated, it must be directed exclusively into the retrocalcaneal bursa, carefully avoiding the tendon itself. 1