Heel pain: Insertional Achilles Tendinopathy

Insertional Achilles Tendinopathy (IAT) accounts for about 20% of all Achilles tendon disorders and is a common source of posterior heel pain. IAT presents with pain and inflammation at the site of insertion of Achilles tendon on the calcaneus (where the Achilles tendon attaches to the heel bone). IAT is quite common in middle and long distance running, athletics, and court sports such as tennis or volleyball. It is believed that compression of the Achilles tendon against one or more underlying structures can lead to tissue damage, pain and inflammation of the affected area, usually 2cm or less from the point of insertion. These structures can include the calcaneus itself through simple overuse, from increased compression stresses caused by bony deformities (Haglund’s Deformity, retrocalcaneal exostosis), retrocalcaneal bursitis, or from degenerative processes within the Achilles Tendon itself (Achilles tendinosis).

People with IAT will usually present with a diffuse pain at the posterior calcaneus (back of the heel) that is worse for activity and often limits how much they can do. Often running or walking uphill or walking on uneven ground will make the pain worse. Some people may even feel pain when driving or any other time with the foot is dorsiflexed at the ankle, compressing the Achilles against the neighbouring structures at the site of insertion on the calcaneus.

There may be palpable pain at the site of the insertion of the Achilles on the calcaneus, and perhaps some swelling of the area or a palpable posterior heel spur. Differential diagnoses are Retrocalcaneal Bursitis and Superficial Calcaneal Bursitis, although these conditions can occur simultaneously, Sever’s Disease (only found in children), and Rheumatoid Disease or seronegative spondyloarthropothies (such as ankylosing spondylitis). In most cases, a clinical examination would be enough to diagnose a case of IAT. In more complex cases, plain X-rays can be helpful, as well as MRI and ultrasound imaging techniques, although these are expensive and often unnecessary.

During the initial stages of treatment, pain reduction should be the primary focus of treatment. This may involve non-steroidal anti-inflammatory drugs (NSAIDs), rest, ice, compression, elevation (RICE), and reducing the load placed on the Achilles tendon. Reducing loading of the Achilles tendon, especially compression, involves avoiding activities that involve excessive ankle dorsiflexion, such as uphill walking. Temporary heel raises and changes in footwear are also helpful at this stage. Stretching and strengthening of the Achilles is not helpful for IAT in the acute stages, as this may lead to more loading and exacerbation of the condition, but this may be helpful in long term management. Other options for long term management include functional foot orthoses (insoles) to correct any underlying or complicating biomechanical issues in the foot, ankle or lower leg, acupuncture for pain relief, Shockwave Therapy, and surgery in cases that do not respond to conservative treatment.

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