Question
A 54 year old man has posterior heel pain, worse after rest and with shoes that rub the back of the heel.
- Describe the radiograph.
- How does insertional tendinopathy differ from midportion tendinopathy?
- Outline management.
Answer
Radiograph
- Calcification at the Achilles insertion
- Prominent posterosuperior calcaneal tuberosity (Haglund deformity) may coexist
Insertional versus midportion
| Feature | Insertional | Midportion |
|---|---|---|
| Site | Within 2 cm of insertion | 2 to 6 cm proximal |
| Age | Older, less active | Athletes |
| Associated | Haglund deformity, retrocalcaneal bursitis | Paratenonitis |
| Eccentric exercise | Less effective, avoid dorsiflexion past neutral | Effective (Alfredson) |
Management
- Heel lift, open backed shoes, activity change
- Modified eccentric loading
- Extracorporeal shockwave therapy
- Avoid steroid injection into the tendon
- Surgical debridement, excision of calcification and Haglund deformity
- Reattach with suture anchors if over half the insertion is detached
- FHL transfer for extensive degeneration in older patients
Related pages
Author Contributions
Orthofracs team
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.