Insertional Achilles tendinopathy is pain where the Achilles tendon attaches to the back of the heel bone. It causes pain and stiffness at the back of the heel, often with a bony bump, and is worse first thing in the morning, with uphill walking and in shoes that press on the heel. It behaves differently from Achilles pain higher up the tendon, and the exercise programme has to be adapted so that the heel is not lowered below the level of the forefoot.
Also known as Haglund's deformity, pump bump, retrocalcaneal bursitis, Achilles enthesopathy
Anatomy: where the problem is
Side view of the lower leg. Highlighted in the diagram: Achilles attachment on the heel.
Symptoms
- Pain at the very back of the heel, where the tendon meets the bone
- Stiffness and pain for the first steps in the morning or after sitting
- Pain when walking uphill, climbing stairs or running
- A firm bump at the back of the heel
- Pain from shoes that rub or press on the area
- Swelling or thickening around the tendon attachment
Causes and risk factors
- A sudden increase in walking, running or hill work
- Tight or weak calf muscles
- A prominent bony bump on the heel bone (Haglund's deformity)
- Shoes with a hard or tight heel counter
- Being overweight, diabetes and increasing age
- Bony spurs or calcium deposits within the tendon attachment
What the evidence says helps
- Guidelines recommend starting with education, managing load and at least 12 weeks of progressive calf strengthening for all types of Achilles tendinopathy.3
- For insertional pain, exercises are adapted so that the heel is lowered only to floor level and not off the edge of a step. A pilot study of this approach reported that about two-thirds of people were satisfied and back to their previous activity.2
- A systematic review found that this floor-level method was better accepted than the traditional full-range heel drop, which often aggravates insertional pain.1
- Shockwave therapy is an option if exercise has not helped enough after about three months. The same review found evidence that it is effective when there is no calcium deposit in the tendon.13
- Surgery is considered only when at least six months of good conservative treatment has failed.3
Things you can try at home
- Reduce hills, stairs and running for a few weeks, without stopping activity altogether
- Wear shoes with a slightly raised heel and a soft or open back, and avoid going barefoot or in flat shoes for a while
- Try a small heel lift in both shoes to ease the load on the tendon
- Avoid stretching the calf with the heel dropped off a step
- Do calf raises on flat ground, building up the number and then the load
- Be patient: improvement usually takes three months or more
When to get urgent help
Contact your GP urgently, call NHS 111, or call 999 in an emergency if you have:
- A sudden snap or pop at the back of the ankle with difficulty pushing off: go to A&E or a minor injuries unit the same day
- A hot, red, swollen heel with a fever or feeling unwell: get same-day medical help
- A swollen, warm, tender calf in one leg: get same-day medical help
- Heel pain at night or at rest that does not ease, especially with pain in other joints or morning back stiffness: see your GP
- Heel pain that started while taking a fluoroquinolone antibiotic: contact your GP or pharmacist promptly
How Apollo can help
We confirm where the pain is coming from, because the exercises that suit mid-tendon Achilles pain can aggravate the insertion. Treatment combines load management, a floor-level calf strengthening programme that is progressed step by step, and footwear advice. Our podiatry and biomechanics services can assess foot posture, pressure and footwear, and advise on heel lifts or orthoses where they are likely to help. If you are not improving after around three months, we discuss further options with you and your GP.
No GP referral needed. Clinics in Sheringham, Coltishall and Norwich.
Related reading
Frequently asked questions
What is the difference between insertional and mid-portion Achilles tendinopathy?
Mid-portion tendinopathy causes pain and thickening a few centimetres above the heel. Insertional tendinopathy is right at the back of the heel bone. The distinction matters because insertional pain is aggravated by dropping the heel below the forefoot, so exercises and footwear advice differ.
What is Haglund's deformity?
It is a bony prominence at the upper back corner of the heel bone. It can rub against the tendon and the small fluid sac in front of it, especially in stiff-backed shoes. Many people have the bump without any pain.
Should I do heel drops off a step?
Not for insertional pain. Lowering the heel below the level of the step compresses the tendon against the heel bone and often makes it worse. Calf raises on flat ground are the usual starting point.
References
- Wiegerinck JI, Kerkhoffs GM, van Sterkenburg MN, Sierevelt IN, van Dijk CN (2012). Treatment for insertional Achilles tendinopathy: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy 21:1345-1355. View source
- Jonsson P, Alfredson H, Sunding K, Fahlström M, Cook J (2008). New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. British Journal of Sports Medicine 42:746-749. View source
- de Vos RJ, et al. (2021). Dutch multidisciplinary guideline on Achilles tendinopathy. British Journal of Sports Medicine 55:1125-1134. View source
This page is general information, not a diagnosis or a substitute for medical advice. If you are worried about your symptoms, speak to your GP or a registered healthcare professional. Content prepared from the sources above, November 2026.
