The Achilles tendon attaches to the heel bone (the calcaneus) over a very broad area. Although the tendon is only approximately one-centimeter thick, its attachment spreads over a three and a half-centimeter area on the calcaneus. Recurrent stress on the tendon where it attaches (the insertion) leads to inflammation, microscopic tearing of the tendon, swelling and pain. This can be associated with inflammation of the space between the tendon and the calcaneus, called the retrocalcaneal bursa. At times the back of the heel can begin to enlarge and get quite thick. The thickening is partly as a result of bone spurs that may develop on the back of the calcaneus. These can then grow up into the substance of the Achilles tendon causing further wear and tear of the tendon.

This is the typical appearance of a painful heel from a bump on the back of the heel bone. This is aggravated by rubbing from shoes (in some countries this condition is called a pump bump because of the "pump" type of shoe).

This is the appearance of the back of the heel on an XR taken from the side view. The abnormal bone projecting into the Achilles is easy to see, and the normal heel bone contour is shown with the dotted line.

Treatment of the insertion of Achilles tendonitis begins with rest, elevation of the heel on the sole of the shoe and physical therapy treatments. All of these are designed to decrease the inflammation on the tendon. Inflammation occurs with every step we take when walking because of the stretching of the Achilles tendon. Padding of the shoe, elevated heels and physical therapy treatments are commonly successful. Cortisone (steroid injection) should not be used to treat inflammation of the insertion of the Achilles tendon since this can lead to further deterioration of the tendon itself.

Here you see the back of the heel and the bump on the heel bone shown on the left. Right: A bone chisel is used to remove the bump completely.

The appearance of the heel after the bone has been cut.

The bone on the back of the heel has been removed. On the XR on the right, note a white object in the bone. This is a small bone screw that is used at times to re-attach the Achilles in severe cases where a lot of bone has to be removed.

Alternatively, the tendon may need to be repaired if there is tearing of the tendon where it attaches to the bone. In addition to repairing the tendon, a transfer of a tendon is used (transferring the tendon to the big toe, called the flexor hallucis longus). This tendon transfer adds strength and support to the weakened damaged tendon.

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