Medically Reviewed | Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle, Michigan
Quick Answer: Pain directly behind the ankle bone (posterior ankle) most commonly indicates insertional Achilles tendinitis, FHL (flexor hallucis longus) tendinitis, or posterior ankle impingement from an Os Trigonum or bone spur. Location within the posterior ankle — medial vs. central vs. lateral — helps distinguish the cause.
Achilles Tendinitis at the Insertion
The most common cause of pain directly at or around the posterior calcaneus (heel bone) is insertional Achilles tendinitis — inflammation at the tendon-bone junction where the Achilles inserts on the posterior superior calcaneal tuberosity.
Insertional Achilles tendinopathy has a distinct pathological pattern: calcification within the tendon at the insertion, impingement of the calcified tendon against the posterior superior calcaneus (Haglund’s deformity), and degeneration of the tendon fibers at the attachment zone.
Presentation: pain at the very back of the heel — not at the ‘bump’ but on the posterior superior surface where the tendon inserts. Tender directly at the bone-tendon junction. Morning stiffness that slowly improves. Worse with stiff-backed shoes (the heel counter presses on the Haglund’s prominence).
Treatment: heel lifts (9mm) reduce Achilles tension at the insertion. Open-back shoes or those with soft heel counters eliminate Haglund’s impingement. Eccentric heel drops are first-line exercise therapy. Ultrasound-guided platelet-rich plasma (PRP) injection for stubborn cases. Surgical Haglund’s resection and tendon debridement for refractory cases.
FHL Tendinitis: The Dancer’s Heel
The flexor hallucis longus (FHL) tendon runs posterior to the medial malleolus and through a tunnel in the posterior talus before entering the foot. It is under maximum tension during plantarflexion (pointing the toes) — the position of ballet dancers, gymnasts, and pushing off forcefully in sports.
FHL tendinitis presents as pain deep to the posterior medial ankle — distinctly medial to the central Achilles location. Crepitus (a creaking sensation) may be palpable with FHL flexion-extension. Triggering (the toe gets caught and releases with a snap) indicates FHL stenosis.
Treatment: activity modification (reducing extreme plantarflexion loads), NSAIDs, ultrasound-guided corticosteroid injection, and surgical release for severe stenosis. FHL tendinitis is particularly challenging in dancers because the provocative position (extreme plantarflexion) is fundamental to their art.
Posterior Ankle Impingement and Os Trigonum
Os trigonum is an accessory bone present in approximately 14% of the population — an unfused secondary ossification center at the posterior aspect of the talus. In most people it is asymptomatic. In athletes who perform repetitive plantarflexion (ballet dancers, soccer players, downhill runners), the os trigonum gets pinched between the calcaneus and posterior tibia.
Posterior ankle impingement syndrome: sharp posterior ankle pain with plantarflexion that is sudden in onset, often triggered by a specific plantarflexion movement. Posterior drawer test and plantarflexion reproduce the pain. MRI or CT scan demonstrates the os trigonum or posterior talar process impingement.
Treatment: activity modification, cortisone injection targeting the impingement site (ultrasound-guided for precision), and surgical excision of the os trigonum (arthroscopic or open) for symptomatic cases that fail conservative care.
Dr. Tom's Product Recommendations
PowerStep Pinnacle with Heel Lift
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Arch support with heel elevation to reduce insertional Achilles tension
Dr. Tom says: “Heel lifts are first-line non-invasive treatment for insertional Achilles tendinitis. PowerStep’s built-in heel cup and elevator reduce Achilles insertion tension immediately.”
Insertional Achilles tendinitis, Haglund’s pain relief, heel elevation
FHL tendinitis and Os Trigonum (different mechanism — see specialist)
Disclosure: We earn a commission at no extra cost to you.
Doctor Hoy’s Natural Pain Relief Gel
⭐ Highly Rated | Foundation Wellness Partner | 30% Commission
Topical relief for Achilles insertion and posterior ankle soreness
Dr. Tom says: “Applied to the posterior heel and Achilles insertion, Doctor Hoy’s arnica and menthol provides daily topical relief for the most tender area.”
Insertional Achilles soreness, posterior ankle pain, daily topical management
FHL deep pain (superficial topical has limited penetration to deep structures)
Disclosure: We earn a commission at no extra cost to you.
✅ Pros / Benefits
- Insertional Achilles tendinitis responds to heel lifts and eccentric exercises
- FHL tendinitis can be effectively injected under ultrasound guidance
- Os Trigonum excision is a relatively simple procedure with excellent results
❌ Cons / Risks
- Insertional Achilles tendinopathy has worse prognosis than mid-portion — longer treatment course
- FHL stenosis may require surgery in severe cases or in professional athletes
- Os Trigonum impingement requires activity modification that may not be compatible with dance careers
Dr. Tom Biernacki’s Recommendation
The key to posterior ankle pain is precise localization. I ask patients to point with one finger to exactly where it hurts. Central and slightly superior to the heel? Insertional Achilles. Deep to the medial posterior ankle, worse with toe-pointing? FHL. Sharp posterolateral ankle pain with plantarflexion? Os Trigonum impingement. The anatomy tells us the diagnosis, and the diagnosis tells us the treatment.
— Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle
Frequently Asked Questions
Is Os Trigonum a serious problem?
Only if it’s symptomatic. Many people have an Os Trigonum and never know it. In athletes with posterior ankle impingement syndrome, excision provides excellent relief.
How long does insertional Achilles tendinitis take to heal?
Typically 6–12 months with conservative management. Longer than mid-portion Achilles tendinopathy due to the complexity of the insertion zone.
Can I play sports with FHL tendinitis?
Modified activity is possible. Reducing extreme plantarflexion loading allows continued participation in many sports. Dance is particularly challenging.
What is Haglund’s deformity?
A bony prominence on the posterior superior calcaneus that impinges against the Achilles tendon insertion, particularly with stiff-backed shoes. Part of the insertional Achilles tendinopathy complex.
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📞 (810) 206-1402 Book Online →When Shoes Aren’t Enough — Dr. Tom’s Top 9 Orthotics
About 30% of patients I see for foot pain need MORE than a great shoe — they need a structured insole. Below: my complete 2026 orthotic ranking with pros, cons, and the specific patient I’d give each one to.
★ DR. TOM’S COMPLETE 2026 ORTHOTIC RANKING
9 Best Prefab Orthotics by Use Case
PowerStep, CURREX, Spenco, Vionic, and Tread Labs — every orthotic I’ve fitted to thousands of patients across both Michigan offices. Each card includes pros, cons, and the specific patient I’d give it to. Real Amazon ratings, review counts, and prices below.
Best All-Purpose Orthotic for Most Patients
Semi-rigid arch shell + dual-layer cushion + deep heel cup. The orthotic I’ve fitted to more patients than any other for 15 years. APMA-accepted. Trim-to-fit design works in athletic shoes, casual shoes, and most work boots.
✓ Pros
- Semi-rigid arch shell provides true biomechanical correction
- Deep heel cup centers the heel and reduces lateral instability
- Dual-layer cushion (top + bottom) lasts 9-12 months daily wear
- Available in 8 sizes for precise fit
- APMA-accepted and clinically validated
- APMA-accepted with superior cushioning versus rigid alternatives
✗ Cons
- Too thick for most dress shoes (use ProTech Slim instead)
- Some break-in period required (3-7 days for arch tolerance)
- Not enough correction for severe pes planus or rigid pes cavus
Dr. Tom’s Recommendation: If a patient has run-of-the-mill plantar fasciitis, mild flat feet, or arch fatigue, this is the first orthotic I try. Better value than most premium alternatives for 90% of patients, which is why it’s the first orthotic I reach for in the clinic. Sub-$50 typically.
Maximum Motion Control · Flat Feet & Severe Over-Pronation
PowerStep’s most aggressive stability orthotic. Adds a 2°-7° medial heel post on top of the standard PowerStep platform — designed specifically for flat-footed patients and severe pronators who need real corrective force.
✓ Pros
- 2°-7° medial heel post adds aggressive pronation control
- Same trusted PowerStep arch shell, more correction
- Built specifically for flat-foot biomechanics
- Excellent for posterior tibial tendon dysfunction (PTTD)
- Removable top cover for cleaning
✗ Cons
- Too aggressive for neutral-arch patients
- Needs longer break-in (10-14 days) due to stronger correction
- Adds 2-3 mm of stack height — won’t fit slim dress shoes
Dr. Tom’s Recommendation: When a patient comes in with significant flat feet AND symptoms (heel pain, arch pain, knee pain), the Original PowerStep isn’t aggressive enough. The Maxx is what gets prescribed. About 25% of my flat-footed patients end up here.
Low-Profile · Fits Dress Shoes & Narrow Casuals
3 mm slim profile with podiatrist-designed tri-planar arch technology. Engineered specifically to fit inside dress shoes, oxfords, loafers, and women’s flats without crowding the toe box. Vionic was founded by an Australian podiatrist.
✓ Pros
- 3 mm slim profile (vs 7-10 mm for standard orthotics)
- Tri-planar arch technology adds support without bulk
- Built-in deep heel cup despite slim design
- Fits dress shoes WITHOUT having to remove the factory insole
- Trim-to-fit · APMA-accepted
✗ Cons
- Less arch support than full-volume orthotics
- Top cover wears faster than thicker alternatives
- Not enough correction for severe foot deformities
Dr. Tom’s Recommendation: My default when a patient says ‘I need orthotics but I have to wear dress shoes for work.’ Slim enough to fit in oxfords and pumps without the heel sliding out. The single highest-impact change you can make for office workers with foot pain.
Built-In Metatarsal Pad · Morton’s Neuroma · Ball-of-Foot Pain
Standard Pinnacle orthotic with a built-in metatarsal pad positioned proximal to the metatarsal heads — the exact location that offloads neuromas and metatarsalgia. No need for separate met pads or pad placement guesswork.
✓ Pros
- Built-in met pad eliminates DIY pad placement errors
- Specifically designed for Morton’s neuroma + metatarsalgia
- Same trusted PowerStep arch + heel cup platform
- Top cover protects sensitive forefoot skin
- Faster relief than orthotics + add-on met pads
✗ Cons
- Met pad position is fixed (can’t fine-tune individual placement)
- Some patients with very small or very large feet need custom
- Slightly thicker than the standard Pinnacle
Dr. Tom’s Recommendation: If a patient has Morton’s neuroma, sesamoiditis, or generalized ball-of-foot pain (metatarsalgia), this saves a clinic visit and a prescription. The built-in pad placement is anatomically correct for 80% of feet. Way better than DIY met pads.
Adaptive Dynamic Arch · Athletic & Daily Wear
Currex’s flagship adaptive arch technology — the orthotic flexes with your gait instead of fighting it. Different stiffness zones along the length give you targeted support at the heel, midfoot, and forefoot. Available in three arch heights (low/medium/high).
✓ Pros
- Dynamic flex zones adapt to natural gait cycle
- Three arch heights ensure precise fit
- Lighter than rigid orthotics (no ‘heavy foot’ feel)
- Excellent for runners and athletic walkers
- European podiatric design (German engineering)
✗ Cons
- More expensive than PowerStep Original ($55-65 typically)
- Less aggressive correction than Pinnacle Maxx for severe cases
- Three arch heights means you must self-select correctly
Dr. Tom’s Recommendation: I started recommending Currex three years ago for runners who said PowerStep felt ‘too rigid.’ The dynamic flex zones respect natural gait. Best for active patients who walk 8K+ steps daily and don’t need maximum motion control.
Running-Specific · Heel Strike + Forefoot Strike Compatible
Currex’s purpose-built running orthotic. The midfoot flex zone is positioned for runner’s gait mechanics, with a flared heel cushion for heel strikers and a forefoot rocker for midfoot/forefoot strikers. Tested on 1000+ runners during product development.
✓ Pros
- Designed by German biomechanics lab specifically for runners
- Dynamic arch flexes with running gait (not static like PowerStep)
- Three arch heights (low/medium/high)
- Reduces overuse injury risk in mid-distance runners
- Lightweight (no impact on cadence)
✗ Cons
- Premium price ($60-75)
- Not aggressive enough for severe over-pronators (use Pinnacle Maxx)
- Runner-specific design = less ideal for daily walking shoes
Dr. Tom’s Recommendation: If a patient runs 20+ miles per week and has plantar fasciitis or shin splints, this is the orthotic I prescribe. The dynamic flex zones respect running biomechanics in a way that no rigid PowerStep can match. Pricier but worth it for serious runners.
Cavus Foot & High-Arch Patients
Polyurethane base with a deeper heel cup and higher arch profile than PowerStep — built for cavus (high-arched) feet that need maximum cushion and support. The 5-zone cushioning system addresses the unique pressure points of high-arch feet.
✓ Pros
- Deeper heel cup centers the heel for cavus foot stability
- Higher arch profile fills the void under high arches
- 5-zone cushioning addresses cavus foot pressure points
- Polyurethane base lasts 12+ months
- Available in Wide width
✗ Cons
- Too tall/aggressive for normal or low arches
- Won’t fit slim dress shoes
- Pricier than PowerStep Original
- Some patients find the arch height uncomfortable initially
Dr. Tom’s Recommendation: Cavus foot patients are often misdiagnosed and given low-arch orthotics — that makes everything worse. Spenco’s Total Support has the arch profile that high-arch feet actually need. About 15% of my patients have cavus feet; this is what they wear.
Cushion Layer · Standing All Day · Gel Pressure Relief
NOT a true biomechanical orthotic — this is a cushion insole. But for patients who want gel pressure relief instead of arch correction (or to add ON TOP of factory insoles in work boots), this is the best gel option on Amazon.
✓ Pros
- Genuine gel cushioning (not foam pretending to be gel)
- Targeted gel waves under heel and ball of foot
- Trim-to-fit · works in most shoe types
- Sub-$15 price (most affordable option in this list)
- Massaging texture is genuinely soothing
✗ Cons
- ZERO arch support — this is cushion only
- Won’t fix plantar fasciitis or flat-foot issues
- Compresses faster than PowerStep (4-6 months)
- Top cover wears through in high-mileage applications
Dr. Tom’s Recommendation: I recommend these to patients who tell me ‘I just want my feet to stop hurting at the end of my shift’ and who don’t have a biomechanical issue. Construction workers, factory workers, retail. Pure cushion does the job for them.
Tight-Fitting Shoes · Cycling Shoes · Hockey Skates
Tread Labs Pace insole with firm orthotic arch support for flat feet and plantar fasciitis relief. The replaceable top cover design makes it one of the most durable picks in this guide — backed by a million-mile guarantee and recommended for tight-fitting athletic footwear.
✓ Pros
- Firm orthotic arch support shell (podiatrist-grade)
- Slim profile fits tight athletic footwear
- Lasts 12+ months daily wear
- Excellent for cycling shoes specifically
- Built-in odor-control treatment
✗ Cons
- Premium price ($45-55)
- Less cushion than PowerStep equivalents
- Not as aggressive correction as Pinnacle Maxx for flat feet
- The signature ‘heel cup feel’ takes 1-2 weeks to adapt to
Dr. Tom’s Recommendation: If you’re a cyclist with foot numbness, hot spots, or knee pain — this is the orthotic. The stabilizer cap solves cycling-specific biomechanical issues that no other orthotic addresses. Worth the premium for athletes.
None of these solving your foot pain?
Some patients (about 30%) need custom-molded prescription orthotics. We make 3D-scanned custom orthotics in our Howell and Bloomfield Hills offices — specifically built for your foot mechanics.
Schedule a Custom Orthotic Fitting →FSA/HSA eligible · Most insurance accepted · (810) 206-1402
Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.
- Plantar Fasciitis: Diagnosis and Conservative Management (PubMed)
- Plantar Fasciitis (APMA)
- Diagnosis and Treatment of Plantar Fasciitis (PubMed / AAFP)
- Heel Pain (APMA)