Pain at the back of the heel is most often caused by a problem with the Achilles tendon, the thick band of tissue connecting your calf muscle to your heel bone. But several other conditions target this exact spot, and each one feels slightly different. Where the pain sits, when it flares up, and your age all point toward the likely culprit.
Achilles Tendinopathy
This is the most common reason adults feel pain at the back of the heel. The Achilles tendon handles enormous force every time you walk, run, or push off the ground, and when loading exceeds what the tendon can recover from, the tissue begins to break down. The pain is typically achy, occasionally sharp, and gets worse with increased activity or when something presses against the area. You may also notice the tendon feels thicker than usual or that a small bump has formed along it.
There are two forms, and the distinction matters. Insertional tendinopathy hits right where the tendon attaches to the heel bone and is common even in people who aren’t particularly active. Non-insertional tendinopathy causes pain a few centimeters higher, in the middle portion of the tendon, and tends to show up in runners or people who suddenly ramp up their activity level. In insertional cases, excessive compression at the attachment point reduces blood flow inside the tendon, creating a low-oxygen environment that worsens inflammation and slows healing.
Pulling your foot upward (toward your shin) typically makes the pain worse because it stretches and compresses the already irritated area. An X-ray may show bone spurs at the tendon’s attachment or calcium deposits within the tendon itself. Ultrasound can reveal thickening in the tendon tissue.
Haglund’s Deformity (Pump Bump)
If you can see and feel a hard bump on the back of your heel, you may have a Haglund’s deformity, a bony growth on the heel bone right where the Achilles tendon attaches. It’s most common in middle-aged women and earned the nickname “pump bump” because rigid-backed shoes like high heels press directly against it, making the pain significantly worse. The bump can also cause the skin around it to become swollen or discolored.
The growth itself isn’t always the problem. What often happens is the bony prominence irritates a small fluid-filled sac (bursa) that sits between the tendon and the bone. When that bursa gets inflamed, you develop retrocalcaneal bursitis on top of the deformity, compounding the pain. People with Haglund’s deformity tend to notice redness and swelling right around the Achilles tendon, and direct pressure on the area is tender.
Retrocalcaneal Bursitis
Even without a Haglund’s deformity, the bursa behind the heel can become inflamed on its own. This condition produces pain, redness, and swelling around the Achilles tendon and is tender when you press directly on it. One distinguishing feature: research has shown that the pressure inside this bursa is dramatically higher in bursitis compared to Achilles tendinopathy, which explains why the area can feel “full” or puffy, especially when you flex your foot upward.
The primary treatment is reducing pressure on the area. That means switching to shoes with softer, lower backs (or open-backed shoes), applying ice, and using anti-inflammatory pain relievers. Guided injections into the bursa are sometimes used for persistent cases.
Sever’s Disease in Children and Teens
If your child or teenager complains about pain at the back of the heel, the most likely explanation is Sever’s disease. It’s the single most common cause of heel pain in young people, typically affecting athletes between ages 9 and 13. It flares during growth spurts, when the heel bone grows faster than the surrounding tendons and muscles, creating tension and irritation at the growth plate.
The telltale sign is tenderness directly over the back of the heel bone, not in the Achilles tendon or under the foot. Squeezing both sides of the heel also reproduces the pain. X-rays are usually normal. The condition resolves on its own once the growth plate closes, but reducing activity during flare-ups and using cushioned heel inserts help manage pain in the meantime.
Signs of an Achilles Tendon Rupture
A complete tear of the Achilles tendon is a different situation entirely, and it usually announces itself clearly. You’ll feel a sudden snap or pop at the back of your ankle, often during intense physical activity like sprinting or jumping. Sharp pain follows immediately, and walking becomes difficult or impossible.
A simple check can help you gauge whether the tendon is intact. Lie face down with your feet hanging off the edge of a bed. Have someone firmly squeeze your calf muscle. If the foot moves downward when they squeeze, the tendon is likely connected. If the foot doesn’t move at all, the tendon may be torn and you need prompt medical attention.
What Helps at Home
For Achilles tendinopathy specifically, the most evidence-backed home treatment is a structured heel raise program that progressively loads the tendon. In the first two weeks, you start with basic exercises: two-legged heel raises on flat ground (3 sets of 10 to 15), one-legged heel raises (3 sets of 10), and slow lowering (eccentric) heel raises (3 sets of 10), performed daily. During weeks 2 through 5, you progress to doing these off the edge of a stair, which increases the range of motion and load. By weeks 3 through 12, you’re adding weight to single-leg heel raises, still training daily with heavier loads two to three times per week.
A well-studied alternative is the 12-week eccentric protocol: 3 sets of 15 repetitions, twice daily, first with a straight knee then with a bent knee. That’s 180 repetitions per day, seven days a week. It sounds like a lot, and it is. Mild discomfort during the exercises is expected, but sharp or worsening pain means you should scale back.
Heel lifts placed inside your shoes can also help by reducing the stretch on the Achilles tendon. Most studies recommend a lift at least 1.2 centimeters thick (just under half an inch) to make a meaningful difference. Using a lift in both shoes prevents uneven hip alignment.
How Posterior Heel Pain Gets Diagnosed
In many cases, a physical exam is enough. Your provider will press along the tendon, squeeze the heel, and move your foot into different positions to pinpoint the source. The location of tenderness is the most useful clue: pain directly on the tendon suggests tendinopathy, pain between the tendon and the bone suggests bursitis, and a visible bony bump points to Haglund’s deformity.
X-rays are typically the first imaging step if the exam is inconclusive. They can reveal bone spurs, calcium deposits in the tendon, or the characteristic bony prominence of a Haglund’s deformity. Ultrasound is useful for visualizing tendon thickening and bursa swelling in real time. For cases that don’t respond to initial treatment or when a partial tendon tear is suspected, more advanced imaging provides a detailed look at soft tissue damage.
When Conservative Treatment Isn’t Enough
Most posterior heel pain improves with the approaches described above, but some cases prove stubborn. Shockwave therapy, which uses focused pressure waves to stimulate healing in the tendon, has shown success rates of roughly 75 to 80 percent for chronic heel pain that hasn’t responded to other treatments. It’s typically delivered in a series of sessions over several weeks.
Surgery is reserved for cases that fail months of conservative care. For Haglund’s deformity, this means removing the bony prominence. For severely damaged Achilles tendons, the procedure may involve cleaning out deteriorated tissue or, in rare cases, reconstructing the tendon with tissue from elsewhere in the foot. Recovery from Achilles surgery typically means weeks in a boot followed by a gradual return to full activity over several months.