Pain at the back of your heel most often comes from a problem with the Achilles tendon, the thick band of tissue connecting your calf muscles to your heel bone. But the tendon itself is only one possible source. A bony bump on the heel, inflamed fluid-filled sacs near the tendon, or (in kids) an irritated growth plate can all produce pain in the same spot. Figuring out which structure is involved helps determine what to do about it.
Achilles Tendinopathy
This is the most common culprit. Achilles tendinopathy falls into two types based on where the damage occurs, and each tends to affect different people.
Insertional tendinopathy affects the point where the Achilles tendon attaches to the heel bone. You’ll feel pain right at the back of the heel, sometimes with a hard bump where calcium deposits have built up. This type is more common in physically active people and can develop at any age. Tight-fitting shoes that press against the attachment point make it worse.
Non-insertional tendinopathy affects the middle portion of the tendon, roughly 2 to 6 centimeters above where it meets the heel bone. That section of the tendon has the poorest blood supply of any part of the Achilles, which limits its ability to repair itself under stress. Non-insertional problems tend to show up in older, less active, and overweight individuals. You’ll notice pain and sometimes a visible thickening a few inches above the heel rather than right at the bone.
Both types typically start as stiffness after rest, especially first thing in the morning or after sitting for a while. The pain often eases with light movement, then returns after prolonged activity. If you catch it early, severity stays lower and recovery is shorter. Ignore the warning signs and push through, and the tendon deteriorates further.
Retrocalcaneal Bursitis
Two small fluid-filled sacs (bursae) sit near the back of your heel, cushioning the space between the Achilles tendon and the surrounding structures. One lies between the tendon and the heel bone. The other sits between the tendon and the skin. Either or both can become inflamed, causing pain that overlaps with tendon pain in location and feel.
Bursitis here is usually triggered by repetitive stress or overuse. Athletes who suddenly increase training volume are common candidates, but anyone who wears shoes with rigid heel counters that dig into the back of the heel can develop it. The pain tends to be worse with pressure, so shoes that grip tightly around the heel area are a frequent aggravator. Over time, the pain can become chronic, leading to a limp or a noticeable drop in activity tolerance.
Bursitis and Achilles tendinopathy frequently coexist. People with insertional tendon problems often have thickened, inflamed bursae with increased blood flow in the bursa walls, which is one reason posterior heel pain can be stubborn to treat.
Haglund’s Deformity (Pump Bump)
Haglund’s deformity is a bony enlargement on the back of the heel bone. When that bump rubs against rigid shoes, the soft tissue around it becomes irritated and inflamed. The nickname “pump bump” comes from its association with stiff-backed dress shoes and pumps, though any shoe with an unyielding heel counter can provoke it.
There’s no single definitive cause. A tight Achilles tendon, a high foot arch, and heredity all seem to play a role. Runners who overtrain, people with altered foot mechanics from a misaligned subtalar joint, and those who simply inherited a more prominent heel bone are all at higher risk. The bump itself is permanent bone, but the pain it causes comes from the surrounding tissue inflammation, which can be managed.
Conservative treatment starts with reassessing your footwear. Heel pads or heel lifts help in cases involving high arches, and switching to shoes with softer, more flexible heel counters reduces friction against the bump. Open-backed shoes can provide immediate relief during flare-ups.
Sever’s Disease in Children
If your child complains about pain at the back of the heel, the most likely explanation is Sever’s disease, a growth plate irritation that is the single most common cause of heel pain in kids. It typically affects active children between ages 8 and 15, when the heel bone’s growth plate is still open and vulnerable to repetitive stress.
In children, the growth plate is the weakest link in the chain connecting muscle to tendon to bone. Repetitive pulling from the Achilles tendon during running and jumping irritates that growth plate rather than damaging the tendon itself, which is why this condition doesn’t occur in adults whose growth plates have closed.
The pain is located at the back of the heel, near the Achilles insertion, and gets worse with physical activity. Redness and swelling are usually absent, which can be confusing for parents expecting to see visible signs. Kids may walk on their toes or develop a limp to avoid putting weight on the sore heel. It can affect one heel or both. A simple squeeze test, pressing on both sides of the heel, typically reproduces the pain and is the main way the condition is identified. Sever’s disease resolves on its own once the growth plate fully closes, usually by age 14 or 15, but managing activity levels in the meantime keeps the pain under control.
How Footwear Affects Posterior Heel Pain
The heel-to-toe drop of your shoes, the height difference between the heel and forefoot, directly influences how much stress reaches the back of your heel. A shoe with a higher drop (10 to 12 mm) shifts impact forces toward the knees and hips, effectively unloading the Achilles tendon and calf. A shoe with a lower drop (4 mm or less) does the opposite: it spares the knees but places significantly more stress on the foot, ankle, and lower leg, including the Achilles insertion.
This matters if you’re choosing running shoes or everyday footwear while dealing with posterior heel pain. A higher-drop shoe can reduce strain on the tendon and heel in the short term. If you currently wear low-drop or minimalist shoes and have developed heel pain, gradually transitioning to something with more heel elevation may help. The key word is gradually. Abrupt changes in either direction shift forces to structures that aren’t adapted to handle them, which creates new problems.
Beyond drop, the stiffness of the heel counter matters. Rigid backs press directly against the Achilles attachment and any bony prominence, worsening both bursitis and Haglund’s irritation. Shoes with padded, flexible heel collars or notched Achilles cutouts reduce that mechanical pressure.
Treatment and Recovery Timelines
For Achilles tendinopathy, the most well-supported treatment is progressive tendon loading exercise. This means gradually and systematically stressing the tendon through specific exercises, starting with gentle contractions and building toward heavier, more dynamic movements over time. The type of loading (eccentric, slow and heavy, or progressive) matters less than the consistency. Exercise combined with education about load management forms the current first-line approach, and it can be delivered in person or through telehealth. Passive treatments alone, like manual therapy, taping, or dry needling, have limited evidence supporting their use without an active loading component.
Recovery is not fast. A structured rehabilitation program typically follows a phased timeline: one to two weeks of symptom management and load reduction, followed by a recovery phase through roughly week five, a rebuilding phase through week twelve, and a return-to-sport phase from three to six months. Full recovery can take a year or longer, and reinjury is common when people rush back to their normal activity levels too quickly.
For bursitis and Haglund’s deformity, initial management focuses on reducing friction and pressure. Footwear changes, heel lifts, icing, and temporary activity modification are the starting points. Orthotics or insoles can help correct hindfoot alignment when that’s contributing to the problem. If conservative measures fail over several months, surgical options exist for removing the bony prominence, cleaning out inflamed bursa tissue, or addressing degenerated tendon, but most people improve without reaching that point.