Sharp or aching pain at the back of your heel usually comes from one of a few conditions affecting the Achilles tendon, the bursa (a small fluid-filled cushion), or the heel bone itself. The good news is that most causes are treatable without surgery, but the right approach depends on which structure is actually irritated. Where exactly the pain sits, what makes it worse, and how it started can tell you a lot.
Achilles Tendinopathy: The Most Common Cause
The Achilles tendon connects your calf muscles to the back of your heel bone, and it takes enormous force every time you walk, run, or push off the ground. When this tendon becomes irritated or starts to break down, the result is an aching, occasionally sharp pain that gets worse with activity and with direct pressure on the area. You may also notice that the tendon feels thicker than normal or that there’s a slight bump along it.
There are two varieties, and the distinction matters for treatment. Insertional tendinopathy causes pain right where the tendon meets the heel bone, at the lowest point on the back of your heel. Non-insertional (or midsubstance) tendinopathy hurts a couple of inches higher, in the body of the tendon itself. X-rays of the insertional type sometimes show bone spurs at the attachment point. Pulling your toes up toward your shin typically makes either type hurt more, which is a useful self-test.
This condition tends to develop gradually from overuse: ramping up running mileage too fast, adding hill workouts, or spending long hours on your feet in unsupportive shoes. It’s not a sudden injury, so if your pain came on slowly over days or weeks, tendinopathy is the most likely explanation.
Retrocalcaneal Bursitis
Tucked between the Achilles tendon and the heel bone sits a small, fluid-filled sac called the retrocalcaneal bursa. Its job is to reduce friction, but when it gets inflamed, it swells and produces a deep, throbbing pain at the very back of the heel. The pain overlaps with Achilles tendinopathy in location, which is why the two are often confused. An MRI can distinguish them when the diagnosis isn’t clear from a physical exam alone.
Common triggers include suddenly increasing your workout intensity, not stretching before activity, and wearing tight-fitting shoes that press into the back of the heel. Standing, walking, running, and jumping all aggravate it. If you squeeze both sides of the heel just in front of the Achilles and that reproduces the pain, bursitis is a strong possibility.
Haglund’s Deformity (Pump Bump)
Haglund’s deformity is a bony growth on the heel bone right where the Achilles tendon attaches. It creates a visible, firm bump you can see and feel through the skin. The nickname “pump bump” comes from the fact that rigid-backed shoes, like pumps or dress shoes, press directly on the growth and make it especially painful.
This condition almost always develops on both feet. Beyond the bump itself, you’ll typically notice swelling and pain that flares whenever something presses against the back of the heel. X-rays confirm the diagnosis and help rule out other problems. If switching to open-backed or soft-heeled shoes dramatically reduces your pain, Haglund’s is worth investigating.
Sever’s Disease in Kids and Teens
If a child or young teenager is complaining about heel pain, the most likely cause is Sever’s disease, an irritation of the growth plate at the back of the heel bone. It’s not actually a disease. It’s a temporary overuse condition caused by the Achilles tendon pulling on a growth plate that hasn’t fully hardened yet.
It typically strikes girls between ages 8 and 10 and boys between 10 and 12, especially those involved in running or jumping sports like soccer and gymnastics. The condition resolves on its own once the growth plate closes, which happens in most children by age 15. In the meantime, reducing activity, icing the heel, and using cushioned insoles help manage the pain.
Signs of an Achilles Tendon Tear
Most posterior heel pain is a slow-developing overuse problem. A torn Achilles tendon is different. It happens suddenly, usually during intense physical activity, and the hallmark sign is a pop or snap at the back of the ankle followed by sharp pain. You may have difficulty walking afterward, though some people can still bear weight on a partial tear, which makes it tempting to brush off.
If you felt or heard a pop, notice swelling at the back of the ankle, or can’t push off your toes normally, get evaluated promptly. A complete rupture sometimes leaves a gap you can feel in the tendon just above the heel. This is one situation where waiting it out can lead to a worse outcome.
What Helps the Pain
For most overuse-related posterior heel pain, the initial treatment is the same: reduce the activity that triggered it, ice the area for 15 to 20 minutes several times a day, and avoid shoes that press on the back of the heel. Heel lifts or gel cushions placed inside your shoe can take tension off the Achilles tendon and reduce pressure on the bursa.
Once the acute pain settles, eccentric exercises are one of the most effective ways to rehabilitate Achilles tendinopathy. The basic version involves standing on a step with the balls of your feet on the edge, rising up on both feet, then slowly lowering yourself down on the affected leg only. Start with 3 sets of 10 repetitions and progress to 3 sets of 15, increasing speed and resistance as your pain allows. A resistance band version works well in early stages: start with your toes pointed and slowly let your foot pull back against the band’s tension. These exercises strengthen the tendon as it lengthens, which promotes healing in a way that rest alone doesn’t.
Footwear choices matter more than most people realize. Shoes with a higher heel-to-toe drop (the height difference between the heel and forefoot) place less strain on the Achilles tendon and calf. If you’ve been wearing flat shoes, minimalist sneakers, or ballet flats, switching to a shoe with more heel height can provide noticeable relief. Conversely, very low-drop shoes load the Achilles and ankle complex more heavily, which can aggravate an already irritated tendon.
When Pain Doesn’t Improve
If you’ve been managing symptoms at home for six to eight weeks without meaningful improvement, it’s worth getting imaging and a professional evaluation. Insertional tendinopathy, bursitis, and Haglund’s deformity can coexist, and treating the wrong one (or only one of them) stalls recovery.
For chronic cases that haven’t responded to conservative care, extracorporeal shockwave therapy is an option that has shown solid results. In a study of 363 patients with stubborn heel pain, 76% of those treated with a single session reported satisfying pain relief. Some patients needed up to three sessions spaced a week apart. Physical therapy, custom orthotics, and in rare cases surgery to remove a bony growth or repair a damaged tendon are also on the table for persistent pain. The vast majority of people, though, recover with the simpler approaches: load management, the right shoes, and a consistent eccentric exercise program.