Pain at the top of your heel, right where the back of your shoe meets the bone, most commonly comes from irritation of the Achilles tendon where it anchors into the heel bone. This area sits within the lowest two centimeters of the tendon and takes enormous stress with every step, making it one of the most frequent sources of foot pain. Several conditions can cause it, and telling them apart matters because each one responds to different approaches.
Insertional Achilles Tendinopathy
This is the most likely culprit. The Achilles tendon connects your calf muscles to the back of your heel bone, and the exact spot where it attaches is under constant strain. Two forces work against it simultaneously: the calf muscles pull the tendon lengthwise, while the heel bone presses into the underside of the tendon from below. Over time, this combination of pulling and compression breaks down the tendon fibers. The organized, parallel structure of the tendon deteriorates, and fatty tissue and tiny blood vessels grow into areas where they shouldn’t be.
The hallmark symptoms are stiffness after sitting or sleeping and pain that flares with activity. You’ll notice tenderness when you press on the back of the heel, and you may see visible swelling or redness there. Many people find that wearing shoes becomes uncomfortable because of pressure against the swollen area. The pain tends to build gradually over weeks or months rather than arriving suddenly.
The good news: non-surgical treatment works for roughly 80% of people with this condition. That figure is actually higher than the 50 to 70% success rate that was long assumed. Treatment centers on a specific type of exercise called eccentric loading, where you slowly lower your heel off the edge of a step, letting your calf muscle lengthen under tension. The most widely used protocol calls for 180 of these repetitions per day (three sets of 15 on each leg, done twice). The load needs to be relatively high for best results, and you can increase the difficulty over time by holding weights. Staying active during rehabilitation is fine and doesn’t worsen outcomes, though you’ll want to avoid explosive movements like jumping or sprinting for the first couple of weeks.
Haglund’s Deformity (Pump Bump)
Some people develop a bony enlargement right at the back-top corner of the heel bone, at the same spot where the Achilles tendon attaches. This bump, called a Haglund’s deformity, creates a hard lump you can see and feel on the back of your heel. It gets its nickname “pump bump” because rigid-backed shoes, including pumps, press directly against it and make the surrounding soft tissue red and inflamed.
The condition is largely structural. Tight or poorly fitting shoes contribute, but some people simply develop the bony prominence without an obvious cause. Conservative treatment usually involves switching to shoes with a softer or lower heel counter, using heel lifts, or wearing open-backed shoes when possible. If surgery becomes necessary, recovery can take three to six months before you’re comfortable in firmer footwear again.
Retrocalcaneal Bursitis
Between the Achilles tendon and the heel bone sits a small, fluid-filled sac called a bursa. Its job is to reduce friction, but when it gets inflamed, it swells and produces a deep, achy pain in the same area as tendinopathy. Retrocalcaneal bursitis is the more common type of heel bursitis, and it frequently shows up alongside Achilles tendon problems, making it tricky to tell the two apart without imaging. An MRI can distinguish between the two when the source of pain isn’t obvious from a physical exam.
Calcaneal Stress Fracture
Less common but worth knowing about: the heel bone itself can develop a stress fracture from repetitive loading. The pain is deep and aching, localized directly over the bone, and gets worse with activity. This contrasts with tendon pain, which often loosens up once you get moving. A useful clue is the squeeze test. If squeezing both sides of your heel bone together reproduces the pain, a stress fracture is more likely than a soft tissue problem.
People most at risk include those who’ve suddenly ramped up their activity level, older adults, smokers, and anyone with weakened bones from osteoporosis or long-term steroid use. Up to 85% of stress fractures won’t show up on an initial X-ray, so a normal X-ray doesn’t rule it out. MRI is far more reliable for catching early bone stress injuries.
Heel Pain in Kids and Teens
If your child complains about pain at the top of the heel, the most likely explanation is Sever’s disease, which isn’t really a disease at all. It’s inflammation of the growth plate in the heel bone. During early puberty, the heel is one of the first body parts to reach full size, and the muscles and tendons can’t keep pace with the bone growth. The resulting tension irritates the growth plate. Girls are most vulnerable between ages 8 and 10, boys between 10 and 12. It becomes rare after age 15, once the heel’s growth plate closes.
How to Tell These Conditions Apart
- Morning stiffness that loosens up: points toward insertional Achilles tendinopathy
- Visible bony bump on the back of the heel: suggests Haglund’s deformity
- Deep ache that worsens steadily with activity: raises concern for a stress fracture
- Pain when squeezing the sides of the heel bone: a classic stress fracture sign
- Swelling between the tendon and bone, without a hard bump: likely bursitis
What You Can Do at Home
For most causes of upper heel pain, a few strategies overlap. Ice applied to the back of the heel for 15 to 20 minutes after activity helps control inflammation. Temporarily switching to shoes with a soft heel counter, or using heel pads that reduce pressure on the bump, gives the area breathing room. Avoid going barefoot on hard surfaces, which forces the Achilles tendon to work through its full range under load.
Eccentric heel drops remain the single best-supported exercise for Achilles-related heel pain. Stand on a step with just the balls of your feet on the edge, rise up on both feet, then slowly lower one heel below the step level over a count of three to five seconds. Use the other leg to push back up so the injured side only works on the lowering phase. The load should feel challenging but not sharp. This program typically runs for 12 weeks, and about 90% of people with midportion tendon pain see meaningful improvement. Results for insertional pain take longer and can be more variable, but the approach is the same foundation.
Continuing moderate activity during rehab is safe. Walking, cycling, and swimming generally don’t aggravate the tendon. Hold off on jumping, hill sprints, and heavy calf raises for at least the first two weeks of a structured program.
Signs That Need Prompt Attention
A sudden pop or snap at the back of the ankle is a different situation entirely. An Achilles tendon rupture often feels like being kicked in the back of the leg, produces immediate swelling, and makes it difficult or impossible to push off your foot or rise onto your toes. If you experience an audible pop with sharp pain, early evaluation improves treatment options and long-term outcomes significantly.