Pain at the back of the heel usually comes from one of three conditions: Achilles tendonitis at its attachment point, an inflamed fluid sac behind the heel bone, or a bony bump that develops gradually over years. These three problems are so closely linked that orthopedic specialists refer to them as the “terrible triad” of posterior heel pain, since they often show up together. The good news is that most causes respond well to conservative treatment, and understanding which one you’re dealing with helps you manage it faster.
The Three Most Common Causes
Your Achilles tendon connects your calf muscle to your heel bone. Over time, repetitive stress from walking, running, or even standing for long periods causes wear and tear right where the tendon attaches. This is called insertional Achilles tendonitis, and it’s the most frequent reason for pain at the back of the heel. The degeneration triggers inflammation and, eventually, can produce small calcified fragments within the tendon itself. You’ll typically feel it as a deep ache or stiffness right at the base of the heel, often worse first thing in the morning or after sitting for a while.
Sitting just between the Achilles tendon and the heel bone is a small fluid-filled sac called a bursa. Its job is to let the tendon glide smoothly over bone. When the heel bone enlarges or the area gets irritated, that bursa swells and becomes intensely tender. This is retrocalcaneal bursitis, and it can create a visible bump at the back of the heel sometimes called a “pump bump” because rigid shoe backs press directly on it.
The third piece is a Haglund’s deformity: a bony prominence that forms gradually on the upper part of the heel bone. It develops over many years, and once it’s large enough, it irritates both the bursa and the tendon. If you can see or feel a hard bump at the back of your heel that seems to have grown over time, this is likely part of the picture.
Midportion vs. Insertional Tendon Pain
Not all Achilles tendon pain hits the same spot. If the soreness is a few inches above your heel, in the middle of the tendon, that’s midportion tendinopathy. It’s the more common form overall. Pain right where the tendon meets the heel bone is the insertional type, and it behaves differently. Insertional tendinopathy is more likely to involve bursitis, calcification, or a Haglund’s deformity alongside it. It’s also more common in men over 60, though younger, active people get it too.
This distinction matters for treatment. Midportion tendon pain responds well to standard eccentric exercises (lowering your heel off a step edge under load). Insertional pain often needs a modified version of those same exercises because the full stretch at the bottom of the movement can compress the already-irritated attachment point. If stretching off a step edge makes your pain worse, that’s a clue you’re dealing with insertional tendinopathy rather than midportion.
Less Common but Important Causes
A calcaneal stress fracture can mimic tendon or bursa problems but feels different on examination. Instead of pinpoint tenderness at the tendon attachment, the pain is more diffuse across the whole heel and usually develops gradually over days to weeks. A classic screening method is the squeeze test: if squeezing both sides of the heel bone with your hands reproduces the pain, a stress fracture is more likely than a soft tissue problem. This is more common in runners who have recently increased their mileage or people with lower bone density.
An Achilles tendon rupture is the scenario you don’t want to miss. It typically happens during sudden, explosive activity: a hard push-off in basketball, a sprint start, or a jump. You’ll hear or feel a distinct pop at the back of the ankle, followed by sharp pain and difficulty walking. Unlike tendonitis, which builds gradually, a rupture is a single, unmistakable event. If this sounds like what happened to you, you need a medical evaluation promptly.
When It Happens in Kids and Teens
Children and adolescents get posterior heel pain for an entirely different reason. The heel bone has a growth plate at the back where the Achilles tendon attaches, and in growing kids, that cartilage is weaker than the surrounding tendons and ligaments. Repetitive running and jumping stresses this growth plate, causing inflammation. This is Sever’s disease (calcaneal apophysitis), and it’s one of the most common causes of heel pain in young athletes.
It shows up most often during growth spurts, when bones are changing faster than soft tissues can keep up. The Achilles tendon pulls on its attachment point with each stride, and the immature growth plate takes the brunt. The reassuring part: Sever’s disease resolves completely once the growth plate matures into solid bone. It won’t cause lasting damage, though activity modification and rest are needed in the short term to manage pain.
What You Can Do at Home
The cornerstone of recovery for most posterior heel pain is a structured loading program. This means gradually strengthening the tendon and calf through progressive heel raises rather than simply resting and waiting. A well-studied protocol works in phases:
- Weeks 1 to 2: Two-legged heel raises on flat ground (3 sets of 10 to 15 reps), progressing to single-leg raises (3 sets of 10), plus gentle eccentric lowering on flat ground.
- Weeks 2 to 5: Heel raises on the edge of a stair (3 sets of 15), both two-legged and single-leg, with eccentric lowering off the stair edge. Quick rebounding heel raises (3 sets of 20) are added here.
- Weeks 3 to 12: Single-leg heel raises off a stair with added weight in a backpack (3 sets of 15), gradually increasing the load as pain allows.
The key principle is that some discomfort during exercise is acceptable, but sharp or worsening pain means you’ve progressed too fast. For insertional tendinopathy specifically, avoid dropping your heel below the level of the stair step. Doing raises on flat ground or only lowering to neutral keeps you from compressing the irritated attachment point.
Ice after activity, reducing your training volume temporarily, and wearing shoes with a slight heel elevation all help in the early stages. A simple heel lift insert (even a few millimeters) reduces tension on the Achilles tendon by shortening the distance the calf muscle has to stretch. Research suggests that expensive custom orthotics may not outperform a basic heel lift for this specific problem, since any benefit from an orthotic likely comes from the heel elevation itself rather than arch correction.
When Home Treatment Isn’t Enough
Most people see meaningful improvement within 6 to 12 weeks of consistent loading exercises. If you’ve done the work and the pain hasn’t budged, shockwave therapy is a well-supported next step. This involves a handheld device that delivers focused pressure waves to the painful area, stimulating blood flow and tissue repair. It’s typically given as 3 sessions spaced a week or two apart, and clinics that specialize in heel pain report success rates of 75 to 80 percent.
For cases involving a large Haglund’s deformity or significant tendon calcification that hasn’t responded to months of conservative care, surgical options exist to remove the bony prominence and repair the tendon attachment. Recovery from these procedures takes several months, so they’re generally reserved for people who have exhausted other approaches. The vast majority of posterior heel pain, though, resolves without surgery if you give the loading program enough time and consistency.