Back heel pain — pain on the back of the heel, not the bottom — is most often insertional Achilles tendonitis, retrocalcaneal bursitis, or Haglund’s deformity. Each has its own fix.
You’ve come to the right podiatry team. Dr. Tom Biernacki, DPM, FACFAS — board-certified foot & ankle surgeon with 3,000+ surgeries — explains exactly what back of heel pain means and what works. Book online to book an appointment at Howell or Bloomfield Township — or call (810) 206-1402.
Pain at the back of the heel is most often insertional Achilles tendinopathy, retrocalcaneal bursitis, or a Haglund deformity (and Sever disease in active kids). The right treatment depends on the exact cause. Below we explain how to tell them apart and the options that actually help. Call (810) 206-1402.
Quick Answer
Back of heel pain is most commonly caused by insertional Achilles tendonitis (where the tendon attaches to the heel bone), Haglund’s deformity (“pump bump” — bony enlargement of the heel), and retrocalcaneal bursitis (inflamed fluid sac between Achilles and heel bone). Less common causes include calcaneal stress fracture, Sever’s disease in kids, and rheumatoid enthesitis. Treatment depends on the cause — most cases respond to heel lifts, eccentric exercises, and supportive footwear within 8-12 weeks.
9 Most Common Causes of Back of Heel Pain
1. Insertional Achilles Tendonitis
The most common cause — chronic micro-tears where the Achilles tendon inserts into the calcaneus (heel bone). Pain is at the very back of the heel, worse with first steps in morning, and tender to touch. Treatment: supportive shoes with 8-12mm heel drop, eccentric heel raises, heel lifts.
2. Haglund’s Deformity (“Pump Bump”)
A bony enlargement of the back of the heel bone that rubs against shoe heel counters. Often visible as a hard bump. Treatment: shoe modification (open-back shoes), heel pads, ice. Surgery only for chronic cases.
3. Retrocalcaneal Bursitis
Inflammation of the fluid sac (bursa) between the Achilles tendon and the heel bone. Often coexists with Haglund’s. Treatment: ice, NSAIDs, ultrasound therapy and heel lifts. We don’t inject cortisone at the back of the heel: so close to the Achilles, it can weaken the tendon and raise the risk of rupture.
4. Calcaneal Stress Fracture
Hairline fracture of the heel bone, usually from running or military training. Pain with weight-bearing, worse with jumping. Diagnosis requires MRI (X-ray often misses early). Treatment: 6-8 weeks in a CAM walker boot.
5. Sever’s Disease (children/teens)
Growth plate inflammation in active kids ages 8-15. Self-limiting once growth plate closes. Treatment: heel cups, cushioned shoes, activity modification.
6. Plantar Fasciitis (Posterior Variant)
Less common variant where pain is at the back of the heel rather than under it. Same fascial inflammation, different presentation. Treatment same as classic plantar fasciitis.
7. Tarsal Tunnel Syndrome
Compression of the posterior tibial nerve causes burning pain that can radiate to the back and bottom of the heel. Treatment: nerve gliding exercises, supportive footwear, occasional surgical release.
8. Inflammatory Arthritis (Rheumatoid, Psoriatic)
Autoimmune conditions cause enthesitis at the Achilles insertion. Often bilateral. Requires rheumatology workup and disease-modifying treatment.
9. Achilles Tendon Rupture (acute)
Sudden severe pain like being kicked in the back of the heel, often during sports. Inability to push off. Emergency — needs immediate evaluation.
Not sure which one you have? Dr. Tom’s one-minute heel pain quiz sorts out whether it’s your Achilles, a bump or a bursa in four questions, starting with the signs that mean you should be seen today. Take the heel pain quiz.
At-Home Treatment Tools That Actually Work
- Heel cups / pads — silicone heel cups (e.g., Tuli’s Cheetahs) absorb impact and elevate the heel slightly to offload Achilles. Available on Amazon.
- Achilles tendon brace — Bauerfeind AchilloTrain or similar for daytime support.
- Strassburg Sock — overnight stretch device that prevents morning stiffness.
- Eccentric heel raises — 3 sets of 15, twice daily. The single most effective Achilles exercise per research.
- Foam roller / massage gun — calf release reduces tension on the Achilles insertion.
When to See a Podiatrist (Red Flags)
- Pain longer than 4-6 weeks despite home treatment
- Sharp pain with sudden onset (rule out rupture or stress fracture)
- Visible deformity or swelling that doesn’t resolve
- Pain that wakes you at night
- Bilateral heel pain (rule out inflammatory arthritis)
Schedule an evaluation: Howell or Bloomfield Township · (810) 206-1402 · Book online
✅ Medically Reviewed by Dr. Tom Biernacki, DPM
Board-certified podiatric physician & surgeon | Balance Foot & Ankle | Updated April 2026
Watch: Dr. Tom Biernacki, DPM
What Causes Pain in the Back of the Heel?
The back of the heel is one of the highest-load regions in the entire lower extremity. The Achilles tendon — the largest and strongest tendon in the body — inserts here, transferring enormous forces from the calf muscles to the heel bone (calcaneus) with every step. When patients present with posterior heel pain, we systematically work through the most common diagnoses, because treatment differs significantly between them.
1. Achilles Tendonitis (Midportion)
Midportion Achilles tendonitis is inflammation or degeneration of the Achilles tendon 2–6 cm above the heel bone insertion — the classic “runner’s heel.” It develops from repetitive overloading: sudden increases in training mileage, insufficient recovery time, worn-out shoe cushioning, or calf muscle tightness that increases tension on the tendon.
Key signs: Tender, thickened segment of the tendon in the mid-portion (not at the heel bone), morning stiffness that warms up with activity, and pain that returns after activity. The tendon may feel “crunchy” or nodular to touch.
2. Insertional Achilles Tendinopathy
Insertional tendinopathy affects the point where the Achilles attaches to the heel bone. Unlike midportion Achilles issues, insertional disease involves calcification and bony changes at the attachment site. It’s more common in older, heavier, or less active patients. Standard eccentric calf exercises — effective for midportion tendonitis — often aggravate insertional disease and should be modified.
Key signs: Pain and tenderness directly at the back of the heel bone (not in the tendon belly), a visible or palpable bony prominence at the insertion, and pain with direct pressure from shoe counters. X-ray often shows calcification at the attachment.
3. Haglund’s Deformity (Pump Bump)
A Haglund’s deformity is an abnormal bony enlargement of the posterior-superior calcaneus — the upper back corner of the heel bone. It develops from a combination of genetics (high-arched, rigid foot) and shoe friction from stiff heel counters. Women who wear pumps frequently are disproportionately affected, giving rise to the term “pump bump.”
Key signs: A prominent bony bump at the upper back of the heel, redness and skin thickening overlying the bump, and severe pain with shoe wear. Pain is typically localized to the superficial bony prominence rather than the tendon itself.
4. Retrocalcaneal Bursitis
A small bursa (fluid-filled sac) sits between the Achilles tendon and the calcaneus, cushioning the tendon as it moves. Retrocalcaneal bursitis is inflammation of this bursa, often occurring alongside Haglund’s deformity or insertional tendinopathy. It presents as swelling on either side of the Achilles just above the heel bone, and is tender to lateral and medial compression at this level.
• A sudden “pop” in the back of the heel with inability to push up on your toes — possible Achilles rupture
• Severe swelling and bruising after an acute injury
• Pain so severe you cannot bear weight
• Numbness or weakness in the foot alongside heel pain
• Symptoms that are worsening despite 3–4 weeks of rest
How Is Back of Heel Pain Diagnosed?
Accurate diagnosis requires hands-on evaluation. In our clinic, we use a combination of physical examination (palpation of the tendon, squeeze test for bursitis, Thompson test for rupture), weight-bearing X-rays to assess bony pathology, and diagnostic ultrasound to evaluate tendon integrity and bursa fluid. MRI is reserved for cases where ultrasound is inconclusive or surgical planning is needed.
The distinction between midportion and insertional Achilles disease is clinically significant — the two conditions require different treatment protocols, and confusing them leads to prolonged recovery.
Treatment for Back of Heel Pain
For midportion Achilles tendonitis: The Alfredson eccentric calf raise protocol is the gold standard — 3 sets of 15 reps, twice daily, for 12 weeks. Heel lifts (1–2 cm) reduce tendon load during healing. Physical therapy, shockwave therapy (ESWT) for chronic cases, and activity modification are the mainstays. Most patients see significant improvement by 8–12 weeks.
For insertional Achilles tendinopathy: Eccentric exercises must be modified — perform them only to the horizontal (not below), avoiding the range that compresses the insertion. Heel lifts, cushioned heel counters, night splinting, and extracorporeal shockwave therapy (ESWT) are effective. Platelet-rich plasma (PRP) injection is an option for refractory cases. Surgery is reserved for calcific disease unresponsive to 6+ months of conservative care.
For Haglund’s deformity: Conservative management focuses on eliminating friction — open-back shoes, heel lifts to shift the calcaneus forward, and custom orthotics to unload the posterior heel. Surgical resection of the bony prominence is very effective when conservative care fails and delivers lasting relief.
For retrocalcaneal bursitis: Ice, NSAIDs, and heel lifts are first-line. We don’t use cortisone injections here, even into the bursa: it sits right against the Achilles, and steroid that reaches the tendon can weaken it and raise the risk of rupture.
Recommended Products for Back of Heel Pain
If home care isn’t resolving your heel pain, a visit with a board-certified podiatrist is the fastest path to accurate diagnosis and a personalized plan. At Balance Foot & Ankle Specialists, Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin offer appointments at both our Howell and Bloomfield Township offices. We perform on-site diagnostic ultrasound, digital X-ray, conservative care, advanced regenerative treatments, and minimally invasive surgery when indicated.
Call (810) 206-1402 or request an appointment online. Most insurance plans accepted, including Medicare, Blue Cross Blue Shield, Aetna, Cigna, and United Healthcare.
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Frequently Asked Questions
Is back of heel pain the same as plantar fasciitis?
No — they are distinct conditions affecting different anatomical structures. Plantar fasciitis causes pain on the bottom of the heel (inferior calcaneus), typically worst with the first steps of the morning. Back of heel pain affects the posterior calcaneus and Achilles insertion. Treatment protocols differ significantly, which is why accurate diagnosis matters.
How long does back of heel pain take to heal?
Acute Achilles tendonitis in active patients: 6–8 weeks with a structured eccentric loading protocol. Chronic insertional tendinopathy or Haglund’s deformity: 3–6 months of consistent conservative care, with some patients requiring shockwave therapy or surgery. Early diagnosis and appropriate treatment dramatically shortens recovery time.
Can I run with back of heel pain?
For mild Achilles tendonitis, modified running (reduced volume, softer surfaces, slower pace) is generally acceptable as long as pain during and 24 hours after running stays below 4/10. For insertional disease, bursitis, or Haglund’s deformity with significant pain, a temporary running hiatus (2–4 weeks) while initiating a rehabilitation program produces better long-term outcomes than running through it.
The Bottom Line
Back of heel pain has four main causes — Achilles tendonitis (midportion), insertional tendinopathy, Haglund’s deformity, and retrocalcaneal bursitis — each with its own treatment approach. Getting the diagnosis right from the start is the single most important factor in a fast, complete recovery. Most patients do not need surgery. With the right protocol started early, 80–90% of posterior heel pain cases resolve with conservative care.
Pain at the back of the heel splits into two problems that want different exercise: one sits in the cord of the tendon, the other right on the bone. Midportion versus insertional Achilles tendonitis explains how to tell which you have, and why the standard heel-drop off a step is the wrong advice for one of them.
Get Expert Care at Balance Foot & Ankle
Appointments at our Howell and Bloomfield Township offices. Board-certified podiatric surgeons. Most insurance accepted.
Dr. Tom Biernacki, DPM is a board-certified foot & ankle surgeon (ABFAS & ABPM) at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has made him one of the most-followed foot & ankle educators on YouTube.
More questions patients ask
What causes heel pain?
Heel pain most commonly results from plantar fasciitis, accounting for ~80% of cases. Other causes include Achilles tendinitis, heel spurs, stress fractures, and Baxter's nerve entrapment. Dr. Biernacki performs thorough biomechanical evaluations. Call 810-206-1402 to book an appointment.
How long does plantar fasciitis take to heal?
With proper treatment, most cases improve within 6-12 weeks. Options include custom orthotics, stretching, physical therapy, and injections. For persistent cases, Dr. Biernacki offers shockwave therapy and minimally invasive procedures.
Should I see a podiatrist for heel pain?
Yes. A board-certified podiatrist can accurately diagnose heel pain using X-rays and diagnostic ultrasound, ruling out stress fractures. Early intervention leads to faster recovery. Call 810-206-1402.
More Plantar Fasciitis Guides from Dr. Tom
Pediatric Heel Pain: Sever’s Disease, Differential Diagnosis, and Management in Growing Athletes
Ankle Equinus: How Gastrocnemius Tightness Drives Plantar Fasciitis, Flatfoot, and Forefoot Pain
Calcaneal Apophysitis vs. Achilles Insertional Tendinopathy: Overlapping Posterior Heel Pain in Adults
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