Pain at the back of the heel most commonly comes from irritation of the Achilles tendon where it connects to the heel bone, inflammation of a small fluid-filled sac (bursa) behind the heel, or a bony bump that rubs against your shoe. Less commonly in adults, it can signal a stress fracture or, in children, a growth-plate issue. The location, timing, and quality of the pain can help you narrow down what’s going on.
Achilles Tendon Problems
The Achilles tendon runs down the back of your lower leg and attaches to your heel bone. When this tendon gets overworked or degenerates over time, you feel pain right at the back of your heel or a few inches above it. This is the single most common reason for posterior heel pain in adults, and it comes in two distinct forms depending on exactly where the damage sits.
Insertional tendinopathy affects the spot where the tendon meets the heel bone. It tends to show up in more physically active people and can involve calcium deposits or bone spurs at the attachment point. You’ll feel pain right at the base of the tendon, especially when pressing on the back of the heel or pushing off during walking and running. Non-insertional tendinopathy hits the middle portion of the tendon, roughly 2 to 6 centimeters above the heel bone. This type is more common in older, less active, or overweight individuals, and the tendon itself may feel thickened or tender when you squeeze it between your fingers.
Both types tend to feel worst first thing in the morning or after sitting for a long time, then improve slightly with gentle movement before worsening again with sustained activity. Stiffness that loosens up within the first few minutes of walking is a hallmark sign.
Bursitis Behind the Heel
Tucked between the Achilles tendon and the heel bone is a small bursa, a cushioning sac that reduces friction. When this sac gets inflamed, a condition called retrocalcaneal bursitis, you get a deep, achy pain at the back of the heel that can appear with visible swelling on the sides of the tendon. A second, more superficial bursa sits between the tendon and the skin, and when that one flares up, you may notice a tender, puffy area right at the surface of the heel.
Bursitis often coexists with Achilles tendon problems, so the two can be hard to tell apart without imaging. A key difference: bursitis pain tends to be more localized to one spot and may worsen with direct pressure (like the back of a shoe pressing into the heel) rather than with the pulling force of pushing off your toes.
Haglund’s Deformity (Pump Bump)
If you can see or feel a hard, bony bump on the back of your heel, you may have a Haglund’s deformity. This is an enlargement of the bone at the back of the heel that creates a visible prominence. It earned the nickname “pump bump” because rigid-backed shoes like pumps and dress shoes press directly against it, causing pain, redness, and swelling over the bump.
Haglund’s deformity is especially common in people who regularly wear tight, narrow shoes with stiff heel counters. The bump itself isn’t dangerous, but the constant friction can irritate the overlying skin and the bursa beneath it, triggering a cycle of inflammation. Switching to shoes with a soft or open back, or using heel pads to shift pressure away from the bump, often provides significant relief.
Sever’s Disease in Children and Teens
If the person with heel pain is between 8 and 15 years old, there’s a strong chance the culprit is Sever’s disease. This is not actually a disease but an inflammation of the growth plate in the heel bone. It shows up during growth spurts, typically around age 12 in boys and 11 in girls, and is especially common in kids who run and jump in sports like soccer, basketball, and gymnastics.
The classic pattern is heel pain that starts during or after activity and goes away completely with rest. It can affect one heel or both. Sever’s disease resolves on its own once the growth plate fully hardens, but managing activity levels and using cushioned heel inserts can keep kids comfortable in the meantime.
How to Tell These Conditions Apart
- Pain right where the tendon meets the bone, worse with morning stiffness and activity: likely insertional Achilles tendinopathy.
- Pain a few inches above the heel bone, in the thickened middle of the tendon: likely non-insertional Achilles tendinopathy.
- Deep pain with swelling on either side of the tendon, worse when shoes press against the heel: likely bursitis.
- A visible bony bump that gets red and irritated in certain shoes: likely Haglund’s deformity.
- A child or teen with activity-related heel pain that disappears with rest: likely Sever’s disease.
What Helps Posterior Heel Pain
Most causes of back-of-the-heel pain respond well to conservative measures, especially when you catch them early. The basics work: reducing the activities that provoke pain, icing the area for 15 to 20 minutes after activity, and wearing shoes with a slight heel lift and a soft, flexible heel counter that doesn’t dig into the back of the foot. Heel insoles or orthotic inserts can correct alignment issues that put extra stress on the tendon and heel bone.
For Achilles tendon problems specifically, eccentric exercises (slowly lowering your heel off the edge of a step) are the most well-studied rehabilitation tool. The original protocol that became the standard calls for 3 sets of 15 repetitions, performed twice a day, seven days a week, for 12 weeks. That’s a significant commitment, and the exercises may feel uncomfortable at first, which is expected. Other approaches use 3 sets of 10 repetitions once daily, combined with stretching before and after. The key across all programs is consistency over weeks, not days. You won’t feel improvement in a few sessions, but most people notice meaningful progress within 6 to 12 weeks.
For bursitis and Haglund’s deformity, the priority is removing the source of irritation. Open-backed shoes, moleskin padding over the bump, and temporarily switching to softer footwear can break the cycle of inflammation. Stretching the calf muscles also helps by reducing tension on the structures at the back of the heel.
When Pain Persists
If your heel pain hasn’t improved after 6 to 8 weeks of consistent home treatment, or if it’s getting worse, imaging can help clarify the diagnosis. Ultrasound is a quick, accessible option that can show tendon thickening, bursal inflammation, and bony spurs in real time. MRI provides a more detailed picture and is better at identifying bone swelling, partial tendon tears, and stress fractures that ultrasound might miss.
Sudden, sharp pain at the back of the heel, especially if accompanied by a popping sensation and difficulty pushing off your toes, is a different situation entirely. That pattern suggests a possible Achilles tendon rupture, which needs prompt medical evaluation. Similarly, heel pain accompanied by significant swelling, warmth, and redness that doesn’t track with activity levels could point to an infection or inflammatory condition that warrants further workup.