The most common reason the back of your heel hurts when you walk is a problem with the Achilles tendon, the thick band of tissue connecting your calf muscles to your heel bone. But several other conditions can cause pain in the same spot, including inflamed fluid-filled sacs, bony growths, and in children, growth plate irritation. Where exactly the pain hits, when it’s worst, and how it started can help you narrow down what’s going on.
Achilles Tendon Problems
Achilles tendinopathy is the single most common cause of posterior heel pain. It comes in two forms, and the distinction matters because they feel different and respond to different approaches.
Insertional tendinopathy affects the lowest part of the tendon, right where it anchors into the heel bone. The pain and tenderness concentrate within the bottom two centimeters of the tendon, and you’ll often see swelling or redness at the back of the heel. This type develops when the tendon’s internal structure breaks down over time: the normally parallel collagen fibers lose their alignment, fat infiltrates the tissue, and tiny new blood vessels grow into the damaged area. Bone spurs form at the attachment point in 65% to 80% of people with this condition, and larger spurs (averaging about 13 mm on the painful side versus 3.5 mm in pain-free heels) tend to cause more symptoms.
Midportion tendinopathy hits higher up, in the body of the tendon a few centimeters above the heel. You’ll feel a tender, sometimes thickened area in the tendon itself rather than at the bone.
Both types share a hallmark pattern: stiffness after sitting or sleeping that loosens up with movement, then pain that worsens with activity. Many people notice it most during the first steps of the morning or after getting up from a desk. The pain often limits work, exercise, and even shoe choices, since pressure on the back of the heel becomes uncomfortable.
Bursitis Behind the Heel
Tucked between your Achilles tendon and heel bone sits a small fluid-filled sac called the retrocalcaneal bursa. Its job is to reduce friction, but when it becomes inflamed, it produces a deep, achy pain at the back of the heel that can mimic tendon problems closely. Retrocalcaneal bursitis is actually the more common type of heel bursitis, and distinguishing it from Achilles tendinopathy sometimes requires an MRI because the pain location overlaps so much.
One clue: bursitis pain often feels deepest when you squeeze both sides of the heel at the tendon’s base, rather than pressing directly on the tendon. Swelling may spread to either side of the tendon rather than sitting right on top of it.
Haglund’s Deformity (Pump Bump)
Some people have a bony enlargement on the back of the heel bone itself, right where the Achilles tendon attaches. This growth, called a Haglund’s deformity, creates a visible bump you can see and feel through the skin. It earned the nickname “pump bump” because rigid-backed shoes like pumps press directly against it, but any shoe with a stiff heel counter can trigger pain.
The bump itself isn’t always the problem. It becomes painful when it irritates the overlying tendon or compresses the retrocalcaneal bursa, so Haglund’s deformity, bursitis, and insertional tendinopathy frequently coexist. If you notice a hard bump on the back of your heel and your pain gets dramatically worse in certain shoes, this is worth investigating.
Sever’s Disease in Kids and Teens
If your child is complaining about heel pain, the most likely explanation is Sever’s disease, which is not actually a disease but inflammation of the heel bone’s growth plate. It’s extremely common between ages 8 and 14, when growth spurts happen fastest. During these spurts, bones can outpace tendons, leaving the Achilles tendon tight and pulling on the heel bone with each step. Contributing factors include flat feet and carrying extra weight.
Diagnosis is straightforward. A doctor applies gentle pressure to different parts of the heel and may ask the child to walk, run, or jump. Imaging is typically only used to rule out other problems. The condition resolves on its own once the growth plate matures and fuses, though managing activity levels and pain in the meantime matters.
How Walking Patterns Play a Role
The way your foot hits the ground directly affects how much stress reaches the back of your heel. When posterior heel pain develops, your gait changes in measurable ways. Research shows that people with heel pain reduce the force and time their rearfoot spends bearing weight during the initial landing phase of each step. To compensate, the midfoot and forefoot pick up more of the load, contact time increases, and the normal rhythm of weight transfer through the step gets delayed.
These compensations are your body’s attempt to protect the painful area, but they can create secondary problems in the midfoot, forefoot, or even the knees and hips over time. That’s one reason addressing heel pain early, rather than simply limping through it, pays off.
Shoes That Help (and Hurt)
Footwear choices can make posterior heel pain significantly better or worse. For Achilles-related problems, a higher heel-to-toe drop of 9 mm or more shifts some mechanical load away from the tendon and toward the muscles higher in the leg. Shoes with a rocker-shaped sole reduce the force your Achilles tendon has to generate during push-off by about 13%, both when walking and running.
Look for shoes with good cushioning, a firm midsole, and a stiff heel counter that holds your heel steady without pressing into a tender bump. Avoid flat, minimalist shoes if your Achilles is irritated. Switching abruptly from cushioned shoes to barefoot-style footwear increases the tendon’s workload and can trigger or worsen tendinopathy. For Haglund’s deformity specifically, the priority is avoiding any shoe with a rigid back that presses against the bump. Open-backed shoes, soft heel collars, or padding around the area all help.
Exercises That Build Tendon Strength
The most studied rehabilitation exercise for Achilles tendinopathy is the eccentric heel drop, often called the Alfredson protocol. You stand on the edge of a step, rise onto your toes using both feet, then slowly lower your heel below the step level using only the affected leg. The full program calls for 180 repetitions per day (split into sets) for 12 weeks. That’s a significant time commitment, but five-year follow-up data shows it produces lasting results for midportion tendinopathy.
The exercise works by progressively loading the tendon under controlled lengthening, which stimulates the collagen fibers to reorganize and strengthen. It should produce mild discomfort during the exercise but not sharp pain. For insertional tendinopathy, the protocol is sometimes modified to avoid dropping the heel below the step level, since that position can compress the tendon against the heel bone and worsen symptoms.
Recovery Timelines
Mild to moderate Achilles tendinopathy typically improves with a period of relative rest, activity modification, and progressive loading exercises. Doctors may recommend immobilizing the ankle for two to three weeks after diagnosis to calm acute inflammation before starting rehabilitation. From there, recovery takes weeks to months depending on severity, with the 12-week eccentric exercise protocol serving as a rough timeline for when meaningful improvement often occurs.
Bursitis and Haglund’s-related pain usually improve once the mechanical irritant is addressed, whether that’s a shoe change, padding, or reduced activity. More severe or longstanding cases may need additional interventions.
Signs of Something More Serious
Most posterior heel pain is a gradual-onset overuse problem, but a sudden pop or snap at the back of the ankle during intense activity is a red flag for an Achilles tendon rupture. The pain is immediate and sharp, and you’ll have difficulty walking afterward. A simple clinical test involves lying face down with your feet hanging off the table while someone squeezes your calf muscle. Normally this makes the foot point downward. If the foot doesn’t move, the tendon may be torn, and that needs prompt medical attention. Complete ruptures typically require 12 weeks or more of immobilization.