Why Does the Back of My Heel Hurt When I Walk?

Pain at the back of the heel during walking most often traces to a problem with the Achilles tendon or the structures immediately surrounding it, though the specific culprit can range from tendon overuse to a bony bump on the heel bone to inflammation driven by an autoimmune condition. The Achilles tendon is the thickest and strongest tendon in the body, and the spot where it meets the heel bone absorbs enormous force with every step, making it a common site for trouble. Sorting out which structure is actually hurting matters, because treatments that help one cause can be useless or even harmful for another.

Insertional Versus Midportion Tendinopathy

Achilles tendinopathy is split into two broad types based on where along the tendon the problem sits. Insertional tendinopathy affects the lowest portion, right where the tendon anchors into the heel bone. Noninsertional, or midportion, tendinopathy strikes higher up, usually a few centimeters above the heel.¹ The distinction is not just academic. Insertional tendinopathy tends to be more stubborn and is the type most likely to cause pain exactly at the back of the heel when you push off during walking. It often involves some combination of tendon degeneration, calcification at the attachment site, and irritation of the nearby bursa. Midportion tendinopathy, by contrast, usually hurts a bit higher and responds somewhat differently to exercise programs.

Both types share a core feature: the tendon tissue is not acutely inflamed in the classic sense but has undergone structural changes. Collagen fibers become disorganized and the tissue loses its normal springy quality. This is why the word “tendinopathy” has largely replaced “tendinitis” in clinical circles. The pain you feel is less about active swelling and more about a tendon that has been slowly breaking down under repetitive load.

Retrocalcaneal Bursitis

Tucked between the Achilles tendon and the back of the heel bone sits a small, fluid-filled sac called the retrocalcaneal bursa. Its job is to reduce friction as the tendon glides over bone. When this bursa becomes inflamed and swollen, it produces a deep ache right at the back of the heel that can be hard to distinguish from tendon pain.² Squeezing the heel from both sides at the level of the tendon insertion often reproduces the pain, whereas pure tendon problems tend to hurt more when you pinch the tendon itself from front to back.

Bursitis in this spot rarely shows up alone. It frequently accompanies insertional tendinopathy or a bony prominence on the heel, and treating the bursa without addressing the underlying mechanical problem tends to produce only temporary relief.

Haglund’s Deformity and the “Pump Bump”

Some people have a naturally prominent ridge of bone on the back-upper corner of the heel bone. This bony enlargement, called Haglund’s deformity, presses into the Achilles tendon and retrocalcaneal bursa with every step. Pain is characteristically worse when you start walking after sitting or resting for a while.³ The nickname “pump bump” comes from the fact that rigid shoe heel counters, like those on classic women’s pumps, press against the prominence and aggravate it. Shoes with a stiff, unyielding back can impinge on the soft tissues overlying the bump and produce visible swelling and redness at the skin surface.⁴

Haglund’s is diagnosed on a lateral X-ray, where several angle measurements can confirm whether the bony prominence is large enough to be causing symptoms. In one study of symptomatic heels, the most reliable radiographic marker was a specific angle measurement at the back of the heel bone, which was positive in about three-quarters of cases.⁵ If your heel pain came on gradually and is worst when wearing closed-back shoes, Haglund’s is worth investigating.

The Role of Tight Calves

One of the strongest and most modifiable risk factors for posterior heel pain is tightness in the calf muscles, particularly the gastrocnemius (the larger, more superficial calf muscle). In a study of patients with plantar heel pain, the correlation between gastrocnemius tightness and pain severity was strong, both for the pain felt on first steps in the morning and for the worst pain of the previous week.⁶ A tight gastrocnemius limits how far the ankle can bend upward, which forces the Achilles tendon to work under greater strain during the push-off phase of walking.

People with heel pain also tend to have reduced ankle range of motion, weaker ankle muscles on the outer side of the foot, and weaker toe flexors compared to pain-free individuals.⁷ Higher body weight compounds the issue by adding more load per step. The practical takeaway is that calf stretching and ankle strengthening can address several of these factors at once and are worth trying early, before more invasive options.

When Heel Pain Points to Something Systemic

Posterior heel pain is not always a local mechanical problem. In inflammatory conditions like ankylosing spondylitis and psoriatic arthritis, the immune system attacks the spots where tendons and ligaments anchor into bone, a process called enthesitis. The Achilles insertion is one of the most commonly affected sites. In a registry of patients with ankylosing spondylitis, those who had Achilles enthesitis at baseline had significantly higher disease activity scores and worse function over two years of follow-up than those without it. Only about 16% of patients with Achilles enthesitis achieved low disease activity after two years, compared to roughly 32% of those without.⁸

MRI studies of patients with spondyloarthritis and clinical heel enthesitis confirm that the vast majority show structural damage or inflammation at the heel on imaging. In the ACHILLES trial, over 80% of patients with clinically diagnosed heel enthesitis had MRI-confirmed entheseal inflammation or structural damage at the Achilles or plantar fascia insertion.⁹ If your heel pain is accompanied by morning stiffness in your lower back, swelling in other joints, or alternating buttock pain, a rheumatologic workup is worth pursuing.

Nerve Entrapment Near the Heel

Nerve problems in the foot and ankle can mimic or coexist with tendon-related heel pain, and they are commonly missed. The sural nerve and its branches run near the back and outer side of the heel, and when these nerves become trapped or scarred, they can produce burning pain, tingling, or a deep ache that worsens with walking.¹⁰ In athletes with persistent posterior heel pain that does not respond to standard tendon treatments, surgical exploration has found perineural scarring, adhesions, and even small neuromas (nerve tissue overgrowths) around the lateral calcaneal branch of the sural nerve.¹¹

Nerve entrapment should be on the radar if your heel pain has a burning or electric quality, if it radiates along the outer edge of the foot, or if it has persisted for months despite diligent rehab for a presumed tendon problem.

Heel Pain in Children and Adolescents

When a child or teenager complains of pain at the back of the heel, the most likely diagnosis is Sever’s disease, also called calcaneal apophysitis. This is an overuse condition affecting the growth plate at the back of the heel bone, and it is one of the most common causes of heel pain in the pediatric population.¹² It typically strikes between ages eight and fourteen, during periods of rapid growth, and is especially common in kids who play running or jumping sports. The pain can be on one side or both.¹³

The reassuring news is that Sever’s disease resolves once the growth plate closes, and long-term complications are rare. Management revolves around activity modification, stretching, heel cups, and sometimes a short break from the aggravating sport. It does not require imaging in straightforward cases, though X-rays may be ordered to rule out other problems if the presentation is unusual.

Medications That Can Cause Posterior Heel Pain

A class of antibiotics called fluoroquinolones, which includes ciprofloxacin and levofloxacin, is well known to damage tendons. Fluoroquinolone-associated tendinopathy occurs in roughly two to six percent of patients taking these drugs, and the Achilles tendon is the target in up to 90% of cases.¹⁴ The risk climbs sharply in older adults and in anyone also taking oral corticosteroids. If you develop new posterior heel pain during or shortly after a course of these antibiotics, it should not be dismissed as a simple strain. Stopping the drug promptly and avoiding strenuous loading of the tendon can prevent progression to a full rupture.

Hormonal and Metabolic Influences

Estrogen appears to play a protective role in tendon health, and its decline around menopause may partly explain why tendon disorders become more common in women as they age. Research on the relationship between estrogen deficiency and tendon pathology is still limited, but there is growing interest in metabolic factors, including hormone levels, as contributors to tendon degeneration.¹⁵ Sex differences in muscle and tendon properties are thought to be related at least in part to differences in hormone activity. For postmenopausal women dealing with recurrent Achilles tendon problems, this is an area where clinical awareness is slowly catching up to the biology.

Exercise-Based Rehabilitation

Loading exercises remain the first-line treatment for Achilles tendinopathy, and the evidence here is encouraging. For years, eccentric exercises (slow lowering of the heel off a step) were considered the gold standard. A randomized controlled trial comparing eccentric training to heavy slow resistance training found that both approaches produced good, lasting results at one year. Patients doing heavy slow resistance tended to report greater satisfaction at the three-month mark, though the difference evened out by one year.¹⁶ A broader review of loading therapies concluded that there is no convincing evidence that eccentric exercises alone outperform other types of progressive loading.¹⁷

The practical message is that the specific type of loading matters less than the consistency and progressiveness of the program. If heel raises on a step bother you, calf raises with a barbell or leg press can work just as well. The key is gradually increasing the load over weeks and not abandoning the program because the first few sessions are uncomfortable. Some early soreness is expected and does not mean you are making things worse.

Heel Lifts and Orthotics

One of the simplest interventions for insertional Achilles pain is a heel lift placed inside your shoe. By slightly elevating the heel, these wedges reduce how much the ankle needs to bend upward during walking, which lowers the tension on the Achilles tendon. Biomechanical testing has confirmed that a 12-millimeter orthotic heel lift reduces the tensile load on the tendon during walking.¹⁸ In patients with insertional tendinopathy, fitting a heel lift produced an immediate and significant drop in pain during walking, and symptoms continued to improve over the following two weeks.¹⁹

Custom arch-support orthoses can achieve a similar reduction in tendon load, and in one trial comparing the two during running, both heel lifts and arch supports lowered Achilles tendon loading to a comparable degree.²⁰ Heel lifts are inexpensive, available over the counter, and easy to trial before committing to custom orthotics. They are especially useful as a bridge while you build strength through a rehab program.

Shockwave Therapy and Its Mixed Evidence

Extracorporeal shockwave therapy (ESWT), which delivers focused acoustic pulses to the affected tissue, has been marketed heavily for Achilles tendinopathy. The evidence, however, is mixed and depends on which type of tendinopathy you are treating. For insertional tendinopathy specifically, a systematic review with meta-analysis found no clinically meaningful benefit of shockwave therapy over sham treatment.²¹ An earlier systematic review of randomized trials reached a similar conclusion, finding that shockwave therapy added no value over standard care for insertional Achilles tendinopathy.²²

That said, one older controlled trial of high-energy shockwave therapy did report significant pain reductions compared to a control group at 12 months, with 83% of the shockwave group rated as having a successful outcome.²³ The conflicting results across studies likely reflect differences in energy levels, treatment protocols, and patient selection. If you are considering shockwave therapy, the weight of the current evidence suggests it should not be your first or only approach, particularly for insertional disease.

Corticosteroid Injections and the Rupture Risk

Corticosteroid injections near the Achilles tendon come with a unique caution that does not apply to most other injection sites. Corticosteroids can inhibit collagen production and damage the local blood supply within the tendon, potentially triggering a degenerative cascade that weakens the tendon over time.²⁴ The overall incidence of side effects from local corticosteroid injections is estimated at around one percent, and many of those side effects are temporary. But Achilles tendon rupture, while the subject of many case reports, remains difficult to quantify because rigorous comparative studies evaluating the risk have not been published.²⁵

When corticosteroid injections are used in this area, ultrasound guidance is considered important so that the needle can be directed precisely into the bursa and kept out of the tendon substance. The risk-benefit conversation here is different from, say, a cortisone shot into a shoulder bursa, and most clinicians treat the Achilles region with more conservatism.

When Surgery Becomes an Option

Surgery for posterior heel pain is reserved for cases that have failed months of structured conservative treatment. The most common procedures include removal of the bony prominence in Haglund’s deformity, debridement of damaged tendon tissue, and reattachment of the Achilles tendon when it has been significantly detached from the bone. Newer minimally invasive techniques, such as a dorsal closing wedge calcaneal osteotomy, aim to accomplish the same goals through smaller incisions, with the potential for faster recovery.²⁶ Recovery from any Achilles-area surgery tends to be slow, often requiring several months of protected weight-bearing and rehabilitation before returning to full activity. This prolonged timeline is one reason clinicians push hard to exhaust nonsurgical options first.

Why the Achilles Tendon Is So Vulnerable

Given how common Achilles problems are, it is reasonable to wonder why evolution left us with such a seemingly fragile structure. The Achilles tendon is believed to have developed around two million years ago as early humans shifted from a more arboreal lifestyle to long-distance walking and running on two legs. It acts as a spring and shock absorber, storing and releasing elastic energy with each stride, and it enabled early humans to cover the distances required for persistence hunting.²⁷ The paradox is that the same design that makes it the strongest tendon in the body, capable of handling loads several times your body weight, also concentrates enormous mechanical stress at a single narrow attachment point on the heel bone. Add modern factors like prolonged sitting, rigid footwear, and sudden spikes in training volume, and you have a tendon that evolved for steady endurance locomotion being asked to tolerate a very different pattern of use.