Soreness at the back of your heel usually comes from irritation of the Achilles tendon, the fluid-filled cushion (bursa) next to it, or the heel bone itself. These three structures sit within millimeters of each other, and problems in one often trigger problems in the others. The good news is that most causes are mechanical, not dangerous, and respond well to straightforward treatment.
The Three Main Culprits
Massachusetts General Hospital identifies a “terrible triad” behind posterior heel pain: insertional Achilles tendonitis, retrocalcaneal bursitis, and Haglund’s deformity. You can have one, two, or all three at the same time, which is why back-of-the-heel pain can feel complicated. Each condition has a slightly different signature, but they overlap enough that many people can’t tell exactly which structure is causing the problem without a clinical exam.
Insertional Achilles Tendonitis
Your Achilles tendon connects your calf muscle to your heel bone. Insertional tendonitis happens right at that connection point, the lowest part of the tendon. Years of repetitive loading cause microscopic wear and tear in the tendon fibers where they anchor into bone. The body responds with inflammation, and you feel a deep ache or sharp pain right at the back of your heel. Over time, calcium deposits can form inside the damaged tendon, sometimes creating small bone-like spurs you can feel through the skin.
This is different from the type of Achilles tendonitis that hits runners in the middle of the tendon, a few inches above the heel. That mid-portion version tends to affect younger, active people. Insertional tendonitis can strike at any age and any activity level, though tight calf muscles are a consistent driver because they put extra stress on the attachment point. If your heel hurts most when you first stand up in the morning or after sitting for a while, this is a likely explanation.
Retrocalcaneal Bursitis
A bursa is a small, fluid-filled sac that reduces friction between moving parts. The retrocalcaneal bursa sits between the back of your heel bone and the Achilles tendon, letting the tendon glide smoothly. When the heel bone is slightly enlarged or when repetitive pressure irritates the area, this bursa swells. The result is tenderness right at the back of the heel, sometimes with visible puffiness, warmth, or a change in skin color. Standing on your toes typically makes it worse because the motion compresses the inflamed bursa.
There’s also a second, less common type called subcutaneous calcaneal bursitis, where the inflamed bursa sits between the skin and the tendon rather than between the tendon and bone. This version is more directly caused by shoe pressure and tends to be tender right at the surface.
Haglund’s Deformity (Pump Bump)
Haglund’s deformity is a bony enlargement on the back of the heel bone, right where the Achilles tendon attaches. It develops gradually over years and creates a visible, hard bump you can see and feel through your skin. The bump itself isn’t always painful, but it irritates the nearby bursa and tendon, setting off a chain reaction of inflammation.
It’s nicknamed “pump bump” because rigid-backed shoes like pumps and high heels press directly against the growth. Tight, narrow shoes are a major aggravating factor. Haglund’s deformity almost always develops on both feet, so if you notice a matching bump on your other heel, that’s a strong clue. Avoiding shoes with stiff backs is the single most effective way to keep symptoms from flaring.
Sever’s Disease in Kids and Teens
If your child is complaining about heel pain, the most likely cause is Sever’s disease, a growth-plate irritation at the back of the heel bone. Girls typically develop it between ages 8 and 10, boys between 10 and 12. By age 15, the growth plate has fused and the condition resolves on its own. Active kids, especially those in running or jumping sports, are most affected. A physical exam and health history are usually enough to confirm it, with no imaging needed in most cases.
What a Full Achilles Rupture Feels Like
A complete Achilles tendon tear is far less common than tendonitis, but it’s worth knowing the difference. A rupture usually happens during a sudden push-off movement, like sprinting or jumping. People describe hearing a pop and feeling as though someone kicked them in the heel. The pain is sudden and severe, and you’ll have difficulty pointing your foot downward or pushing off to walk. If this sounds like your situation, you need prompt medical evaluation. Clinicians use a simple physical test where they squeeze your calf while you lie face down: if your foot doesn’t move, the tendon is likely torn.
Home Treatment That Actually Works
Most posterior heel pain improves without surgery. The cornerstone of treatment is eccentric calf exercises, where you slowly lower your heel below the level of a step. Research shows this approach produces meaningful improvement in 50% to 60% of patients, with most programs running for 12 weeks. Some people notice gains as early as three weeks. The technique matters more than the effort: controlled, slow lowering is the key, not aggressive stretching.
Heel lifts placed inside your shoes reduce the tension on the Achilles tendon by slightly raising the heel. Heights between 7.5 and 15 millimeters are commonly recommended, roughly the thickness of a few stacked coins. They’re inexpensive, available at most pharmacies, and can provide noticeable relief within days. Combining heel lifts with open-backed or soft-backed shoes takes pressure off both the tendon and any bony prominence.
Ice applied to the back of the heel for 15 to 20 minutes after activity helps control inflammation. Reducing your training volume temporarily, rather than stopping entirely, lets the tendon recover without losing fitness. Complete rest can actually weaken the tendon further.
When Simpler Measures Aren’t Enough
For pain that persists beyond three to six months of consistent home treatment, shockwave therapy is an option with solid evidence behind it. The procedure uses focused pressure waves to stimulate healing in chronically damaged tendon tissue. Reviews of the research confirm its effectiveness for stubborn Achilles tendon problems, and sessions are performed without local anesthesia. It’s typically offered as a series of treatments spaced a week or two apart.
Surgery is reserved for cases where conservative treatment fails entirely, usually after at least six months of dedicated effort. Procedures range from removing the inflamed bursa or shaving down a Haglund’s bump to detaching and reattaching the Achilles tendon after removing damaged tissue and bone spurs. Recovery from surgical repair takes several months and involves a period of immobilization followed by gradual rehabilitation.
Clues That Point to Each Condition
- Pain right at the bone, worse in stiff shoes: likely Haglund’s deformity or bursitis
- Stiffness first thing in the morning that loosens with walking: typical of insertional Achilles tendonitis
- Visible swelling or warmth behind the heel: suggests bursitis
- A hard bump you can see on both heels: characteristic of Haglund’s deformity
- Pain that increases when rising onto your toes: points to bursitis or tendonitis
- Sudden onset during explosive movement with a popping sensation: possible Achilles rupture
Because these conditions frequently coexist, your pain may match more than one pattern. That’s normal and doesn’t change the initial approach: reduce irritation from footwear, start eccentric exercises, use heel lifts, and give the area 12 weeks of consistent effort before considering more aggressive options.