Pain at the back of your heel usually comes from one of three closely related problems: inflammation where the Achilles tendon attaches to the heel bone, irritation of a small fluid-filled sac nestled behind that bone, or a bony bump that develops on the heel itself. These three conditions often overlap, and in many cases more than one is happening at the same time. The good news is that most posterior heel pain responds well to changes in footwear, stretching, and targeted exercises.
The Three Main Causes
Massachusetts General Hospital describes a “terrible triad” of conditions responsible for most pain at the back of the heel: insertional Achilles tendonitis, retrocalcaneal bursitis, and Haglund’s deformity. Each involves a different structure, but they sit so close together that one problem frequently triggers the others.
Achilles Tendonitis at the Heel
Your Achilles tendon is the thick band connecting your calf muscles to your heel bone. Every time you walk, run, or push off a step, that connection absorbs force. Over time, the repeated loading causes microscopic wear right where the tendon meets the bone. The body tries to repair the damage with inflammation, and you feel a deep ache at the back of your heel. If this cycle continues long enough, small calcium deposits can form inside the tendon, making the area feel hard or bumpy to the touch.
This type of tendonitis is not usually triggered by one specific injury. It builds gradually from everyday activity, and because you can’t rest the tendon completely (you still need to walk), the tissue rarely gets a full chance to heal on its own. Pain is typically worst in the morning or after sitting for a while, then improves as you move around. It often flares again after exercise or climbing stairs.
Bursitis Behind the Heel
A small, fluid-filled cushion called the retrocalcaneal bursa sits between the Achilles tendon and the heel bone, helping the tendon glide smoothly. When that bursa gets squeezed or irritated, it swells and becomes painful. You may notice redness, warmth, or visible puffiness on the back of your heel. The area can be tender enough that even light pressure from the back of a shoe is uncomfortable. Stiffness and difficulty rotating your ankle are also common.
Haglund’s Deformity (Pump Bump)
Haglund’s deformity is a bony enlargement that forms on the upper edge of your heel bone, right where the Achilles tendon attaches. It develops gradually over years and creates a visible bump you can see and feel through the skin. The bump itself isn’t always painful, but it presses against nearby soft tissue and rubs against the backs of shoes. It earned the nickname “pump bump” because rigid-backed shoes like pumps and high heels make the friction especially bad. Any shoe with a stiff heel counter can aggravate it.
Why These Problems Develop
Tight calf muscles are one of the biggest contributors. When your calves are inflexible, every step pulls harder on the Achilles tendon and increases stress on the heel bone. People who spend long hours on their feet, ramp up exercise too quickly, or carry extra body weight are also at higher risk. Footwear plays a major role too. Shoes with rigid backs press directly against the heel bone and bursa, while shoes with minimal cushioning force the heel to absorb more impact than it should.
Age matters as well. The tendon gradually loses elasticity over the years, making it less able to handle the same loads it tolerated when you were younger. And because Haglund’s deformity forms slowly, many people don’t notice the bump until it’s already large enough to cause friction problems.
Heel Pain in Children and Teens
If your child complains about pain at the back of the heel, the most likely cause is Sever’s disease, a growth-related condition that affects the heel’s growth plate. It typically appears between ages 8 and 12, when kids are growing quickly and the heel bone hasn’t fully hardened. Active children who run and jump a lot are especially prone. The condition is uncommon after age 15, once the growth plate closes. A doctor can usually diagnose it with a physical exam alone, without X-rays or blood tests.
Signs That Need Prompt Attention
Most posterior heel pain is a nuisance, not an emergency. But a sudden, sharp pain in your lower calf or heel, especially if it feels like you were kicked or snapped by something, could signal an Achilles tendon tear. With a complete tear, you may notice a visible gap or dent in the tendon, swelling and bruising in the calf, and significant difficulty walking or pointing your toes downward. Complete tears most often happen a few centimeters above where the tendon meets the bone. If you experience a sudden pop followed by weakness, get it evaluated quickly, as treatment options and outcomes depend on how soon the tear is addressed.
Stretching and Strengthening
Daily calf stretching is one of the simplest ways to reduce tension on the back of the heel. Stretching both before and after exercise, and again in the morning, helps keep the tendon flexible. Hold each stretch for at least 30 seconds and avoid bouncing.
For more stubborn tendon pain, a specific exercise program called the Alfredson protocol has strong evidence behind it. You stand on the edge of a step and slowly lower your heel below the level of the step (an “eccentric” heel drop), then rise back up. The original program calls for 3 sets of 15 repetitions with a straight knee, then 3 more sets of 15 with a slightly bent knee. You do both rounds twice a day, seven days a week, for 12 weeks. That adds up to 180 repetitions per day, which sounds like a lot, but each rep takes only a few seconds. The bent-knee version targets a deeper calf muscle that a straight-leg stretch misses.
This protocol can feel uncomfortable at first, especially during the first couple of weeks. Mild discomfort during the exercise is generally expected, but sharp or worsening pain is a signal to back off and get a professional assessment.
Footwear Changes That Help
Switching shoes can make a noticeable difference, sometimes within days. Look for these features:
- Heel-to-toe drop of 8 to 12 mm: a slightly elevated heel reduces the load on the back of your heel during each step.
- Firm but not rigid heel counter: stabilizes the heel without pressing hard against a bump or inflamed bursa.
- Moderate cushioning: softens impact without collapsing under your weight.
- Removable insoles: lets you swap in custom orthotics or gel heel cups if needed.
- Rocker sole profile: encourages a smoother roll from heel to toe, easing pressure at the back of the heel.
If you have a Haglund’s bump, avoid any shoe with a stiff back that presses directly against the protrusion. Open-backed shoes, soft-heeled running shoes, or shoes with a notched heel collar can all reduce friction. Temporary heel lifts placed inside your regular shoes can also take tension off the Achilles tendon while you work on flexibility.
Other Treatment Options
Ice applied to the back of the heel for 15 to 20 minutes after activity helps control inflammation and pain, especially during flare-ups. Over-the-counter anti-inflammatory medications can provide short-term relief but don’t address the underlying cause.
Physical therapy is worth considering if stretching and shoe changes alone aren’t enough. A therapist can identify specific muscle imbalances, work on ankle mobility, and guide you through a strengthened version of the eccentric loading program. For bursitis or Haglund’s deformity that doesn’t respond to conservative measures over several months, a specialist may discuss options like padding, injection therapy, or in rare cases, surgery to remove the bony prominence or inflamed bursa.
Most people see meaningful improvement within 6 to 12 weeks of consistent stretching, eccentric exercises, and better footwear. The key is consistency. Tendons heal slowly compared to muscles, so even after the pain fades, continuing your stretching routine helps prevent it from coming back.