By Dr. Kayla Wright, DPM
If you can point with one finger to the most painful spot, that information is often more useful than simply saying “my heel hurts.”
A location-based guide to posterior heel pain
| Where it hurts | Common possibilities |
|---|---|
| Several centimeters above the heel | Midportion Achilles tendinopathy; partial tear in selected cases |
| Directly where Achilles meets the heel bone | Insertional Achilles tendinopathy; calcific changes |
| Deep between Achilles and heel bone | Retrocalcaneal bursitis; insertional Achilles pathology |
| Superficial skin-side area where shoe rubs | Superficial bursitis / mechanical irritation |
| Hard prominence at upper back of heel | Haglund-type prominence, often with surrounding soft-tissue irritation |
| Focal heel-bone pain after major load increase | Calcaneal stress injury |
These categories overlap. A patient can have insertional tendinopathy, bursitis, and a bony prominence at the same time.
1. Midportion Achilles tendinopathy
Midportion Achilles tendinopathy usually causes pain and thickening several centimeters above the heel insertion.
Typical features include:
- gradual onset
- stiffness after rest
- pain with running or jumping
- tenderness within the tendon
- reduced calf endurance
- symptoms that may loosen during warm-up and return after heavier loading
Current clinical guidelines emphasize progressive tendon-loading exercise as a core treatment rather than prolonged complete rest.
2. Insertional Achilles tendinopathy
Insertional tendinopathy occurs at the lowest part of the Achilles where it attaches to the calcaneus.
It may be aggravated by:
- uphill running
- deep ankle dorsiflexion
- stiff shoe counters
- direct pressure against the heel
- repeated jumping or push-off
Because the insertion is compressed against the heel bone in deep dorsiflexion, an exercise that works well for midportion tendinopathy is not automatically ideal for insertional disease. For example, dropping the heel far below a step can increase compression at the insertion and may need modification.
3. Retrocalcaneal bursitis
A bursa is a small fluid-filled sac that reduces friction. The retrocalcaneal bursa sits deep between the Achilles tendon and the heel bone.
When irritated, pain may be felt deep at the back of the heel and can overlap substantially with insertional Achilles symptoms. Swelling may be visible on either side of the tendon near its attachment.
Because the structures are so close together, examination and sometimes imaging are needed to determine whether the primary issue is tendon, bursa, bone, or a combination.
4. Superficial bursitis and shoe-counter irritation
Another bursa lies more superficially between the Achilles/skin and footwear. A stiff shoe counter can repeatedly rub that area and produce a tender, irritated bump.
A useful clue is direct pressure sensitivity: if the heel is relatively tolerable barefoot but becomes sharply painful in a rigid-backed shoe, superficial irritation or a prominent heel contour may be contributing.
Footwear modification can matter more in this pattern than in a deep midportion tendon problem.
5. Haglund-type bony prominence
A prominent upper-posterior calcaneus is often called a Haglund deformity. But the presence of a bump does not automatically make the bone itself the pain generator.
Many anatomical prominences are asymptomatic. Symptoms usually arise when the prominence interacts with the Achilles insertion, bursae, and shoe pressure.
The better question is not simply “Do I have a Haglund bump?” It is:
Which structure around the bump is painful, and what is loading it?
That distinction helps avoid treating an X-ray instead of a patient.
6. Calcaneal stress injury
A heel-bone stress reaction or fracture is less common but important, particularly after a substantial increase in impact activity.
Concern rises with:
- rapidly increasing running or hiking volume
- pain that becomes progressively more constant
- focal bone tenderness
- pain with impact that does not “warm up” like a tendon
- symptoms at rest in more advanced injuries
A bone stress injury should not be treated as “tight Achilles” and stretched aggressively without evaluation.
What about a sudden pop in the Achilles?
A sudden pop plus immediate weakness or loss of push-off raises concern for rupture and requires prompt evaluation. A rupture may occur even if you can still move the ankle or walk with a limp.
Read Achilles tendinitis vs. Achilles tear if the pain began suddenly during a sprint, jump, or push-off.
How a foot-and-ankle exam separates these conditions
A focused evaluation may assess:
- exact pain location
- tendon thickness and tenderness
- pain with resisted plantar flexion
- single-leg heel-raise capacity
- ankle range of motion
- shoe pressure and heel contour
- calf strength
- rupture tests when relevant
- squeeze/tenderness findings if bone stress is suspected
A 2025 Delphi consensus on Achilles-tendinopathy assessment identified pain location, activity-related pain, provocative tests, and palpation as essential diagnostic domains while also highlighting partial tear, bursitis, calcaneal stress injury, posterior impingement, and other important differentials.
When is imaging useful?
Many Achilles problems are diagnosed clinically.
Imaging becomes more helpful when:
- diagnosis remains uncertain
- a partial or complete tear is suspected
- symptoms are persistent despite appropriate treatment
- surgery is being considered
- bone stress injury is possible
- there is unusual swelling, calcification, or mechanical symptoms
Ultrasound can evaluate tendon structure dynamically, while MRI can provide detailed views of tendon, bone, bursae, and surrounding soft tissues.
Treatment depends on the structure—not just the symptom “heel pain”
Examples:
Midportion Achilles tendinopathy: progressive loading is central.
Insertional Achilles tendinopathy: loading may need modification to reduce compression at the heel insertion.
Superficial shoe irritation: footwear changes can be disproportionately helpful.
Retrocalcaneal bursitis: treatment addresses the irritated bursa and contributing mechanics while distinguishing it from tendon disease.
Stress injury: impact loading may need substantial restriction until bone healing progresses.
That is why posterior heel pain benefits from a location-specific diagnosis.
Frequently asked questions
Is pain behind the heel plantar fasciitis?
Usually not. Plantar fasciitis classically causes pain on the bottom/inner heel. Pain at the back of the heel more often points toward Achilles or posterior-heel structures, although conditions can coexist.
Why does the back of my heel hurt only in shoes?
Direct shoe-counter pressure can irritate a superficial bursa, a prominent heel contour, or an already sensitive Achilles insertion. Comparing barefoot vs. shoe symptoms is useful clinical information.
Can a heel spur be on the back of the heel?
Yes. Bony growth or calcification can occur near the Achilles insertion, which is different from the plantar heel spur often discussed with plantar fasciitis.
Should I stretch an insertional Achilles problem off a stair?
Aggressive heel-drop stretching below the level of the step can increase compression at the tendon insertion and may aggravate some insertional cases. Exercise selection should match the location and irritability of the problem.
When is back-of-heel pain urgent?
A sudden pop, major loss of push-off strength, significant trauma, neurovascular changes, or inability to bear weight warrants prompt assessment. Gradual pain is usually less urgent but still deserves evaluation if persistent or worsening.
Posterior heel pain evaluation in Tempe
Metro Foot & Ankle evaluates Achilles tendon conditions, bursitis, stress injuries, and other causes of heel pain in Tempe and the East Valley. If pain at the back of the heel keeps limiting walking, shoes, running, or sport, request an evaluation.
This article is for general educational purposes and does not replace individualized medical advice, diagnosis, or treatment.
Sources
- de Vos RJ, van der Vlist AC, Zwerver J, et al. Dutch multidisciplinary guideline on Achilles tendinopathy. British Journal of Sports Medicine. 2021. https://pubmed.ncbi.nlm.nih.gov/34187784/ (opens in a new tab)
- Chimenti RL, et al. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2024. J Orthop Sports Phys Ther. 2024;54(12):CPG1-CPG32. https://pubmed.ncbi.nlm.nih.gov/39611662/ (opens in a new tab)
- Malliaras P, et al. Diagnostic domains, differential diagnosis and conditions requiring further medical attention that are considered important in the assessment for Achilles tendinopathy: a Delphi consensus study. British Journal of Sports Medicine. 2025. https://pubmed.ncbi.nlm.nih.gov/40240126/ (opens in a new tab)
- Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline—revision 2010. J Foot Ankle Surg. 2010. https://pubmed.ncbi.nlm.nih.gov/20439021/ (opens in a new tab)
- American Academy of Orthopaedic Surgeons. Sprains, Strains, and Other Soft-Tissue Injuries. https://orthoinfo.aaos.org/en/diseases--conditions/sprains-strains-and-other-soft-tissue-injuries (opens in a new tab)