Pain at the back of the heel: causes and what helps
Pain right at the back of the heel, where the Achilles tendon attaches to the bone, behaves differently from pain higher up the tendon. It's common in runners and in people who spend long days on their feet, and it often needs a slightly different approach.
What causes pain at the back of the heel?
The usual causes are insertional Achilles tendinopathy, irritation of the tendon where it attaches to the heel bone; bursitis, irritation of the small fluid sac between the tendon and the bone; and a bony prominence on the back of the heel called a Haglund's deformity, which can rub on both. They often occur together.
What is insertional Achilles tendinopathy?
It's a tendon problem at the attachment rather than in the middle of the tendon. A review notes it accounts for about 20% to 25% of all Achilles tendinopathy presentations, and that diagnosis is mainly clinical, supported by X-ray, ultrasound or MRI (Maffulli et al., British Medical Bulletin, 2026). Calcium deposits or spurs can form at the attachment.
What does it feel like?
Pain and tenderness at the back of the heel, often stiff first thing in the morning and when starting to walk or run, then worse after activity. Uphill walking, stairs and shoes with a firm heel counter that presses on the area aggravate it. There may be swelling or a visible bump.
How is it different from mid-tendon Achilles pain?
Mid-portion tendinopathy is felt two to six centimetres above the heel, in the tendon itself. Insertional pain is right at the bone. The difference matters, because the insertion is compressed against the heel bone when the ankle is bent upwards, so stretching and some exercises that help the mid-tendon can aggravate the insertion.
See our post on Achilles tendinopathy.
What should I avoid?
For now, avoid calf stretches that drop the heel, deep squats with the heel down, heel drops off a step, and running up hills. Avoid shoes with a stiff heel counter that presses on the sore spot, and walking barefoot on hard floors.
What helps?
Reducing the load on the attachment, then rebuilding strength. A small heel lift in both shoes takes some tension off. Shoes with a soft or low heel counter, or backless shoes, avoid pressure. Strengthening starts with calf raises on a flat floor rather than off a step, so the heel doesn't drop below level, progressing gradually in load.
Can I keep running?
Often, with changes: flat routes, shorter runs, slightly slower pace, and avoiding hills and speed work for now. Pain that's mild during a run and settles by the next morning is generally acceptable. Pain that builds run by run means reduce further.
What about the bump on the back of my heel?
A Haglund's deformity is a bony enlargement of the back of the heel bone. It's often harmless but can irritate the bursa and tendon, especially in stiff-backed shoes. Changing footwear and padding usually help. Surgery to remove the bump is considered only when conservative care fails.
Do injections or shockwave help?
Corticosteroid injections near the Achilles are generally avoided because of the risk of tendon rupture. Shockwave therapy is used by some clinicians for persistent insertional pain; we don't offer it, but can advise on whether it's worth considering.
How long does it take to improve?
Insertional tendon pain tends to be slower than mid-tendon pain. Expect gradual improvement over three to six months of consistent load management and strengthening.
Could it be something else?
In children and teenagers, heel pain at the back is usually Sever's disease, an irritation of the growth plate. Pain under the heel is more often plantar fasciitis. A sudden snap at the back of the ankle suggests a rupture.
See our posts on Sever's disease and torn Achilles tendons.
Is it worse in the morning?
Often. Tendons stiffen overnight, so the first steps of the day and the first few minutes of a run are usually the worst. Stiffness that eases within minutes is typical of tendon pain. Morning stiffness lasting more than half an hour, especially in both heels or with other joints involved, is worth mentioning to your GP.
How can an osteopath help?
We work out whether the pain is at the insertion, the bursa or the mid-tendon, check the calf, foot and running load, and build a loading program that avoids compressing the insertion early on.
When should heel pain be checked?
Book in for heel pain lasting more than a couple of weeks. See a doctor promptly for a sudden pop with weakness, a hot, red, swollen heel, or heel pain with joint pain elsewhere, which can be inflammatory.
See our foot pain guide. Book an assessment at our Berwick clinic. A 60-minute initial consultation is $149, with no referral needed and HICAPS on-site.
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Book an initial consultation at RISE Sports & Spinal in Berwick. Clear diagnosis, hands-on treatment, and a plan that actually gets you better.
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