Pain in the back of the heel usually comes from where the Achilles tendon attaches to the heel bone (insertional Achilles tendinitis), a bony bump called Haglund’s deformity, or an irritated bursa between the tendon and the bone. In active children it is often Sever’s disease, irritation of the heel growth plate. A sudden pop with weakness is different and needs urgent care; otherwise an independent physical therapist near Carmel can test the tendon and set a loading plan.
Last reviewed By the Monon Therapy Collective editorial team
- Most common adult cause
- Insertional Achilles tendinitis
- Common in active kids
- Sever’s disease (growth plate)
- Typical recovery
- Often a few months, per AAOS
Is my pain at the Achilles insertion or higher up the tendon?
Pain on the bone where the tendon attaches is insertional; pain and thickening a few finger-widths above the heel is mid-portion (noninsertional). AAOS OrthoInfo separates the two because they are managed differently, and the difference matters for which exercises you do.
Insertional pain often comes with a hard bump on the back of the heel that rubs on shoe counters. Mid-portion pain is common in younger runners and often feels like a sore, thickened cord. If your pain is mostly above the heel, the Achilles tendinitis page covers that pattern in more detail.
What are the usual causes of posterior heel pain?
The table lists the common sources and how each tends to behave. A physical therapist confirms which one fits after examining you.
| Possible cause | What it tends to feel like | Read more |
|---|---|---|
| Insertional Achilles tendinitis | Pain and stiffness at the attachment, worse in the morning and when going uphill | Achilles tendinitis |
| Haglund’s bump with bursitis | Tender, sometimes red bump that rubs on shoe backs | Tendinitis |
| Sever’s disease (growing children) | Heel pain in a growing child after running and jumping sports | Sever’s disease |
| Calf strain referring down | Tightness and pain higher in the calf after a push-off | Calf strain |
| Achilles rupture | Sudden pop or kick sensation, weak push-off, often a gap | Achilles rupture |
Why can heel drops off a step make insertional pain worse?
Letting the heel sink below the step stretches the tendon over the heel bone and compresses it at the insertion, which can aggravate insertional pain. AAOS OrthoInfo says heel-drop exercises should be done only for noninsertional Achilles tendinitis, not for the insertional type.
For insertional pain, therapists usually keep calf strengthening on flat ground at first, so the heel does not drop below the level of the forefoot, and add a small heel lift in the shoe. OrthoInfo also suggests shoes that are softer or open at the back. The eccentric heel drop page explains when that exercise fits and when it does not.
Which checks at home help describe back-of-heel pain?
Gather these details over a few days; they make the first visit more useful. Do not test anything that is sharply painful.
- Pinch the tendon gently from the heel upward: where is it most tender?
- Is there a hard bump on the back of the heel, and do shoe counters press on it?
- How stiff is the first ten steps in the morning, and how long until it eases?
- Can you do ten single-leg heel raises on each side? Compare the counts.
- Did your mileage, hills or footwear change in the last month?
What does a therapist assess for posterior heel pain?
A therapist palpates the insertion, bursa and tendon body, measures ankle bend, counts single-leg heel raises, and checks hop tolerance if you are a runner. They look at training history closely: back-of-heel pain often follows a jump in hill work or speed sessions during spring build-ups for the Carmel Marathon in April and the Indy Mini in May.
Treatment centers on graded calf and tendon loading, temporary changes to running volume and hills, and footwear tweaks. AAOS notes that nonsurgical care can take a few months and that surgery is considered only after about six months without progress. Start with the ankle and foot questionnaire; the running injury service explains how a return to running is staged.
Seek urgent care for back-of-heel pain if
- You felt a pop or a kick at the back of the ankle and now cannot push off or rise on your toes.
- There is a gap you can feel in the tendon.
- The heel is hot, red and swollen with a fever.
- The calf is swollen and tender, especially after travel or surgery.
If you think it is an emergency, call 911.
