Key Takeaways
Pain in the back of the heel is different from pain underneath the heel. Posterior heel pain commonly involves the Achilles tendon, surrounding bursae, or the area where the tendon attaches to the heel bone.
The precise location of tenderness helps distinguish the cause. Pain several inches above the heel may suggest a different Achilles problem from pain directly at its attachment.
Shoe pressure can be an important clue. A prominent heel bone or irritated bursa may become particularly uncomfortable when the back of a shoe presses against it.
Morning stiffness and pain after activity are common with Achilles tendinopathy. These symptoms often reflect changes in tendon loading tolerance rather than a simple inflammatory injury.
Not every bump on the back of the heel requires surgery. Some patients have a prominent heel bone without significant symptoms, while others benefit from footwear changes and rehabilitation.
Treatment should match the affected structure. Appropriate loading exercises, footwear modifications, and selected conservative therapies may help, while suspected tendon rupture requires urgent evaluation.
Why Does the Back of Your Heel Hurt?
You get out of bed in the morning and notice a sharp, pulling sensation at the back of your heel.
The first several steps are uncomfortable. After walking around the house, the stiffness begins to ease.
Later, you put on a pair of shoes and discover that the rigid material around the heel presses directly against the painful area.
Perhaps you’ve also noticed a small bump where the Achilles tendon attaches to the heel bone.
You may assume that you have plantar fasciitis because the pain involves your heel. However, plantar fasciitis usually produces discomfort underneath the heel, while pain at the back often involves a different set of structures.
At Doyle Chiropractic in Huntersville, North Carolina, Dr. Geoffrey Doyle evaluates posterior heel pain by first identifying exactly where the discomfort occurs.
Is the pain directly where the Achilles tendon attaches to the heel? Is it located several inches above that attachment? Does the back of a shoe aggravate it? Is there swelling, warmth, or a visible bump?
These distinctions matter because several conditions can produce similar symptoms but respond differently to treatment.
Understanding the anatomy is the first step toward identifying the problem.
Understanding the Achilles Tendon and the Back of the Heel
The Achilles tendon is the large, strong tendon connecting the calf muscles to the calcaneus, or heel bone.
The gastrocnemius and soleus muscles generate force through the Achilles tendon to help lift the heel, push the body forward during walking, and provide power during running and jumping.
Every time you take a step, the Achilles tendon helps transfer force from the calf muscles to the foot.
The tendon is remarkably strong, but it must repeatedly tolerate substantial mechanical loads.
At the back of the heel, several structures are positioned close together.
The Achilles tendon attaches to the posterior calcaneus. A small fluid-containing structure called the retrocalcaneal bursa sits between the tendon and the heel bone, helping reduce friction and compression.
Another bursa may be present between the tendon and the skin, where shoe pressure can create irritation.
The upper back portion of the calcaneus can also have a prominent bony contour, sometimes associated with Haglund’s deformity.
Because these structures occupy a relatively small area, symptoms can overlap.
A patient may have Achilles tendon irritation and bursitis simultaneously, while another may have a bony prominence that becomes painful primarily because of footwear pressure.
The examination helps determine which structure is most likely responsible.
Achilles Tendinopathy: When the Tendon Becomes Painful
Achilles tendinopathy is a common cause of pain along the back of the heel and lower calf.
The condition involves changes in tendon structure and its ability to tolerate mechanical loading.
Although patients frequently describe the problem as Achilles tendonitis, persistent Achilles tendinopathy is not simply an inflammatory condition.
Tendon pain may involve altered collagen organization, changes in tendon cells and surrounding tissues, and increased sensitivity to mechanical loading.
These changes can develop when the tendon is exposed to more stress than it is currently prepared to tolerate.
For example, someone who begins walking several miles each day after months of inactivity may overload the Achilles tendon.
A runner who suddenly increases mileage, hill training, or speed work may experience similar symptoms.
However, Achilles tendinopathy can also occur in people who are not particularly athletic.
Reduced calf strength, changes in activity, footwear, and certain medical factors may influence tendon health and loading tolerance.
Why Achilles Pain Is Often Worse in the Morning
One characteristic of Achilles tendinopathy is stiffness or discomfort during the first steps after getting out of bed.
The tendon has remained relatively inactive overnight. When walking begins, it must immediately tolerate repeated loading.
The first several steps may be painful, but symptoms sometimes ease as the tendon warms up and movement continues.
This improvement does not necessarily mean the tendon has healed.
A patient may feel better during activity and experience increased soreness later that day or the following morning.
This pattern is particularly important when deciding how quickly to increase exercise.
The goal is not to avoid every activity that produces mild discomfort. It is to find an appropriate amount of loading that encourages adaptation without repeatedly aggravating the tendon.
Midportion Versus Insertional Achilles Tendinopathy
Not all Achilles tendon problems occur in the same location.
This distinction is important because certain exercises that help one condition may aggravate the other.
Midportion Achilles Tendinopathy
Midportion Achilles tendinopathy typically produces pain approximately two to six centimeters above the tendon attachment.
Patients may notice localized thickening or tenderness along the tendon.
Symptoms often increase with running, jumping, climbing stairs, or repeated calf raises.
A structured strengthening program is commonly an important part of treatment.
Progressive calf loading helps improve the tendon-muscle system’s capacity to tolerate activity, although improvement often requires patience and consistent rehabilitation.
Insertional Achilles Tendinopathy
Insertional Achilles tendinopathy occurs where the tendon attaches directly to the heel bone.
Patients often describe pain at the very back of the heel, particularly when walking uphill, climbing stairs, or wearing shoes that press against the attachment.
One important difference is that the insertional region can be sensitive to compression.
When the ankle bends upward into dorsiflexion, the Achilles tendon may experience increased compression against the heel bone near its attachment.
For this reason, aggressive heel-drop exercises performed below the edge of a step may aggravate insertional symptoms.
Rehabilitation often begins with controlled calf strengthening that avoids excessive dorsiflexion, progressing as symptoms permit.
The precise location of tendon pain therefore influences which exercises are appropriate.
Retrocalcaneal Bursitis: When the Cushion Behind the Heel Becomes Irritated
The retrocalcaneal bursa is a small fluid-filled structure located between the Achilles tendon and the upper back portion of the calcaneus.
Its function is to reduce friction and compression as the ankle moves.
When the bursa becomes irritated, patients may experience pain near the Achilles tendon attachment, sometimes accompanied by swelling.
Symptoms may increase when the ankle moves into dorsiflexion or when pressure is applied around the back of the heel.
This can resemble insertional Achilles tendinopathy because the two structures are anatomically close together.
In fact, both conditions may occur at the same time.
A patient with retrocalcaneal bursitis may experience discomfort when wearing certain shoes, particularly those with a rigid heel counter.
The examination considers the location of tenderness, swelling, ankle movement, and whether direct pressure reproduces the familiar symptoms.
Treatment may involve modifying footwear, reducing aggravating compression, and addressing associated tendon-loading problems.
Haglund’s Deformity: When a Bony Prominence Irritates the Back of the Heel
Haglund’s deformity describes a prominent bony contour along the upper posterior portion of the calcaneus.
Patients sometimes call this a pump bump because the prominence may become irritated by shoes with rigid backs.
The bony prominence itself is not necessarily painful.
Some people have a noticeable bump for years without experiencing significant discomfort.
Problems may develop when the prominence contributes to irritation of the surrounding soft tissues, particularly the retrocalcaneal bursa or Achilles tendon insertion.
A patient may notice redness, swelling, or tenderness directly where the shoe contacts the heel.
This is an important distinction because a visible bump does not automatically mean that surgery is necessary.
For many patients, reducing pressure from footwear and addressing associated tendon or bursal irritation may improve symptoms.
However, persistent pain associated with significant structural prominence may require additional imaging or orthopedic evaluation.
Why Shoe Selection Can Make Such a Difference
The back of a shoe contains a structure called the heel counter, which helps maintain the shoe’s shape and support the rearfoot.
When the heel counter is rigid or positioned directly over a tender prominence, it may repeatedly compress the irritated tissues.
A patient may feel reasonably comfortable barefoot or in open-backed footwear but develop pain shortly after putting on certain shoes.
This pattern suggests that external pressure is contributing to the problem.
Footwear modifications may include selecting a shoe with a softer heel counter or temporarily reducing direct pressure over the painful area.
In selected cases, a modest heel lift may reduce strain and compression around the Achilles insertion, although it should be used according to the patient’s needs rather than as a permanent solution for everyone.
The goal is to reduce unnecessary irritation while maintaining comfortable walking mechanics.
When Posterior Heel Pain May Be Something More Serious
Most cases of posterior heel pain develop gradually, but sudden injuries require a different level of concern.
An Achilles tendon rupture may occur during running, jumping, or a sudden push-off movement.
Patients sometimes describe feeling as though someone kicked them in the back of the leg, followed by immediate pain or difficulty walking.
A popping sensation may occur, although not every rupture produces an obvious sound.
Significant weakness when pushing off the foot, inability to perform a single-leg heel raise, or a palpable defect along the tendon raises concern for rupture.
Importantly, some patients with an Achilles rupture can still move the ankle or walk with difficulty because other muscles contribute to plantarflexion.
The ability to walk therefore does not rule out a rupture.
Suspected Achilles rupture requires prompt medical assessment because early diagnosis influences treatment decisions.
Other concerning findings include rapidly increasing redness, warmth, swelling, fever, or severe unexplained pain, particularly when infection or another acute condition is possible.
Certain medications, including fluoroquinolone antibiotics and systemic corticosteroids, are also associated with increased risk of Achilles tendon injury. Patients with new Achilles pain should mention relevant medication exposure during their evaluation.
These possibilities reinforce why the history and examination matter.
Pain in the back of the heel may involve a tendon, bursa, bony prominence, or another condition, and the appropriate treatment depends on identifying which structure is responsible.
A careful evaluation can help distinguish these problems and determine whether rehabilitation, footwear modification, additional imaging, or medical referral is the most appropriate next step.
How Doyle Chiropractic Evaluates Pain in the Back of the Heel
When a patient comes to Doyle Chiropractic with pain in the back of the heel, Dr. Geoffrey Doyle begins by determining exactly where the discomfort originates.
This is particularly important because Achilles tendinopathy, retrocalcaneal bursitis, and Haglund’s deformity can produce overlapping symptoms.
The examination begins with the patient’s history. Did the pain develop after increasing walking or running? Is it worse during the first steps in the morning? Does the back of a shoe press against the painful area? Was there a sudden injury or a popping sensation?
These details help distinguish gradual tendon overload from compression-related irritation or a more significant injury.
Identifying the Painful Structure
The location of tenderness provides useful information.
Pain several centimeters above the heel attachment may suggest midportion Achilles tendinopathy, particularly when localized tendon thickening is present.
Tenderness directly where the Achilles tendon attaches to the calcaneus raises consideration of insertional tendinopathy.
Pain deeper between the tendon and heel bone, especially when accompanied by swelling or discomfort during ankle dorsiflexion, may suggest retrocalcaneal bursitis.
A visible bony prominence that becomes uncomfortable when wearing rigid-backed shoes may indicate Haglund’s deformity with associated soft-tissue irritation.
Dr. Doyle also evaluates ankle range of motion, calf flexibility, foot mechanics, and the patient’s ability to tolerate weight-bearing activity.
The examination may include controlled calf raises to assess strength and tendon-loading tolerance.
These findings are considered together rather than relying on one tender location to establish the diagnosis.
Evaluating Tendon Strength and Function
The Achilles tendon plays an essential role in walking, climbing stairs, and pushing the body forward.
When the tendon becomes painful, patients may begin shortening their stride or avoiding normal push-off through the affected foot.
Dr. Doyle considers whether the patient can perform a comfortable double-leg heel raise and, when appropriate, a single-leg heel raise.
These movements provide information about calf strength and the tendon-muscle system’s ability to tolerate loading.
However, significant pain or weakness may limit testing, and exercises should not be forced when a substantial tendon injury is suspected.
When the history suggests an acute Achilles rupture, appropriate clinical testing may include the Thompson calf-squeeze test and assessment for a tendon defect.
A suspected rupture requires prompt medical evaluation rather than routine rehabilitation.
When X-Rays, Ultrasound, or MRI May Be Necessary
Most uncomplicated cases of Achilles tendinopathy can be evaluated clinically without immediate advanced imaging.
X-rays may help identify a prominent posterior calcaneus, insertional calcifications, or other bony abnormalities.
Diagnostic ultrasound can provide information about tendon structure, thickening, and certain tears. MRI may be appropriate when the diagnosis remains uncertain, significant injury is suspected, or persistent symptoms require additional evaluation.
Imaging findings must be interpreted alongside the examination.
Tendon thickening and structural changes can sometimes be present without significant pain. Likewise, a prominent heel bone does not automatically explain every episode of posterior heel discomfort.
The purpose of imaging is to answer a question that may influence treatment.
Treatment Options for Pain in the Back of the Heel
The appropriate treatment depends on whether the primary problem involves the Achilles tendon, a bursa, a bony prominence, or a combination of these structures.
At Doyle Chiropractic, Dr. Doyle considers the patient’s activity level, examination findings, and functional goals when discussing conservative treatment options.
Progressive Achilles Tendon Rehabilitation
For many patients with Achilles tendinopathy, progressive strengthening is one of the most important components of treatment.
Tendons respond to mechanical loading, but the amount and type of loading must be appropriate.
Early rehabilitation may begin with controlled calf contractions or heel raises performed within a comfortable range.
As symptoms improve, exercises may progress toward greater resistance and eventually more demanding activities such as faster walking, running, or jumping.
The approach differs according to the location of the problem.
For midportion Achilles tendinopathy, progressive calf strengthening through an appropriate range of motion is commonly used.
For insertional Achilles tendinopathy, excessive dorsiflexion may increase compression at the tendon attachment. Rehabilitation may therefore begin with heel raises performed on level ground rather than lowering the heel below the edge of a step.
This distinction is important because an exercise that helps one patient may aggravate another.
Dr. Doyle emphasizes gradual progression rather than attempting to stretch or strengthen aggressively through significant pain.
Footwear Modifications and Reducing Heel Compression
When posterior heel pain is aggravated by shoe pressure, footwear changes may provide meaningful relief.
A rigid heel counter can irritate a sensitive Achilles insertion, inflamed bursa, or prominent calcaneus.
Selecting shoes with a softer heel counter or temporarily reducing direct pressure may help the tissues become less irritated.
A modest heel lift may also be considered in selected cases to reduce Achilles loading and compression near the insertion.
However, footwear changes are usually only part of the solution.
If reduced calf strength or poor tendon-loading tolerance contributed to the original problem, rehabilitation remains important for long-term function.
Chiropractic Care and Associated Joint Dysfunction
Selected patients with posterior heel pain may also demonstrate restricted ankle movement or associated dysfunction involving the foot and lower extremity.
When clinically appropriate, Dr. Doyle may consider ankle or foot joint mobilization or adjustments to address relevant mechanical limitations.
These treatments do not repair a torn Achilles tendon, remove a Haglund’s deformity, or directly reverse chronic tendon changes.
Their role is to address associated joint restrictions when those restrictions appear to contribute to the patient’s functional difficulties.
Treatment should be guided by the examination rather than assuming that every case of heel pain requires an adjustment.
Class IV Laser Therapy and Soft-Tissue Treatment
Doyle Chiropractic offers Summus Class IV laser therapy, which may be considered as an adjunct for selected painful tendon or musculoskeletal conditions.
Photobiomodulation has been studied for potential effects on pain and tissue-related biological processes, but evidence for Achilles tendinopathy remains limited and varies by treatment protocol.
Laser therapy should not replace progressive tendon rehabilitation or necessary medical treatment.
Selected soft-tissue techniques may also help address associated calf muscular discomfort.
However, aggressive direct pressure over an irritated Achilles insertion or inflamed bursa may worsen symptoms.
The treatment approach should respect the specific tissues involved and their tolerance for compression.
When Medical or Surgical Treatment May Be Appropriate
Persistent posterior heel pain sometimes requires additional medical evaluation.
An orthopedic foot-and-ankle specialist or other appropriate medical provider may consider additional imaging, immobilization for selected injuries, or other interventions based on the diagnosis.
Surgery is generally not the first treatment for uncomplicated Achilles tendinopathy or Haglund-related discomfort.
However, significant tendon tears, persistent disabling symptoms despite appropriate conservative management, or certain structural problems may warrant surgical consideration.
Corticosteroid injections directly into the Achilles tendon are generally avoided because of the potential risk of tendon weakening and rupture. Any injection near the tendon or bursa requires careful medical judgment.
The objective is to identify when conservative management is reasonable and when another treatment approach may provide a better opportunity for recovery.
Recovery and Functional Outcomes
Recovery from posterior heel pain depends on the underlying condition, symptom severity, and the amount of stress placed on the affected tissues.
Achilles tendinopathy often improves gradually rather than immediately.
Some patients notice reduced morning stiffness within several weeks, while restoring full tendon-loading capacity may require several months of consistent rehabilitation.
Patients with insertional symptoms may also need time to identify footwear and activities that reduce excessive compression.
For someone who enjoys walking around Lake Norman, meaningful improvement may involve returning to longer walks without increasing heel pain the following morning.
Another patient may measure progress by climbing stairs comfortably, wearing regular shoes, or returning to recreational exercise.
At Doyle Chiropractic, functional improvement is considered alongside pain reduction.
The ability to perform calf raises, walk with normal push-off, and gradually tolerate greater activity provides useful information about recovery.
Why Feeling Better During Exercise Can Be Misleading
One characteristic of Achilles tendinopathy is that discomfort sometimes decreases after the tendon warms up.
A patient may begin walking with pain, feel considerably better after several minutes, and assume the problem has resolved.
However, symptoms may return later that evening or the following morning.
This is why Dr. Doyle considers the patient’s response after activity, not simply how the tendon feels while exercising.
A reasonable rehabilitation program gradually increases loading while monitoring whether symptoms remain manageable.
The goal is to improve the tendon-muscle system’s capacity to tolerate activity without repeatedly provoking significant flare-ups.
The Dr. Doyle Perspective
One of the first things I want to know when someone describes pain in the back of the heel is exactly where they can point to the discomfort.
That small distinction can change the direction of the examination and the treatment plan.
If the patient points several centimeters above the heel bone, I begin thinking about midportion Achilles tendinopathy.
If the pain is directly where the tendon attaches to the heel, I become more concerned about insertional tendon irritation and the possibility that compression is contributing to the symptoms.
If the patient tells me that certain shoes are almost unbearable but walking barefoot is much more comfortable, I want to evaluate the posterior heel contour and surrounding bursae.
Those presentations may overlap, but I would not automatically treat them the same way.
One important example involves stretching.
Patients frequently assume that an irritated Achilles tendon needs to be stretched as aggressively as possible.
However, if someone has insertional Achilles tendinopathy, forcing the ankle into substantial dorsiflexion can increase compression where the tendon attaches to the heel bone.
In that situation, a well-intentioned stretching program may actually aggravate the problem.
I also explain that tendon pain does not always mean the tendon is actively tearing.
Many patients with Achilles tendinopathy have changes in how the tendon tolerates loading. Appropriate strengthening may help restore function, but the progression must match the condition.
Another important consideration is whether a visible bump is actually responsible for the pain.
A Haglund’s deformity may appear on an X-ray, but that does not automatically mean the patient needs surgery. The relationship between the bony prominence, surrounding tissues, footwear, and symptoms is what matters.
My goal is to explain which structure appears to be involved, what activities are aggravating it, and how we can reasonably improve function.
Sometimes that involves footwear changes and progressive calf strengthening. Sometimes selected manual therapies or adjunctive treatments may be useful. And sometimes the examination indicates that additional imaging or orthopedic evaluation is necessary.
The most important part of treating posterior heel pain is recognizing that the location and mechanism of the problem determine which treatments are appropriate.
Our Clinical Experience
Posterior heel pain illustrates how several conditions can produce similar complaints while requiring different management strategies.
Consider three hypothetical presentations.
Presentation One: Morning Stiffness Above the Heel
A recreational walker develops pain several centimeters above the Achilles attachment after increasing daily walking distance.
The first steps each morning are uncomfortable, and the tendon feels better after warming up.
The examination identifies localized tendon tenderness and reduced tolerance for repeated calf raises.
This presentation may be consistent with midportion Achilles tendinopathy.
Treatment could emphasize appropriate activity modification and progressive calf strengthening.
Presentation Two: Pain Directly at the Achilles Attachment
Another patient experiences pain directly at the back of the heel, particularly when climbing hills or performing deep calf stretches.
The examination suggests insertional Achilles tendinopathy.
In this situation, rehabilitation may initially avoid excessive dorsiflexion and focus on controlled strengthening within a more tolerable range.
Aggressive heel-drop exercises below the edge of a step may be inappropriate early in recovery.
Presentation Three: A Painful Bump Irritated by Shoes
A third patient notices a prominent bump on the back of the heel.
Walking in open-backed footwear is relatively comfortable, but rigid shoes produce localized pain and irritation.
The examination raises consideration of Haglund’s deformity with associated bursal or insertional irritation.
Footwear modifications and appropriate conservative management may be reasonable before considering more invasive treatment.
These examples are hypothetical and illustrate clinical decision-making rather than actual patient histories or guaranteed outcomes.
The important lesson is that posterior heel pain should not be treated as one universal condition.
Frequently Asked Questions
Why does the back of my heel hurt when I walk?
Posterior heel pain may involve Achilles tendinopathy, bursitis, irritation from a bony prominence, or another condition. The location of tenderness and response to activity help distinguish the cause.
Is pain in the back of the heel plantar fasciitis?
Usually not. Plantar fasciitis typically causes pain underneath the heel, while posterior heel pain more commonly involves the Achilles tendon or surrounding structures.
Why is my Achilles tendon painful in the morning?
Achilles tendinopathy often causes stiffness and discomfort during the first steps after inactivity. Symptoms may improve as movement continues, although this does not necessarily indicate complete recovery.
What is the difference between Achilles tendonitis and tendinopathy?
Tendonitis suggests an inflammatory process. Tendinopathy is a broader term describing painful tendon dysfunction that may involve structural and loading-related changes rather than inflammation alone.
Can a heel spur cause pain in the back of my heel?
A posterior calcaneal spur or bony prominence may contribute to irritation around the Achilles insertion. However, the presence of a spur does not automatically mean it is responsible for the pain.
What is Haglund’s deformity?
Haglund’s deformity is a prominent bony contour along the upper back portion of the heel. It may become painful when it contributes to irritation of surrounding tissues, particularly with shoe pressure.
Should I stretch my Achilles tendon if it hurts?
It depends on the diagnosis. Gentle stretching may be appropriate for some patients, but aggressive dorsiflexion can aggravate insertional Achilles tendinopathy.
Can I continue walking with Achilles tendinopathy?
Many patients can remain active with appropriate modifications. Walking distance, intensity, terrain, and symptom response should guide activity levels.
Can chiropractic care help posterior heel pain?
Selected conservative treatments may help address associated joint restrictions, muscular discomfort, and functional limitations. Progressive tendon rehabilitation is often particularly important for Achilles tendinopathy.
Does Class IV laser therapy heal Achilles tendinopathy?
Laser therapy may be considered as an adjunct for selected patients, but evidence is limited and it has not been established as a replacement for progressive strengthening or other appropriate treatment.
How long does Achilles tendinopathy take to heal?
Recovery varies. Some patients improve within several weeks, while rebuilding tendon-loading capacity may take several months.
