Achilles Tendon
Achilles tendinopathy may involve the tendon above the heel or the insertion where the tendon attaches to the calcaneus. Tendon load, calf function, training volume and compression around the insertion can all influence symptoms.
PAIN IN THE BACK OF THE HEEL
Posterior Heel Pain
Pain in the Back of the Heel
Pain behind the heel can arise from the Achilles tendon, the bursae around the tendon, the posterior heel bone, or a combination of structures. Identifying which structure is involved changes what should happen next.
Heel-pain focused clinical assessment
More than 7,000 patients assessed
Sydney CBD · Parramatta · Crows Nest · Miranda
4.9 rating · 240+ reviews
Recognising the Pattern
Does This Sound Familiar?
Posterior heel pain often follows a recognisable pattern. Patients commonly report one or more of the following.
Pain on the first few steps after rest
Stiffness after sitting or periods of inactivity
Discomfort during push-off, hills or stairs
Localised tenderness or swelling behind the heel
Symptoms that settle, then return with activity
Persistent Symptoms
Why Posterior Heel Pain Persists
Patients with pain in the back of the heel have often already tried rest, stretching, massage, calf raises, footwear changes or another form of treatment.
Sometimes symptoms improve temporarily. Sometimes they do not change at all.
One reason is that posterior heel pain is often treated as though every case is the same. It is not. The Achilles tendon, surrounding bursae and posterior calcaneus have different tissue properties and different tolerances to load and compression.
A treatment that is appropriate for one structure may be poorly timed or inappropriate for another.
- Different structures require different management.
- The same exercise can help one presentation and aggravate another.
- Footwear can reduce symptoms in one case and increase compression in another.
- Treatment timing matters, particularly where tendon tears are suspected or shockwave therapy is being considered.
Clinical Differentiation
Pain in the Back of the Heel Is Not One Condition
The location of pain may be similar, but the structure responsible can be different.
Bursae
Retrocalcaneal bursitis and irritation of the superficial bursa can produce tenderness, swelling and pain around the posterior heel, particularly where local compression is present.
Posterior Calcaneus / Haglund's Deformity
A prominent posterior calcaneus may increase local pressure around the Achilles insertion and adjacent soft tissues. Footwear shape, heel-counter pressure and repetitive compression can all influence symptoms.
Investigative Assessment
A Successful Investigative Assessment Should Establish Four Things
Clinical investigation should establish the diagnosis, identify the mechanical drivers behind the problem, and determine which clinical and biomechanical findings are relevant to the individual patient.
Correctly identifying the symptomatic tissue is fundamental. Failure to diagnose the structure responsible can direct subsequent treatment towards the wrong tissue from the outset.
1
Diagnosis & Differential Diagnosis
Clinical history and examination are used to diagnose the tissue or structures responsible for the symptoms and differentiate between other potential causes of posterior heel pain.
2
Mechanical Drivers
Mechanical loading patterns, occupational demands, habitual foot positions, training exposure, calf function, footwear interaction and repetitive compressive or tensile forces are evaluated to identify the factors perpetuating tissue stress.
3
Relevant Biomechanical Findings
Gait, foot and ankle function, joint movement, calf function and footwear are assessed to determine which biomechanical findings are clinically relevant to the individual presentation.
4
Treatment Sequence
Clinically identify which load modifications are required, which mechanical driving forces need to be reduced or removed, and determine the appropriate sequence in which treatment interventions should then be introduced.
Treatment Options
Treatment Depends on the Diagnosis
Once the diagnosis and relevant mechanical drivers have been established, treatment can be selected and sequenced according to the clinical findings rather than applying the same intervention to every presentation.
Load Modification
Altering the forces, activity or loading pattern aggravating the symptomatic tissue.
Calf Function & Tendon Loading
Calf capacity, ankle function and tendon loading are evaluated to determine how much mechanical demand the Achilles region can currently tolerate.
Footwear-Specific Recommendations
Advice around heel height, heel-counter pressure, shoe geometry and appropriate current-market footwear.
Shockwave Therapy
Considered according to diagnosis, tissue irritability and the appropriate stage of treatment.
Heel Lifts & Mechanical Modification
Used where changing local tension or compression is clinically relevant.
3D-Printed Custom Footbeds
Customised orthotic geometry can be incorporated where foot mechanics or footwear requirements form part of the treatment strategy.
The treatment itself is only part of the equation. Selecting the correct intervention, at the correct stage, for the correct tissue is what matters.
Sydney Heel Pain Clinic
A Clinic Built Around Heel Pain
Sydney Heel Pain Clinic is focused on the investigation and treatment of heel and lower-limb pathology, combining clinical diagnosis, biomechanical assessment and treatment planning within the same clinical process.
More Than 7,000 Patients
Clinical experience across a broad range of heel-pain presentations.
Heel Pain Is Our Clinical Focus
Assessment and treatment are centred on heel and lower-limb pathology rather than general podiatry.
Led by Karl Lockett, Sports Podiatrist
Former podiatrist to the Sydney Opera House, guest lecturer at Western Sydney University, and international speaker on heel pain.
Four Sydney Locations
Sydney CBD, Parramatta, Crows Nest and Miranda.
Your Consultation
What Happens at Your First Appointment?
The consultation begins with your history, followed by clinical examination and investigation of the factors contributing to the problem.
Step 1
Clinical History
We listen first. Your backstory matters. When did the pain begin? What were you doing at the time? What treatments have you already tried? What aggravates it, what settles it, and how has it changed over time?
Step 2
Clinical Examination & Differential Diagnosis
Examination is used to diagnose the symptomatic tissue and differentiate between the possible causes of pain in the posterior heel.
Step 3
Mechanical & Biomechanical Investigation
Gait, foot mechanics, calf function, footwear, activity and relevant loading patterns are investigated to identify the contributing mechanical drivers.
Step 4
Findings & Treatment Plan
The diagnosis and contributing factors are explained, required load modifications are identified, and the appropriate treatment strategy is established.
You leave with an understanding of the diagnosis, the factors contributing to it and the rationale behind the treatment plan.
Patient Experience
Patients Who Came In With Persistent Heel Pain
K
Kim Brierley
Google review
★★★★★
“Fantastic clinic. I had Achilles tendonitis which was extremely painful. I had seen another podiatrist who gave me exercises that made my condition worse. The shock treatment and new orthotics have worked wonders. I highly recommend this clinic.”
B
Bao Pham
Google review
★★★★★
“My heel pain problem had been going on for over 6 years. I've been through several physio therapy clinic, the issue only got slightly better but never completely heal. After two sessions with Karl, for the first time in 6 years, I didn't feel pain in the morning and didn't need to tip toe for a few minutes after getting out of bed.”
E
Emmanuel Giannaros
Google review
★★★★★
“For almost 4 years I was barely able to walk for 2–3 days after participating in any high impact sport/activity. After just one consultation with Karl, he provided me with injury specific educational information, recommendations on appropriate footwear and he also designed custom made orthotics for me. For the first time in 4 years, I was able to return to playing competitive sport.”
4.9 ★ from 240+ Google reviews
Read further patient experiences on Google.
Timing
When Should Pain in the Back of the Heel Be Assessed?
If posterior heel pain is persisting, repeatedly returning, or changing the way you walk, exercise or choose footwear, establishing a diagnosis becomes more useful than continuing to trial different treatments without knowing which tissue is involved.
Clinical Information
Detailed Information About Posterior Heel Pain
Achilles Tendinopathy and Pain Behind the Heel
The Achilles tendon transfers force from the calf muscles to the heel during walking, running and push-off. Pain may occur within the tendon above the heel or at the insertion where the tendon attaches to the calcaneus.
In insertional Achilles tendinopathy, both tensile load and compression around the posterior heel may be relevant. Symptoms can therefore be influenced by training load, calf function, ankle movement, footwear and the shape of the posterior calcaneus.
Retrocalcaneal Bursitis
The retrocalcaneal bursa sits between the Achilles tendon and the posterior calcaneus. Irritation in this region may produce pain, local tenderness and swelling.
Compression from footwear, repetitive loading and nearby structural prominence can contribute. Distinguishing bursitis from Achilles tendon pain is clinically important because management may differ.
Haglund's Deformity and Posterior Calcaneal Prominence
Haglund's deformity describes a prominent area at the posterosuperior calcaneus. In some patients this prominence increases compression against the Achilles insertion, surrounding bursae or footwear.
The presence of a bony prominence does not automatically establish it as the sole cause of symptoms. Clinical findings need to be considered together with footwear pressure, local tissue irritation and mechanical load.
Mechanical Load, Footwear and Calf Function
- ongoing mechanical load
- training or activity volume
- footwear construction and heel-counter pressure
- calf strength and function
- gait and foot mechanics
- joint movement and tissue compression
- timing and progression of treatment
Imaging
Imaging is not required in every presentation of posterior heel pain. Where the clinical presentation or differential diagnosis warrants further investigation, X-ray, ultrasound or other imaging may be considered to assess bone, tendon and surrounding soft tissues.
Treatment Considerations
Treatment is directed by the diagnosis and the mechanical factors contributing to continued tissue load or compression.
Depending on the clinical findings, management may incorporate load modification, calf rehabilitation or stretching programmes, footwear-specific recommendations, current-market footwear advice, shockwave therapy, heel lifts and 3D-printed custom footbeds.
The sequence of treatment can be as important as the intervention itself, particularly where tissue irritability, local compression or suspected tendon tearing needs to be considered.
References
Aldridge T. Diagnosing heel pain in adults. American Family Physician. 2004;70:332–338.
Hendrix CL. Calcaneal apophysitis (Sever disease). Clinics in Podiatric Medicine and Surgery. 2005;22:55–62.
Pearce CJ, Tan A. Non-insertional Achilles tendinopathy. EFORT Open Reviews. 2016;1:383–390.
Vaishya R, Agarwal AK, Azizi AT, Vijay V. Haglund's Syndrome: A Commonly Seen Mysterious Condition. Cureus. 2016;8(10).