PAIN IN THE BACK OF THE HEEL
Understand the cause and why symptoms do not improve
Patients presenting with posterior heel symptoms have often trialled some form of self-management.
This may include rest, stretching, massage, calf raises or footwear changes.
In some cases, symptoms reduce temporarily.
In many cases, they persist.
This is usually due to a mismatch between the structure involved, the treatment applied, and the timing of that treatment.
For example, in many cases, treatment such as shockwave therapy is introduced before the underlying cause has been addressed and before load has been managed appropriately. This reduces its effectiveness and can delay recovery.
Pain around the back of the heel can involve the Achilles tendon, the bursa, or the posterior calcaneus. Each structure has a different role, a different tissue type, and a different tolerance to load.
Without identifying the structure under stress, management is often inconsistent.
Common Presentation Patterns
Patients will typically report one or more of the following:
- pain on first steps after rest
- discomfort during push-off or incline walking
- localised tenderness at the back of the heel
- stiffness after periods of inactivity
- fluctuating symptoms with activity
These patterns are used to guide diagnosis.
Figure 1. Diagram of the anatomy of the foot, showing the location of the growth plate (apophysis) at the heel bone. The red area shows the typical area where a patient with Sever’s disease may feel pain and tenderness.
Figure 2. Showing swelling of the patient’s leg due to Achilles tenonditis3.
Assessment Focus
Assessment is directed at determining:
- the structure involved
- the type of load causing irritation
- contributing mechanical factors
This allows treatment to be specific rather than general.
Variation in Recovery
Recovery timelines vary.
In many cases, this is not due to severity, but due to:
- ongoing mechanical load
- footwear influence
- calf muscle function
- timing of intervention
These factors are often not addressed with general advice.
Once identified and managed appropriately, symptoms tend to settle more predictably.
Figure 3. Clearly shows the prominent swelling on the back of both heels of the patient, caused by Haglund’s deformity4.
Figure 4. Diagram of the anatomy of the foot, showing the locations of the bursae associated with the Achilles tendon that may become inflamed and cause pain in the back of the heel.
Treatment Objective
Treatment is not directed at symptoms alone.
The objective is to:
- identify the driver behind the load
- reduce load on the affected structure
- allow tissue recovery
- modify the contributing factors
- stimulate healing (shock wave therapy)
- Precision footwear education
This approach reduces recurrence and improves consistency of outcome.
What Occurs at Initial Appointment
The initial consultation is used to:
- identify the affected structure
- assess contributing mechanical factors
- determine appropriate load modification
- outline a structured management plan
- consider shock wave therapy
Patients are provided with clear direction on what to change and why.
Timing of Intervention
If symptoms persist beyond 2–3 weeks without improvement, spontaneous resolution becomes less likely.
Delayed management is associated with longer recovery timeframes and increased severity of conditions. Tears become more common
If posterior heel symptoms are not improving, assessment is indicated.
Accurate identification of the structure involved allows for targeted management and more predictable recovery.
Appointments are available for assessment and treatment planning.
ADDITIONAL INFORMATION
Diagnosing the cause of pain in the back of the heel
Your sports podiatrist, often associated with a sports injury clinic for heel pain / Achilles tendon /plantar fasciitis, is an expert in diagnosing the conditions that cause pain in the back of the heel.
Your consultation will begin with a discussion about your pain and symptoms and your podiatrist is likely to ask you questions about things such as:
- Occupational influences
- Whether your pain feels worse at particular times of the day or with particular activities
- Whether you’ve had any recent injury to the area
- Whether you participate in any sports or physical activities
- What type of shoes you normally wear, and how often you replace them with a new pair – Specific shoe models should be brought to your appointment
- Medical history related to your legs and feet (such as injuries, arthritis, diabetes)
- Whether you are currently taking any medications.
During your consultation, your sports podiatrist will also conduct a thorough physical examination of your feet, which may include:
- A biomechanical assessment to evaluate your gait (walking pattern) and detect imbalances, malalignment or other load abnormalities related to the function of your feet and ankles.
- A physical examination of your feet and ankles, including a comparison between the painful and non-painful foot for any clinical imbalances. They will also check for pain and tenderness, any palpable abnormalities such as swelling, muscle weaknesses and range of motion.
- A neurological examination, to assess the nerves and muscles by checking for strength, reflexes and sensation.
In some cases, your sports podiatrist may ask you to have an xray or ultra sound which may help in diagnosing the cause of your pain in the back of the heel.
Treatment for pain in the back of the heel
Heel pain treatment will be based on the diagnosis. In most cases, especially with Achilles tendonitis / bursitis / plantar fasciitis - heel pain, treatment for pain in the back of the heel is conservative and does not involve surgery. Your sports podiatrist may suggest treatments such as rest, application of ice packs, shoe inserts for plantar fasciitis, shock wave therapy, heel lifts, stretches or orthoses.
Disclaimer
Please be aware that the information provided above, regarding pain in the back of the heel should not be taken as general advice and is for informational purposes only. If you are experiencing heel pain you should endeavour to consult with a suitably qualified sports podiatrist to discuss your condition. You can make an appointment with one of our specialist podiatrists by visiting our website at sydneyheelpain.com.au or by calling 02 9388 3322.
References
1Alridge, T., (2004), Diagnosing heel pain in adults, American Family Physician, 70 (332-338)
2Hendrix, C. L., (2005), Calcalneal apophysitis (Sever disease), Clinics in Podiatric Medicine and Surgery, 22 (55-62).
3Pearce, C. J., Tan, A., (2016), Non-insertional Achilles tendinopathy, EFFORT Open Reviews, 1 (383-390).
4Vaishya, R., Agarwal, A. K., Azizi, A. T., Vijay, V., (2016), Haglund’s Syndrome: A Commonly Seen Mysterious Condition, Cureus, 8 (10).
Written by Karl Lockett, Sports Podiatrist