What causes pain in the back of the heel?
Pain in the back of the heel, or posterior heel pain, as it is medically referred to, is most commonly caused by either calcaneal apophysitis (Sever’s disease), Achilles tendonitis, Achilles tendon bursitis (retrocalcaneal or retroachilles bursitis), or a heel spur at the back of the heel (Haglund’s deformity, ‘pump bump’, retrocalcaneal exostosis).
Pain in the back of the heel due to Calcaneal apophysitis (Sever’s disease)
Sever’s disease is a common cause of heel pain in the back of the heel in children and adolescents aged between 8 and 14 years old2. This condition occurs when excessive tension and stress are placed on the calcaneal apophysis (the growth plate area of the heel bone), causing inflammation and irritation in this area. Young patients with this condition may complain of pain in one or both heels. The pain in the back of the heel is often described as a constant bruise, which feels more painful with exercise. Whilst any child may become affected, Sever’s disease is most common in those who participate in sports where lots of jumping is required, such as basketball, volleyball or gymnastics.
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.
Pain in the back of the heel due to Achilles tendonitis
In adults, pain in the back of the heel is most commonly associated with Achilles tendonitis1. Achilles tendonitis occurs when the Achilles tendon at the back of the lower leg, becomes irritated and inflamed. This happens most commonly due to intense or repetitive strain on the tendon. Patients describe the pain in the back of the heel as uncomfortable and limiting. Patients often have reduce range of motion in their ankle and tightness in their calf because of the pain. Sometimes there may be redness, swelling or heat in the back of the heel and stiffness.
Figure 2. Showing swelling of the patient’s leg due to Achilles tenonditis3.
Pain in the back of the heel due to a Haglund’s deformity (Pump Bump, retrocalcaneal exostosis)
Haglund’s deformity is a very common clinical condition that causes pain in the back of the heel of the patient4. It is also known as a ‘pump bump’ or retrocalcaneal exostosis, in medical terms. It occurs when an abnormal bony heel spur forms at the back of the heel bone, at the insertion point of the Achilles tendon. The soft tissues in the area then become irritated and inflamed when the bone spur rubs against tight fitting or rigid shoes. The condition is most common in middle-aged females, but males may also be affected. A painful enlargement is often visible at the back of the heel and the pain is usually worse after a period of rest.
Figure 3. Clearly shows the prominent swelling on the back of both heels of the patient, caused by Haglund’s deformity4.
Pain in the back of the heel due to Achilles tendon bursitis (retrocalcaneal or retro Achilles bursitis)
When the bursae in the posterior area of the calcaneus become inflamed or irritated, this is known as bursitis, and causes pain in the back of the heel. The bursae are flat, fluid-filled sacs that provide cushioning and reduce friction in areas where muscles, tendons and ligaments run over bones. Retrocalcaneal bursitis is the inflammation of the bursa between the Achilles tendon and the heel bone. Treatment for achilles tendons is particularly relevant here given the involved anatomy. Retro Achilles bursitis is the inflammation of the bursa between the Achilles tendon and the skin. Retrocalcaneal bursitis usually occurs from constant irritation and pressure on the bursa, such as lots of uphill running, or in association with Haglund’s deformity. Retro Achilles bursitis is almost exclusively caused by footwear that digs into the back of the heel. Sometimes both types of bursitis occur at the same time. Symptoms of bursitis include swelling, redness, and achy pain that becomes worse when the foot is flexed upwards or pointed down.
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.
Diagnosing the cause of pain in the back of the heel
Your sports podiatrist, often associated with a sports injury clinic for 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. Your podiatrist is likely to ask you questions about things such as:
- Your age and regular occupation
- 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, how well they fit and how often you replace them with a new pair
- 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 of your feet, to evaluate your gait (walking pattern) and detect imbalances, malalignment or other abnormalities related to the function of your feet and ankles
- A physical examination of your feet and ankles, including comparing the painful and non-painful foot for any differences. 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 other medical imaging, which will 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 many cases, especially with plantar fasciitis heel pain, treatment for pain in the back of the heel is conservative. 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. In cases where pain is severe or conservative treatments are not working, NSAIDs (non-steroidal anti-inflammatories) such as ibuprofen may be recommended for short term use.
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.
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