Upper Heel & Achilles Pain
Pain around the upper heel is commonly associated with the Achilles tendon above its attachment to the heel bone, the retrocalcaneal bursa, or a combination of the two.
Determining exactly where the pain originates is important. Pain higher around the Achilles tendon represents a different clinical presentation from pain concentrated directly at the tendon insertion and posterior heel bone.
Recognising the Pattern
Upper heel and Achilles pain often follows a recognisable pattern, particularly when tendon loading or the retrocalcaneal bursa is involved.
Pain or stiffness around the Achilles tendon above the heel bone.
Morning stiffness or discomfort during the first few steps after rest.
Symptoms that initially ease as the tendon warms up during activity.
Tenderness, thickening or swelling around the lower Achilles tendon.
Discomfort with running, hills, stairs, jumping or repeated push-off.
Pain that settles during exercise but returns later or the following morning.
Clinical Differentiation
When symptoms are positioned above the posterior heel bone rather than directly at the Achilles insertion, two structures warrant particular attention.
Mid-portion, or non-insertional, Achilles tendinopathy affects the tendon above its attachment to the calcaneus. Pain is therefore generally felt higher than the classic insertional Achilles presentation.
Patients may describe morning stiffness, tenderness within the tendon, thickening, discomfort during push-off, or pain that initially improves as they become active before returning afterwards.
The retrocalcaneal bursa is a small fluid-filled structure positioned between the Achilles tendon and the upper posterior calcaneus.
When irritated, it can produce local pain, stiffness and tenderness around the upper heel. Achilles tendon irritation and retrocalcaneal bursitis may also occur together rather than as completely separate conditions.
Location Matters
Pain felt directly where the Achilles attaches to the back of the heel represents a different clinical pattern.
When symptoms are concentrated around the posterior calcaneus and Achilles insertion, insertional Achilles tendinopathy, posterior calcaneal prominence or Haglund's deformity, posterior calcaneal spur formation and adventitial bursitis become more relevant.
This distinction matters because tendon loading, compression against the heel bone, footwear pressure and the appropriate rehabilitation strategy may be quite different.
Persistent Symptoms
Achilles and bursal symptoms can persist when treatment focuses only on the painful area without identifying what continues to load or compress the tissue.
Rest may settle symptoms temporarily. Stretching or strengthening may help some presentations but aggravate others when tissue irritability, compression or exercise dosage has not been considered.
Investigative Assessment
The objective is not simply to confirm that the Achilles region hurts. It is to establish which tissue is involved and why it continues to be stressed.
Clinical history and examination are used to differentiate mid-portion Achilles pathology, retrocalcaneal bursitis, insertional symptoms and other potential sources of pain.
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.
Gait, foot and ankle function, joint movement, calf capacity and footwear are assessed to determine which findings are clinically relevant.
Treatment is selected and sequenced according to the diagnosis, tissue irritability and the factors perpetuating load or compression.
Clinical Management
Upper heel pain is not managed from a single treatment template. The diagnosis, tissue response and mechanical findings determine what should happen next.
Training exposure, walking load, hills, running speed and other repetitive demands may need temporary modification while tissue capacity is rebuilt.
Calf capacity, ankle function and tendon loading are evaluated to determine how much mechanical demand the Achilles region can currently tolerate.
Heel height, heel-counter construction, cushioning and the mechanical interaction between footwear and the Achilles region may influence symptoms.
Temporary heel elevation can alter Achilles tendon tension and ankle position and may be useful in selected clinical presentations.
Shockwave therapy may be considered in appropriate chronic tendon presentations when clinical findings and treatment timing support its use.
Where gait or foot mechanics are contributing meaningfully to ongoing tissue stress, footwear strategies or individually designed orthoses may form part of the management plan.
Sydney Heel Pain Clinic
Assessment and treatment are centred on heel and lower-limb pathology, with diagnosis, biomechanics, gait, footwear and mechanical drivers considered within the same clinical process.
Clinical experience across a broad range of heel-pain presentations.
Assessment and treatment are centred on heel and lower-limb pathology rather than general podiatry.
Former podiatrist to the Sydney Opera House, guest lecturer at Western Sydney University and international speaker on heel pain.
Sydney CBD, Parramatta, Crows Nest and Miranda.
Upper Heel Pain Assessment
If upper heel or Achilles pain is persisting, repeatedly returning or limiting walking, exercise or footwear, establishing the tissue involved provides a more useful starting point than continuing to trial treatment without a clear diagnosis.
Clinical Information
The Achilles tendon transfers force generated by the calf muscles to the heel during walking, running and push-off. Mid-portion Achilles tendinopathy affects the tendon above its insertion into the calcaneus.
Symptoms may include local tenderness, stiffness, tendon thickening and pain during or following loading. Morning stiffness and discomfort after periods of inactivity are commonly reported.
The retrocalcaneal bursa lies between the anterior surface of the Achilles tendon and the upper posterior calcaneus. Its function is to reduce friction as these structures move in relation to one another.
Irritation of the bursa may produce upper heel pain, stiffness and tenderness. Because of its anatomical proximity to the Achilles tendon, bursal and tendon symptoms may coexist.
Pain higher within the Achilles region is more suggestive of mid-portion tendon pathology than classic insertional Achilles tendinopathy.
Conversely, symptoms positioned directly around the Achilles attachment and posterior heel bone make insertional tendon pathology, posterior calcaneal prominence, posterior calcaneal spur formation and adventitial bursitis more clinically relevant.
We assess the factors that may be increasing load through the Achilles region or contributing to ongoing compression and irritation.
Imaging is not required in every case of upper heel pain. When the clinical presentation warrants further investigation, ultrasound, X-ray or MRI may assist in evaluating tendon structure, the retrocalcaneal bursa, adjacent bone and other potential sources of symptoms.
Frequently Asked Questions
When pain is located above the posterior heel bone, mid-portion Achilles tendinopathy and retrocalcaneal bursitis are important possibilities. In some patients both structures may be symptomatic.
Yes. Achilles tendinopathy commonly produces stiffness or discomfort during the first few steps in the morning or after prolonged sitting. Symptoms may temporarily improve as the tendon warms up.
Mid-portion Achilles tendinopathy generally produces pain within the tendon above its attachment to the heel bone. This differs from insertional Achilles tendinopathy, where symptoms are centred directly around the attachment at the posterior calcaneus.
Retrocalcaneal bursitis can produce pain, stiffness and local tenderness around the upper posterior heel, between the Achilles tendon and the heel bone. Symptoms can overlap with Achilles tendon pain.
Yes. The Achilles tendon and retrocalcaneal bursa are anatomically close, so irritation affecting one structure can coexist with symptoms from the other.
Not necessarily. Insertional Achilles tendinopathy is centred where the tendon attaches directly to the posterior heel bone. Pain felt higher above the heel is more suggestive of a non-insertional Achilles presentation or adjacent retrocalcaneal bursal irritation.
Tendon symptoms can temporarily reduce as the area becomes warm and active even though mechanical loading continues. Pain or stiffness may therefore return later that day or after rest the following morning.
Assessment becomes particularly useful when symptoms persist, repeatedly return, worsen with activity, alter the way you walk or exercise, or have failed to respond to treatment directed at an assumed diagnosis.
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van Dijk CN, van Sterkenburg MN, Wiegerinck JI, Karlsson J, Maffulli N. Terminology for Achilles tendon related disorders. Knee Surgery, Sports Traumatology, Arthroscopy. 2011;19:835–841.
