Pain at the back of the heel is common. Doctors call it posterior heel pain — meaning pain behind the heel rather than underneath it. There are several causes, including heel bursitis, Haglund’s deformity, Achilles tendon bursitis and tendonitis, the plantaris tendon, and a calcaneal (bone) spur. So how do we find the exact cause, and how do we treat it?
Anatomy of the back of the heel
You might think the anatomy at the back of the heel is simple, but it’s a little complex.
You have the large heel bone, the calcaneus. Attached to it from above is the large Achilles tendon. Two bursae protect the tendon: the larger retrocalcaneal bursa, which sits under the Achilles tendon, and the more superficial retro-Achilles bursa, which sits on top of the tendon near the skin. Next to the deeper bursa lies a large fat pad — Kager’s fat pad. And the back of the ankle joint sits between the tendon and the fat pad. With such intricate anatomy, it’s no wonder problems such as Achilles bursitis, tendonitis, and heel bursitis arise.
Causes of back-of-heel pain
Heel bursitis
The heel bursae are usually thin-walled sacs of fluid that protect the Achilles tendon. Under sudden excessive stress — a rapid change in activity, or ill-fitting shoes — these bursae become irritated and swollen. This is heel bursitis.
Achilles tendonitis
The Achilles tendon can become swollen and irritated where it inserts onto the heel bone. The tendon and the heel bursa are closely related, so swelling of the tendon often comes with swelling of the bursa.
Calcaneal (bony) spur and Haglund’s deformity.
A bone spur can form in the Achilles tendon where it attaches to the heel bone, developing over time. Bone within the tendon is irritating and can cause associated tendonitis and bursitis. A bony prominence at the back of the heel — Haglund’s deformity — can rub against and irritate the bursa in the same way.
How do we diagnose back-of-heel pain?
Diagnosis can be difficult because several of these conditions often coexist. The factors that irritate the bursa also swell the Achilles tendon, and a Haglund’s deformity can irritate the bursa on top of that.
We use a combination of clinical assessment and imaging. Features that point towards heel bursitis or Achilles tendonitis include:
- Pain at the back of the heel that warms up with activity
- Pain in the morning on waking
- Swelling where the Achilles inserts into the heel bone — a painful bump on the heel
- Pain while wearing tight-fitting shoes
Ultrasound assesses the structures involved — heel bursitis, Achilles tendonitis, a heel bump, and Haglund’s deformity. We use MRI only if we suspect another cause, such as the back of the ankle joint (os trigonum) or a cyst in the heel bone.
Heel bursitis or plantar fasciitis: how to tell them apart
These two conditions occur close together in the heel, and the location of the pain is the clue. Plantar fasciitis causes pain under the heel. Heel bursitis causes a painful bump at the back of the heel.
Heel bursitis treatment
Start with simple treatments: changing your footwear, gel pads to reduce pressure, and heel lifts in your shoes, along with anti-inflammatory measures such as ice and ibuprofen gel. The best shoes for heel bursitis are comfortable and supportive through the heel and mid-arch, and the heel counter shouldn’t compress the bursa — direct pressure makes it worse. Sometimes a doughnut pad relieves that pressure.
Second, a rehabilitation programme to strengthen the calf muscle is essential. See a therapist who has a particular interest in heel pain. Because heel bursitis is often associated with Achilles tendonitis, treating both conditions together improves outcomes.
Third, adjuncts to rehabilitation help — shockwave therapy and GTN patches. GTN patches, in particular, improve pain and reduce bursal swelling.
Finally, set your expectations realistically. Conditions such as heel bursitis and Achilles tendonitis take a long time to improve.
Heel bursitis injection: is it a good idea?
Maybe — but with real caution. Heel bursitis is an inflammation of the bursa, and cortisone is a potent anti-inflammatory, so a cortisone injection into the bursa reduces pain and swelling. The problem is that cortisone has side effects, including weakening the nearby Achilles tendon and thinning the skin. On balance, for most people with heel bursitis, we think the risk of a cortisone injection is too high.
So are there other injection options where cortisone is too risky? Yes. We use sclerosant treatments — high-concentration sugar (dextrose) or polidocanol — to target the nerves surrounding the tendon and bursa. Abnormal nerves can contribute to heel bursitis or Achilles tendonitis, following blood vessels that show up clearly on ultrasound. By injecting alongside these vessels under ultrasound, we can target the nerves that cause the pain, without the tendon-weakening risk of cortisone. Dr Masci has written a paper summarising the effectiveness of injections in tendonitis.
Is surgery a good option for retrocalcaneal bursitis?
Overall, the results of surgery are unpredictable at best. We strongly advise avoiding it unless you’ve failed all other treatment, including rehabilitation and injections. Surgical options range from removing the bursa and the Haglund’s deformity to debriding and reattaching the Achilles tendon. Some people do well, but others struggle with persistent pain afterwards, and there are risks including wound breakdown and infection.
Frequently asked questions about retrocalcaneal bursitis
Can you get gout at the back of the heel?
Yes, but it’s rare. Gout usually presents as sudden pain with swelling and redness, and — unlike Achilles tendonitis — it’s typically unrelated to exercise.
Can I run with retrocalcaneal bursitis?
Yes, but only while the pain stays mild and stable. We generally recommend modifying your running at the same time as treating the bursitis, rather than pushing through worsening pain.
Do heel lifts help heel bursitis?
Yes. A recent study found that a 2 cm heel lift improved the pain of insertional Achilles tendonitis after just two weeks, with the biggest improvements in people who had calcification or a Haglund’s deformity. Heel lifts appear to work by increasing the ankle’s range of motion and reducing the load at the back of the heel.
What’s the difference between heel bursitis and Haglund’s deformity?
They frequently occur together. Haglund’s deformity is a bony prominence at the back of the heel bone; heel bursitis is inflammation of the fluid-filled bursa. The bony bump of a Haglund’s deformity often rubs against and inflames the bursa, which is why treating the pressure — through footwear and padding — helps both.
How long does heel bursitis take to settle?
It’s usually slow — weeks to several months — particularly when Achilles tendonitis is present too. Setting realistic expectations and sticking with footwear changes and a calf-strengthening programme gives the best result.
Final word from Sport Doctor London about retrocalcaneal bursitis
Heel bursitis can be a challenging condition to treat. Start with simple, non-invasive treatments first. Move on to injections only if needed — and be cautious with cortisone, given its effect on the nearby Achilles tendon. Avoid surgery in almost all cases.
If you have persistent pain at the back of your heel, Dr Masci can assess you in London, including ultrasound in clinic. Contact the team here or call +44 (0) 203 488 0350.
Lorenzo
It’s velia from Brisbane. Tony D’ARIENZO wife. I am a runner with a problem heel. I googled to see what it is I might have snd your article came up. Great read and very informative. I think I have bursitis and perhaps Achilles tendinopathy.
It’s so painful
Hope you are well
Velia
Hi Velia, Good to hear from you. Yes, I suspect you have insertional Achilles tendinopathy. Simple management strategies work best – avoid tight shoes, calf exercises and topical anti-inflammatories.
LM
I have a white lp on the back of my foot I use to work on concrete floors wearing steal toes shoes .I m no longer working there so I do another job that I be on my feet all the time wear I wore crops shoe almost every day the one you just slide your feet in and I wore low flat heels shoes I start noticing that it was hard for me to walk on my feet so I start wear thick rubber heel tennis shoes that helped and sometimes I put shoe pads in that helps as well but the lump is still there.what should I do any suggestions.
Please read my blog for suggestions. I suggest you avoid heel compression – which means avoiding tight-fitting shoes.
LM