Pain at the back of the heel? How to figure out what’s causing it and what to do about it

There are several injuries or conditions that can cause pain in the back of your heel and ankle, and it can be difficult to tell them apart. In this article, we provide an overview of the most common causes and what treatments work best for each. There are also links to in-depth articles on most of these. Remember, if you need help with an injury, you're welcome to consult one of our team via video call.

The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in most of our articles.

In this article:

1. Pain right at the back of the heel

2. Pain at the outer back of the heel

3. Pain at the inner back of the heel

4. How we can help

Pain right at the back of the heel

Achilles tendonitis

Where you feel the main symptoms: Insertional Achilles tendonitis causes pain and/or stiffness in the area where the Achilles tendon inserts into the heel bone. Mid-portion Achilles tendonitis causes pain and/or stiffness in the middle of the tendon, about 5 cm above the heel bone.

How it typically starts: The symptoms set in gradually, either over the course of a training session, or you feel it several hours after an activity (typically the next morning). It can also be caused by a direct hit, certain medications, and inflammatory conditions. Here is more information about the symptoms, causes, and diagnosis of Achilles tendonitis.

Best evidence-based treatments: The treatment that works best for most people is combining relative rest (reducing your activities to what you can do pain-free) combined with a graded strength training plan (to restore the tendon's strength). However, this does not work for everyone – you can find a comprehensive review of the most effective treatments for Achilles tendonitis here.

Achilles tendon tear

Where you feel the main symptoms: The pain is in the Achilles tendon, but if you have a complete rupture, you may not feel much pain.

How it typically starts: You will feel a sudden, sharp pain while doing an activity, or it may feel as if someone has kicked you in the back of your heel. You may also hear a loud snap or cracking sound. Read more about how to diagnose Achilles tendon tears.

Best evidence-based treatments: You must get the injury assessed immediately if you suspect that you may have torn your Achilles tendon. Partial and complete tears can heal well without surgery as long as you receive the correct treatment soon after the incident.

For partial Achilles tears:

• Wear shoes with a bit of a heel (many types of running shoes are designed like this) or place inserts in your shoes to lift your heels – this will take some strain off the tendon.

• Limit how much you walk and stand to what you can do with minimal discomfort.

• Follow a graded strength training plan to restore your tendon’s strength.

Find more information about the treatment of partial Achilles tears here.

Complete Achilles tendon tears must be immobilised in plantar flexion as soon as possible.

For complete Achilles tears or ruptures:

• Your foot has to be immobilised in cast or orthopaedic boot at a 30 degrees plantar flexion (toes pointed) angle as soon as possible.

• As the tendon grows together, the angle of the foot is slowly reduced over 8 to 12 weeks until you can move as normal.

• Follow a progressive rehab plan that starts with very easy exercises and increase in intensity as your tendon heals.

Surgery is only necessary if the ends of the tendon have separated too far to grow together. Find more advice on complete Achilles ruptures here.

Retrocalcaneal (heel) bursitis

Where you feel the main symptoms: There will be pain and swelling on or just above the heel bone. The bursa is a fluid-filled sac between the Achilles tendon and the heel bone. Heel bursitis can occur on its own or in combination with Achilles tendonitis. Read more about heel bursitis.

How it typically starts: It often starts due to something pressing on that area (e.g. the back of a shoe), or a direct hit, or an activity that causes excessive compression between the Achilles tendon and the heel bone (e.g. doing many intense calf stretches or walking long distances in flat shoes).

Best evidence-based treatments:

• Reduce the pressure on the bursa by wearing shoes with a heel or placing heel raising inserts into your shoes.

• Avoid calf and Achilles stretches, as this increases the pressure on the injured bursa and usually makes it worse.

• You may also benefit from anti-inflammatory medication to reduce the inflammation and swelling.

Learn more about heel bursitis treatment.

Tear of the fascia cruris

Where you feel the main symptoms: The fascia cruris is a thin layer of connective tissue that encloses all the muscles and tendons in the calf down to the ankle joint and connects to the Achilles tendon. The most common area for tears is where it attaches to the Achilles tendon near or on the heel bone. It usually tears either on the inner or outer border of the Achilles attachment, causing pain and swelling in that area.

How it typically starts: People usually describe having had tight calves for a period preceding the injury and then feeling a sudden, sharp pain during activity – it can feel like a sharp sting.

Best evidence-based treatments: It is important to get it scanned to ensure that it is a tear to the fascia cruris and not the Achilles tendon. It usually reacts well to a combination of:

• Relative rest (reducing activities to a level that does not irritate it).

• Protecting the injured area (wearing heeled shoes or heel lift inserts to reduce the strain on the area).

• A gradually progressive strength training plan, starting with exercises that avoid stretching the injured area (e.g. heel raises to floor level).

Posterior ankle impingement

Where you feel the main symptoms: The pain is felt at the back of the ankle, above the heel bone. It feels deep and difficult to pinpoint. It may be sharp or dull. More about posterior ankle impingement.

Where you feel the pain when you have posterior ankle impingement.

How it typically starts: It develops gradually if it is caused by overuse, e.g. repetitively taking the ankle into strong plantar flexion (pointing toes down or lifting up on toes), like in ballet, or kicking a football. But it may also develop suddenly after a trauma event, e.g. spraining your ankle.

Best evidence-based treatments:

• You have to allow the injury to calm down by reducing the painful activities and avoiding the movement that causes pain (full plantar flexion).

• Once it has calmed down, you should then rebuild the strength and control around the ankle joint through a progressive exercise plan.

• In some cases a corticosteroid injection may be useful, but this should only be used as a last resort.

Most cases can recover without surgery. Read more about treatments for posterior ankle impingement.

Local nerve irritation

Where you feel the main symptoms: Injuries to the sural or tibial nerves can cause stinging, burning, or tingling sensations, pins and needles, or numbness around the back of the ankle.

The sural nerve and tibial nerve run along the back and sides of the heel.

How it typically starts: It usually starts after an activity or movement that excessively stretches the nerves in that area (e.g. strong calf stretches or lots of steep uphill walking), or when you get hit directly on a nerve (e.g. someone pushes a shopping trolley into the back of your heel). Find more information about nerve pain at the heel here.

Best evidence-based treatments:

• You usually don’t need any special exercises, because this is not a condition that affects the strength of the tendons and muscles. The injured nerves simply have to calm down.

• Avoid movements and activities that increase the nerve-related sensations, e.g. avoid calf stretches, and wear heel-raising shoe inserts to reduce the strain on the nerve.

• Or simply adapt your activities so that they don’t irritate the nerves, e.g. do squats with wedges under your heels.

Nerves can take a very long time to calm down and recover, so you will need a bit of patience with this.

Referred pain from the lower back

Where you feel the main symptoms: Referred pain from the lower back (via your spinal nerves) that you experience at the heel can feel very similar to the strange sensations you get when a local nerve is injured or the pain from an Achilles injury. What catches some people out is that these symptoms are often present without them having any pain in their back, which is why they don’t suspect the back to be the origin of the pain. A physiotherapist can easily test this by putting you through some movement tests like the slump test.

Where injuries to the spinal nerves refer pain and strange sensations.

How it typically starts: There is usually no clear explanation for how the pain started – it is just suddenly there one day. Or it may be that you had or still have an injury to your lower back.

Best evidence-based treatments: The treatment has to be focused on whatever is causing your back to refer the pain to your heel. Doing treatments on the heel itself won’t work, because that’s not where the injury is. Depending on the cause, treatment may involve:

• Back exercises.

• Exercises to help the nerve slide more freely.

• Changing habits and moving more (e.g. how you sit at your computer or perform certain tasks and taking regular breaks from sitting at your desk).

Pain at the outer back of the heel

Peroneal tendon injury

Where you feel the main symptoms: Peroneal tendon injuries (like peroneal tendonitis) cause pain on the outer back of the heel or ankle.

How it typically starts: Peroneal tendonitis symptoms set in gradually either over the course of a training session, or you feel it several hours after an activity (typically the next morning). Peroneal tendon tears cause a sudden, sharp pain and often happen when you sprain your ankle (outer ankle sprain).

Best evidence-based treatments: Similar to other types of tendonitis, peroneal tendonitis usually reacts well to a period of relative rest combined with a progressive strength training plan. Read more about peroneal tendonitis here.

Peroneal tendon tears may require a period of immobilisation in an orthopaedic boot before starting with a strength training plan.

Pain at the inner back of the heel

Plantaris tendon injury

Where you feel the main symptoms: An injured plantaris tendon causes pain on the inner side (medial) of the Achilles tendon, about 6 cm above the heel bone. Because the plantaris tendon runs so close to the Achilles, it is often mistaken for an Achilles injury.

Where the plantaris tendon typically causes pain. Picture credit: Wikimedia commons

How it typically starts: Plantaris tendonitis usually starts gradually towards the end of a training session or over several days, while a tear will cause a sudden, sharp pain. It is usually aggravated by activities that take the ankle into strong dorsiflexion (e.g. calf stretches or doing calf raise exercises over the edge of a step) or overpronation at the ankle.

Best evidence-based treatments:

• If you overpronate, you may benefit from wearing insoles that reduce pronation or taping your ankle, as this will reduce the strain on the plantaris tendon.

• During the early stages of recovery, avoid activities that stretch your ankle into dorsiflexion (e.g. calf stretches, walking or running up hills, wearing flat shoes).

• Follow a progressive strength training plan that include exercises for your plantaris tendon but also improves the stability around your ankle and hips – this will help to reduce over-pronation.

Find out more about plantaris tendonitis here.

Tibialis posterior tendon injury

Where you feel the main symptoms: Tibialis posterior tendon injuries cause pain on the inner part of the ankle and inner back of the heel. But it can also get injured where it attaches to the inner part of the foot arch, causing the pain to radiate all the way from the foot along the inner side of the heel and a short distance above the heel.

How it typically starts: Overpronation at the ankle is one of the main reasons why the tibialis posterior tendon gets overworked and then injured. Like in all other cases, this tendonitis usually develops gradually during an activity, often when the activity has been repeated over several days (e.g. walking far in unsupportive shoes). If the tendon tears, you usually feel a sudden, sharp pain.

Best evidence-based treatments:

• Reducing overpronation is usually important – insoles that support your foot arch are useful, but they have to fit properly or they can cause more discomfort.

• Wearing supportive shoes that lace up can be useful. Don’t tie them too tight; they might irritate the tendon by pressing on it.

• Rehab exercises focused on improving the strength and stability in the foot, ankle, and leg in general are beneficial.

Read more about tibialis posterior tendonitis here.

Tibialis posterior and flexor hallucis longus tendon injuries run next to each other and cause pain in the same area; they can easily be confused.

Flexor hallucis longus tendon injury

Where you feel the main symptoms: The flexor hallucis longus (FHL) muscle is the one we use to flex our big toes down. The muscle itself is located in the back of the calf, and the tendon that attaches the muscle to the toe runs close to the tibialis posterior tendon down the inner back of the lower leg, the inside of the heel and ankle, and then goes under the foot and to the big toe. You can feel the pain and stiffness anywhere along this route, but usually it is on the inside of the heel.

How it typically starts: It is usually brought on by activities where you push off with your big toes (ballet or running). The FHL tendon also helps to control pronation, which is why overpronation may also play a role. The pain usually develops gradually over the course of a training session or several days. Tears are uncommon, but are usually felt as a sudden, sharp incident.

Best evidence-based treatments:

• Allow the tendon to rest by temporarily reducing activities that require you to push down hard with your big toe.

• If you overpronate, wearing supportive insoles and shoes may also help.

• Your rehab plan should address the specific cause, e.g. if overpronation is thought to have played a role, exercises to correct that should be included. You often have to avoid loading the big toe during the early stages, but later on exercises like calf raises where you push off with the big toe must also be included, starting with very low loads and building to what is required for your sport.

How we can help

Need help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

About the Author

Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.

References

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2. Webborn, N., et al. (2015). "Acute tear of the fascia cruris at the attachment to the Achilles tendon: a new diagnosis." British Journal of Sports Medicine 49(21): 1398-1403.

3. Spina, A. A. (2007). "The plantaris muscle: anatomy, injury, imaging, and treatment." The Journal of the Canadian Chiropractic Association 51(3): 158.

4. Kulig K, Pomrantz AB, Burnfield JM, et al. Non-operative management of posterior tibialis tendon dysfunction: design of a randomized clinical trial [NCT00279630]. BMC Musculoskeletal Disorders 2006;7(1):1.

5. Tu, P. (2018). "Heel pain: diagnosis and management." American Family Physician 97 (2): 86-93.

6. Ribbans, W. J., et al. (2015). "The management of posterior ankle impingement syndrome in sport: a review." Foot and Ankle Surgery 21(1): 1-10.