Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

Understanding Posterior Heel and Ankle Pain

Pain at the back of the heel and ankle — the posterior heel — is a distinct category from the more common plantar (bottom) heel pain of plantar fasciitis. When patients point to pain at the very back of the heel, behind the ankle bones, or along the Achilles tendon above the heel, several specific diagnoses come to the forefront. Correctly identifying which posterior heel condition is present determines the treatment approach, which differs substantially between conditions that may seem similar.

The posterior heel region contains several important structures packed into a small area: the Achilles tendon (inserting onto the posterior calcaneus), the posterior calcaneal prominence where Haglund’s deformity forms, the retrocalcaneal bursa (between the Achilles and the calcaneus), and the superficial Achilles bursa (between the Achilles and the skin). Problems with any or all of these structures can cause posterior heel pain — often simultaneously.

Insertional Achilles Tendinopathy

Insertional Achilles tendinopathy is degeneration and micro-tearing of the Achilles tendon at its attachment to the posterior calcaneus. It differs from mid-portion tendinopathy (occurring 2-7cm above the insertion) in its location, biomechanical contributors, and some aspects of treatment. Insertional tendinopathy tends to be more common in older patients, men, and recreational athletes — it’s the Achilles problem of the “weekend warrior.”

The characteristic symptom is pain at the back of the heel bone itself — not just above it — that is worse with the first few steps in the morning and after rest, and with activities that involve maximum dorsiflexion (stair climbing, hill walking, lunging). Calcification within the Achilles insertion is common on X-ray and represents the body’s attempt to stabilize the degenerating tendon with calcium deposits.

Treatment of insertional tendinopathy differs from mid-portion tendinopathy in one important way: eccentric heel drops performed off a step — the standard treatment for mid-portion disease — are contraindicated for insertional tendinopathy because they maximally load the insertion in a dorsiflexed position, worsening the condition. Instead, isometric calf exercises (pressing against an immovable object rather than moving through range of motion), heel lifts to reduce dorsiflexion angle, and extra-cushioned heel footwear form the basis of conservative treatment. Shockwave therapy has excellent evidence for insertional tendinopathy. For refractory cases, surgical excision of calcification and Haglund’s deformity with tendon repair provides good results.

Haglund’s Deformity: The Pump Bump

Haglund’s deformity is a bony enlargement of the posterior superior calcaneal tuberosity — the prominence at the top-back of the heel bone. This prominence may be an exaggeration of the normal bony anatomy or may develop as reactive bone formation in response to chronic trauma. It is often called a “pump bump” because it’s aggravated by pump-style shoes with rigid heel counters that press against the prominence.

The prominence itself causes pain by creating chronic friction between the heel bone and shoe heel counter. More importantly, the mechanical irritation of the Haglund’s prominence on the retrocalcaneal bursa (between the prominence and the Achilles tendon) and on the Achilles insertion creates a cycle of bursitis, tendinopathy, and continued bone irritation.

Diagnosis is confirmed by the characteristic “parallel pitch lines” finding on lateral foot X-ray, where the Haglund’s prominence projects above the normal line of the posterior calcaneus. Conservative treatment includes avoiding heel counters (open-backed shoes, silicone heel cushions that elevate the foot above the shoe counter), heel lifts, and anti-inflammatory treatments. Surgical resection of the Haglund’s prominence through a posterior approach, often combined with retrocalcaneal bursa resection and Achilles tendon debridement, is effective for cases that don’t respond to conservative measures.

Retrocalcaneal Bursitis

The retrocalcaneal bursa is a fluid-filled sac situated between the posterior calcaneus and the Achilles tendon. It lubricates the contact between these structures with normal ankle motion. When this bursa becomes inflamed — from Haglund’s compression, repetitive friction, inflammatory arthritis, or as a component of seronegative spondyloarthropathies — it causes pain and swelling specifically at the back of the heel, between the Achilles tendon and the bone.

Retrocalcaneal bursitis is palpated by squeezing the back of the heel between the thumb and forefinger on either side of the Achilles tendon at the level of the heel bone — the pain is localized deep to the Achilles tendon itself. This distinguishes it from Achilles tendon tenderness, which is at the tendon surface. Ultrasound or MRI confirms fluid in the bursa.

Treatment includes anti-inflammatory medications, ultrasound-guided corticosteroid injection into the bursa (taking care to avoid the Achilles tendon itself), activity modification, and heel lifts. Surgical decompression (removal of the bursa along with any Haglund’s prominence) is reserved for refractory cases.

Posterior Ankle Impingement (Revisited)

For athletes who perform maximum plantarflexion — dancers, soccer players, swimmers — posterior ankle pain just above the heel bone may represent posterior ankle impingement from os trigonum syndrome or FHL tenosynovitis, as discussed elsewhere. The key distinguishing feature is that true posterior ankle impingement pain is most intense during maximum plantarflexion (pointing the foot), while Achilles insertion and Haglund’s pain is most intense during dorsiflexion.

At Balance Foot & Ankle, we systematically differentiate these posterior heel conditions through careful clinical examination and targeted imaging. Many patients with posterior heel pain have been treated empirically for one condition when the actual cause is another — careful diagnosis changes the treatment approach and produces better outcomes. If you’ve had posterior heel pain that hasn’t responded to treatment, a definitive diagnostic evaluation may reveal the real cause.

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Balance Foot & Ankle — Howell & Bloomfield Township, MI

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Posterior Heel & Achilles Pain Treatment in Michigan

Pain at the back of the heel can indicate Achilles tendinitis, Haglund’s deformity, or retrocalcaneal bursitis. At Balance Foot & Ankle, Dr. Tom Biernacki provides accurate diagnosis to determine the right treatment — serving Howell and Bloomfield Hills, MI.

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Clinical References

1. Kvist M. Achilles tendon injuries in athletes. Sports Med. 1994;18(3):173-201.
2. Wiegerinck JI, Kok AC, van Dijk CN. Surgical treatment of chronic retrocalcaneal bursitis. Arthroscopy. 2012;28(2):283-293.
3. Vaishya R, Agarwal AK, Azizi AT, Vijay V. Haglund’s syndrome: a commonly seen mysterious condition. Cureus. 2016;8(10):e820.

Dr. Tom Biernacki, DPM

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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.