Posterior Heel Pain: Achilles Tendinopathy vs. Retrocalcaneal Bursitis

Quick answer: Posterior Heel Pain Achilles Bursitis has multiple potential causes including mechanical, neurological, vascular, and inflammatory. The patterns we see most often are overuse, poorly-fitted shoes, and biomechanical imbalance. Red flags requiring urgent evaluation: warmth/redness (infection), inability to bear weight (fracture), and unilateral swelling without injury (DVT). Call (810) 206-1402.

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

Pain at the back of the heel — the posterior heel — is a common complaint that encompasses several distinct conditions with overlapping symptoms. Knowing which condition you have is not merely academic: each requires a different treatment approach, and confusing them leads to months of misdirected therapy.

The Anatomy of the Posterior Heel

The posterior heel contains several structures that can independently produce pain:

• Achilles tendon: The largest tendon in the body, inserting into the posterior calcaneal tuberosity. It transmits the force of the gastrocnemius and soleus muscles and is essential for push-off.
• Retrocalcaneal bursa: A fluid-filled sac between the Achilles tendon and the superior aspect of the calcaneus, providing cushioning to reduce friction as the tendon glides over the bone during ankle motion.
• Superficial calcaneal bursa: Located between the skin and the back of the Achilles tendon at the heel counter level.
• Haglund’s deformity: A prominent bony protrusion on the superior-posterior calcaneus (sometimes called “pump bump”) that can compress and inflame the retrocalcaneal bursa.

Achilles Tendinopathy: Causes and Symptoms

Achilles tendinopathy encompasses both tendinitis (acute inflammatory) and tendinosis (chronic degenerative) changes within the tendon. It is divided into two types by location:

• Non-insertional tendinopathy: Affects the mid-substance of the Achilles tendon, approximately 2–7 cm above the heel bone insertion. This is the most common type, typically presenting as morning stiffness and aching that improves after a few minutes of activity (“warm-up effect”), then worsens again with prolonged activity. The tendon is thickened, tender to palpation at the mid-tendon, and may have a palpable nodule.
• Insertional tendinopathy: Affects the tendon where it attaches to the calcaneus. Associated with calcification at the insertion point, retrocalcaneal bursitis, and Haglund’s deformity. Pain is at the very back of the heel and is reproduced by squeezing the posterior calcaneus or dorsiflexing the ankle.

Retrocalcaneal Bursitis: Causes and Symptoms

Retrocalcaneal bursitis is inflammation of the bursa between the Achilles tendon and heel bone. It is most often caused by repetitive dorsiflexion stress, shoe heel counter pressure, Haglund’s deformity compressing the bursa, or insertional Achilles tendinopathy that secondarily inflames the adjacent bursa.

The key distinguishing feature is tenderness in the retrocalcaneal recess — the soft area just anterior to the Achilles tendon insertion on both sides of the tendon. Squeezing this area (the two-finger squeeze test) reproduces pain. The bursa may be palpably swollen. Dorsiflexion compresses the bursa against the calcaneus and reproduces or worsens pain — helping distinguish it from mid-substance Achilles tendinopathy where dorsiflexion stretches the tendon but doesn’t compress a bursa.

Haglund’s Deformity (Pump Bump)

Haglund’s deformity refers to a bony enlargement of the posterior-superior calcaneal tuberosity. It creates a rigid bony prominence that irritates the heel counter of shoes (causing superficial bursitis) and compresses the retrocalcaneal bursa during dorsiflexion. Rigid, closed-back shoes with a hard heel counter are the primary provocative factor.

Treatment Approach

Treatment differs meaningfully between these conditions:

• Non-insertional Achilles tendinopathy responds best to eccentric heel drop exercises (the Alfredson protocol), load management, heel lift orthotics to reduce tendon tension, and PRP injection for recalcitrant cases.
• Insertional Achilles tendinopathy and retrocalcaneal bursitis are treated with heel lifts, shoe modification (open-back or flexible heel counter shoes), immobilization in a boot during acute flares, carefully placed cortisone injection into the bursa (not the tendon), and physical therapy. Surgery to remove the Haglund’s deformity and calcific deposits is effective for cases failing conservative management.

When to See a Podiatrist

Any posterior heel pain persisting more than 3–4 weeks should prompt evaluation. Diagnostic ultrasound can distinguish between tendon pathology, bursitis, and calcification in real-time at the first appointment — guiding treatment without waiting for MRI scheduling.

Differential Diagnosis: What Else Could It Be?

Not every case of haglund’s deformity is straightforward. In our clinic we routinely rule out three look-alike conditions before confirming the diagnosis. If your symptoms don’t match the classic presentation, one of these may explain the pain — which is why physical exam matters more than self-diagnosis.

Condition	How It Differs
Retrocalcaneal bursitis alone	Anterior to the Achilles insertion, no posterior bone prominence.
Insertional Achilles tendinopathy	Pain at the tendon-bone junction; calcification may be present on X-ray.
Sever’s disease (pediatric)	Child or adolescent with growth-plate pain; Haglund presents in adults.

Red Flags — When to See a Podiatrist Now

In Our Clinic: What We See

In-Office Treatment at Balance Foot & Ankle

If home treatment isn’t providing relief for your plantar fasciitis, our podiatry team at Balance Foot & Ankle can help with same-day evaluations and advanced in-office care.

Frequently Asked Questions

When should I see a doctor?

See a podiatrist if pain persists past 2 weeks, prevents normal activity, or is accompanied by red-flag symptoms (warmth, swelling, numbness, inability to bear weight).

Can I treat this at home?

Mild cases respond to RICE protocol (rest, ice, compression, elevation), supportive shoes, and OTC anti-inflammatories. Persistent symptoms need professional evaluation.

How long does it take to heal?

Most soft tissue injuries resolve in 2-6 weeks with appropriate care. Bone injuries take 6-12 weeks. Chronic conditions need longer-term management.

What is Heel pain?

Heel pain is a common foot/ankle condition that affects mobility and quality of life. Understanding the underlying cause is the first step in successful treatment. Our podiatrists at Balance Foot & Ankle perform a hands-on biomechanical exam, review your activity history, and use diagnostic imaging when appropriate to identify the root cause—not just treat the symptom. Many patients have been told to “rest and ice” without a deeper diagnostic workup; our approach is different.

Symptoms and warning signs

Common signs of heel pain include pain that worsens with activity, morning stiffness, swelling, tenderness when palpated, and difficulty bearing weight. If you experience sudden severe pain, inability to walk, visible deformity, numbness or color change, contact our office the same day or visit urgent care—these can signal a more serious injury such as a fracture, tendon rupture, or vascular compromise. Diabetics with any foot wound should seek same-day care.

Conservative treatment options

Most cases of heel pain respond to non-surgical care: structured rest, supportive footwear changes, custom orthotics, targeted stretching and strengthening protocols, anti-inflammatory medications when medically appropriate, and in-office procedures such as ultrasound-guided injections. We also offer advanced therapies including MLS laser therapy, EPAT/shockwave, regenerative injections, and image-guided procedures. Treatment is sequenced from least invasive to most invasive, and we explain the rationale at every step.

When is surgery considered?

Surgery is reserved for cases that fail 3-6 months of well-structured conservative care, when there is structural pathology (severe deformity, complete tear, advanced arthritis), or when imaging shows damage that will not heal without intervention. Our surgeons have performed 3,000+ foot and ankle procedures and prioritize minimally-invasive techniques whenever appropriate. We discuss recovery timelines, return-to-activity milestones, and realistic outcome expectations before any procedure is scheduled.

Recovery timeline and prevention

Recovery from heel pain varies based on severity and chosen treatment path. Conservative cases often improve within 4-8 weeks with consistent adherence to the protocol. Post-procedural recovery may range from a few days (in-office procedures) to several months (reconstructive surgery). Long-term prevention involves footwear assessment, activity modification, structured strengthening, and regular check-ins with your podiatrist if you have a history of recurrence. We provide written home-exercise plans and digital follow-up support.