Back-of-Heel Pain: Is It Achilles Tendinopathy, Haglund’s Deformity or Heel Bursitis?

If you have an ache, swelling or a bump at the back of your heel, you may come across several possible explanations: Achilles tendinopathy, Haglund’s deformity and heel bursitis.

These terms describe different tissues, but the tissues sit very close together. A prominent heel bone may be painless, while pain blamed on a “heel bump” may actually involve an irritated bursa or the Achilles tendon insertion. Likewise, pain around the Achilles does not necessarily mean the tendon is the only structure involved.

This guide explains the typical differences, where the conditions can overlap and why a professional assessment may be needed before deciding what to do.

A quick map of the back of the heel

Four structures are particularly relevant:

• The calcaneus: the heel bone. Its upper-back surface can be more prominent in some feet.
• The Achilles tendon: the strong tendon connecting the calf muscles to the heel bone.
• The retrocalcaneal bursa: a small fluid-filled sac between the Achilles tendon and the heel bone.
• The superficial calcaneal bursa: a cushioning sac between the Achilles tendon or heel prominence and the skin.

Because the tendon, bursae and heel bone occupy the same small area, symptoms may be difficult to separate without examining exactly where the tenderness lies and what movements or pressures reproduce it.

If your pain is not clearly at the back of the heel, Step Ahead’s broader heel pain guide covers other possible locations and causes.

Achilles tendinopathy: is the pain in the tendon or at its attachment?

Achilles tendinopathy is a clinical term used when Achilles tendon pain is accompanied by reduced function. It is usually described according to where the symptoms occur.

Midportion Achilles tendinopathy affects the main body of the tendon, above the heel bone. The tender or thickened area is therefore higher than the shoe line and heel attachment.

Insertional Achilles tendinopathy affects the point where the tendon attaches to the calcaneus. Pain is concentrated at the back of the heel bone rather than several centimetres above it.

People with Achilles tendinopathy often report pain during tendon-loading activities such as walking uphill, climbing stairs, running or pushing onto the toes. Stiffness after rest can occur, and some people find the tendon loosens a little after they begin moving. That “warm-up” response is a clue, not proof: other conditions around the heel may behave similarly.

Insertional symptoms also require a particular distinction. As the ankle bends and the shin moves forward over the foot, the Achilles insertion can be compressed against the upper heel bone. This is one reason an exercise that is suitable for pain higher in the tendon may not suit pain at the insertion.

Haglund’s deformity: a bone shape, not automatically the source of pain

Haglund’s deformity is a commonly used name for a prominence at the upper-back part of the heel bone. It may feel like a hard bump and can be particularly noticeable in rigid-backed shoes.

Importantly, the presence of the bump does not prove that it is causing pain. Bone shape varies from person to person, and structural findings can exist without symptoms.

When the area is painful, the discomfort may come from pressure on the skin and superficial bursa (the cushioning sac just under the skin), irritation of the deeper retrocalcaneal bursa (the sac between the Achilles tendon and heel bone), insertional Achilles tendinopathy (pain where the tendon attaches to the heel), or a combination.

You may also encounter the term Haglund’s syndrome. It has been used for painful combinations involving a heel prominence, retrocalcaneal bursitis and changes at the Achilles insertion. However, Haglund terminology has been used inconsistently in medical literature. Clear descriptions of the actual tissues involved are often more helpful than the name alone.

Heel bursitis: deep or superficial?

A bursa is a small sac that helps reduce friction between neighbouring tissues. Two different bursae can be involved in back-of-heel pain.

Superficial calcaneal bursitis

The superficial bursa sits between the skin and the Achilles tendon or heel prominence. It is therefore more exposed to rubbing and direct shoe pressure.

Superficial bursitis may produce a softer or puffier swelling than a hard bony prominence. The area can be tender when touched and irritated by shoes with firm heel counters. Redness or warmth may also occur, although marked heat, spreading redness or systemic illness requires prompt assessment rather than an assumption that the problem is simple mechanical irritation.

Comparing common clues

The patterns below can help you describe your symptoms, but they are not a self-diagnosis tool. Individual presentations vary and more than one structure may be involved.

Why a bump or scan cannot provide the whole answer

It is tempting to match one visible feature to one diagnosis: a hard bump must be Haglund’s deformity, swelling must be bursitis, or tendon thickening on ultrasound must explain the pain. The relationship is not always that simple.

A systematic review of imaging studies found wide variation in Achilles tendon abnormalities among people without Achilles symptoms. Individual studies reported markedly different rates, and the studies were too different to combine into one reliable overall estimate. The practical lesson is not that scans are unhelpful; it is that an imaging finding must be interpreted alongside the person’s pain location, history and clinical examination.

Imaging may be considered when it will answer a specific clinical question—for example, when the diagnosis remains uncertain, another condition or injury is suspected, or progress is not following the expected pattern. It is not automatically required for every case of back-of-heel pain.

How a podiatrist distinguishes the possibilities

An assessment is less about choosing a label from a symptom checklist and more about building a consistent picture.

The history of the problem

Useful questions include:

• Where can you point to your pain with one finger?
• Did it begin gradually or after a sudden incident?
• Is it triggered by activity, first steps after rest, direct shoe pressure or a particular ankle position?
• Have you recently changed your walking, running, work demands, training volume, terrain or footwear?
• Are symptoms present in one heel or both?
• Have you experienced a sudden snap, marked weakness, systemic illness or symptoms in other joints?

Pain location and provocation

The clinician can then examine the tendon, its attachment, the bursal regions and the bony contour separately. The podiatrist can physically press and examine the area (called palpation), while carefully selected movements may help determine whether pain is reproduced by loading the tendon, compressing the insertion, applying pressure near a bursa or contacting a superficial swelling.

Current expert consensus for assessing suspected Achilles tendinopathy emphasises four core areas: pain location, pain during activity, tests that provoke pain and tenderness on palpation. It also recommends considering alternative diagnoses and medical conditions when the presentation is unclear or does not behave as expected.

Function, movement and footwear

Calf strength, ankle movement, walking pattern, activity demands and the shoes worn most often may all influence how the area is loaded. These findings do not diagnose one condition by themselves. They help the podiatrist understand why the heel is being irritated and which changes may be appropriate for that individual.

What can you do while arranging an assessment?

If there has been no sudden injury and you can still walk safely, a few cautious steps may reduce irritation:

• Temporarily scale back the activity or ankle position that clearly aggravates the pain.
• Avoid repeatedly “testing” the heel with painful movements.
• Choose footwear that does not rub or press firmly on the tender area.
• Note whether the pain is at the skin, deep beside the tendon, directly at the heel attachment or higher in the tendon.
• Record which activities and shoes make symptoms better or worse.

Avoid assuming that a generic Achilles programme is suitable. In particular, heel drops performed below the level of a step place the ankle into greater dorsiflexion and may increase compression at a painful Achilles insertion. A 2025 randomised trial found that a lower-compression rehabilitation programme produced better pain and function outcomes than a higher-compression programme in sport-active adults with chronic insertional Achilles tendinopathy. That finding supports tailored rehabilitation, but it does not provide a do-it-yourself programme for every person with back-of-heel pain.

When should back-of-heel pain be assessed promptly?

Seek prompt medical or podiatric assessment if:

• you felt a sudden snap or pop and then struggled to push off, walk normally or rise onto your toes
• pain followed a significant injury or is accompanied by marked bruising or weakness
• the heel becomes very hot, increasingly red or severely swollen, particularly if you feel feverish or unwell
• you cannot bear weight safely
• pain is rapidly worsening, unexplained at rest or regularly disturbing sleep
• symptoms are present in both heels alongside persistent joint stiffness or other general health changes
• the symptoms remain unclear or are not improving as expected

These signs do not identify one diagnosis, but they can indicate that further investigation or medical review is appropriate.