Achilles Tendon & Back of Heel Pain Treatment — Non-Surgical Specialist Care on the GST Road

Three structures at the back of the heel can be the source of pain — often in combination:

The largest and strongest tendon in the human body. It connects the gastrocnemius and soleus calf muscles to the calcaneus (heel bone). Every step you take loads this tendon — it absorbs forces of 6 to 8 times body weight during running.

The Achilles tendon has a poor blood supply compared to muscle — which is why it degenerates under repetitive stress rather than healing normally, and why pain from Achilles tendinopathy is often more persistent than muscular pain.

A small, fluid-filled sac positioned between the front surface of the Achilles tendon and the back of the heel bone. Its job is to reduce friction between the tendon and the bone during ankle movement.

When this bursa becomes inflamed — through repetitive compression, footwear friction, or accompanying Achilles tendon disease — it fills with inflammatory fluid, swells, and becomes a source of pain at the exact point where the tendon meets the bone.

A bony prominence on the posterosuperior aspect of the heel bone — the top back corner. When prominent, it creates a bony impingement on the retrocalcaneal bursa and the Achilles tendon insertion during ankle dorsiflexion and with tight footwear. A prominent bony bump on the back of the heel is called Haglund's deformity and may contribute to insertional Achilles tendinopathy and retrocalcaneal bursitis.

Many patients notice this bump and call it a "lump" on the heel — it is visible as a hard, bony prominence at the back of the heel, often more prominent on one side. Understanding its presence guides both footwear advice and treatment planning.

Achilles tendinopathy is a degenerative condition of the Achilles tendon — characterised by pain, localised tenderness, and often a palpable thickening of the tendon — caused by a failure of the normal tendon repair cycle under repetitive loading.

Like plantar fasciitis, Achilles tendinopathy is now understood to be primarily a degenerative process — a breakdown of tendon collagen architecture under accumulated mechanical stress — rather than simply inflammation. This distinction is clinically important: anti-inflammatory treatments alone do not repair degenerated tendon tissue.

This is the most important clinical distinction within Achilles tendinopathy — because the cause, the rehabilitation protocol, and the interventional approach are completely different for each type.

Affects the Achilles tendon at its insertion point onto the heel bone — the bottom 2cm of the tendon

Often associated with Haglund's deformity and retrocalcaneal bursitis

Pain is localised at the very back of the heel, at the tendon-bone junction

Worsened by activities that compress the tendon insertion against the heel bone — wearing tight-backed shoes, wearing low or flat footwear, ascending stairs, walking uphill

More common in middle-aged and older patients

Rehabilitation requires a specific non-eccentric loading approach — the standard eccentric protocol used for mid-portion tendinopathy can worsen insertional disease

Affects the mid-portion of the Achilles tendon — approximately 2 to 6cm above the heel bone

The tendon in this zone has the poorest blood supply and is therefore the most vulnerable to degeneration

Pain is felt in the tendon itself — not at the heel bone

A fusiform (spindle-shaped) thickening of the tendon is often palpable and sometimes visible

More common in younger, active individuals and runners

Rehabilitation responds well to the eccentric loading protocol — the most evidence-supported rehabilitation approach for this specific condition

Knowing which type you have is not an academic distinction — it changes your rehabilitation protocol completely. The wrong exercise programme for the wrong type of tendinopathy can make things significantly worse.

Retrocalcaneal bursitis is the most common heel bursitis — inflammation of the bursa located between the calcaneus and the anterior surface of the Achilles tendon. It causes posterior heel pain, swelling at the back of the heel, and is often associated with insertional Achilles tendinopathy.

While it can feel similar to other conditions such as Achilles tendinitis, Achilles tendinopathy, or plantar fasciitis, retrocalcaneal bursitis is a distinct problem that may require a different treatment approach — and a differential diagnosis is important because these related pathologies can occur together.

There are two bursae located just superior to the insertion of the Achilles tendon. Inflammation of either or both can cause pain at the posterior heel and ankle region. The retrocalcaneal (subtendinous) bursa is located between the Achilles tendon and the calcaneus. The subcutaneous calcaneal bursa is located between the skin and the posterior aspect of the distal Achilles tendon.

Distinguishing which bursa is inflamed — and whether bursitis accompanies tendinopathy — requires ultrasound. This is clinically important because a cortisone injection into the subcutaneous bursa carries a risk of Achilles tendon weakening if the needle inadvertently enters the tendon. Under ultrasound guidance, this risk is eliminated entirely.

Sudden switch from heeled to flat footwear — an extremely common trigger in Tamil Nadu, particularly in women who change from heeled chappals to flat footwear after medical advice or following pregnancy

Tight-heeled footwear — the back of the shoe pressing into the retrocalcaneal area

Overuse in runners — repetitive ankle loading without adequate recovery

Haglund's deformity — the bony prominence mechanically irritating the bursa during dorsiflexion

Rheumatoid arthritis and seronegative arthropathies — systemic causes of bursitis that must be excluded in appropriate patients

Recognising Back-of-Heel Pain — What Achilles Tendinopathy and Bursitis Feel Like:

Morning stiffness — the Achilles tendon is stiff and sore for the first few minutes of walking after waking or after prolonged rest. This typically eases after 5–10 minutes of movement

Pain during and after activity — in early tendinopathy, the pain begins after activity (post-exercise soreness). As it progresses, pain occurs during activity and eventually limits it

Localised tenderness — pressing directly on the tendon reproduces the pain. In mid-portion tendinopathy, the maximally tender point is in the tendon itself, 2–6cm above the heel. In insertional tendinopathy, tenderness is at the heel bone insertion

Tendon thickening — a palpable and sometimes visible swelling or fusiform thickening of the mid-portion tendon in non-insertional disease

Creaking or crepitus — some patients feel or hear a creaking sensation in the tendon with movement

Reduced calf strength and endurance — difficulty completing a full set of single-leg heel raises, which is both a symptom and the basis of the primary rehabilitation test

Swelling and redness at the back of the heel — often visible as a puffy, sometimes warm area directly behind the heel bone

Sharp pinching pain when the area is squeezed — such as when bending deeply or wearing tight shoes — which distinguishes bursitis from pure tendinopathy

Pain aggravated by shoe heel counters — the rigid back of footwear pressing directly on the inflamed bursa

Pain worse going upstairs or up inclines — dorsiflexion of the ankle compresses the bursa between the tendon and bone

Relief when walking barefoot on flat surfaces — the absence of shoe compression reduces bursal irritation

Tendon thickness — a normal Achilles tendon measures 4–6mm in diameter. In mid-portion tendinopathy, this increases to 8–12mm or more. Quantifying the degree of tendon enlargement guides prognosis and treatment intensity

Tendon texture and collagen organisation — normal tendon has a bright, organised fibrillar pattern. Degenerated tendon shows loss of this pattern, areas of hypoechogenicity (darker regions of collagen breakdown), and calcific deposits in chronic cases

Insertional vs. non-insertional location — precisely identifies which type is present. This changes the rehabilitation prescription immediately

Retrocalcaneal bursa — the bursa is normally a thin virtual space. Inflammation is seen as a distended, fluid-filled sac between the tendon and the heel bone. Ultrasound can measure the extent of bursitis and guide precise injection

Haglund's deformity — visible as a prominent posterior heel bone contour that impinges on the bursa during ankle movement

Doppler vascularity — abnormal blood vessel ingrowth into the degenerated tendon (neovascularisation) is a marker of chronic tendinopathy and can guide interventional targeting

Partial tendon tear — an important finding that significantly changes management. Ultrasound distinguishes tendinopathy (no structural discontinuity) from a partial tear (focal disruption visible in the tendon)

Before any exercise prescription or injection, mechanical load on the Achilles must be modified:

Heel lifts — raising the heel height by 1–1.5cm in both shoes reduces the stretch on the Achilles tendon during walking and standing. This is the fastest-acting symptomatic intervention for both insertional and mid-portion tendinopathy and should begin immediately

Footwear change — switching to a shoe with a firm heel counter, adequate cushioning, and a mild heel drop (8–12mm) reduces insertional compression and bursal irritation significantly. For patients who wear flat chappals, this is often the single most impactful early change

Activity modification — reducing or temporarily stopping the aggravating activity (running, stair climbing, uphill walking) while the loaded rehabilitation begins. Complete rest is counterproductive — the tendon needs load to heal, just the right amount

Avoidance of stretching in insertional tendinopathy — critically important and counterintuitive: aggressive Achilles tendon stretching worsens insertional tendinopathy by compressing the tendon insertion and bursa against the heel bone. Standard stretching advice must be modified for insertional disease

Eccentric and Isometric Loading — The Evidence-Based Core of Achilles Rehabilitation:

This is the most important rehabilitation section on this page — because the correct loading programme for Achilles tendinopathy is one of the most evidence-supported and most consistently effective interventions in musculoskeletal medicine.

Isometric contractions — muscle activation without joint movement — are the safest starting point for painful Achilles tendinopathy. The heel raise is held at a specific point of calf activation without movement.

Isometric loading reduces tendon pain rapidly — often within 45 seconds of beginning the exercise — through pain inhibitory pathways in the nervous system. It is the recommended starting point when pain is significant enough to limit activity.

Protocol: 5 repetitions of 45-second isometric calf holds, at 70% of maximum effort, performed daily.

Eccentric loading — where the calf muscle lengthens under load during the lowering phase of the heel raise — is the gold standard rehabilitation protocol for non-insertional (mid-portion) Achilles tendinopathy.

3 sets of 15 repetitions of slow eccentric heel drops over a step edge

Performed twice daily, 7 days a week

Continued for a minimum of 12 weeks

Pain during the exercise is expected and does not indicate damage — the protocol is specifically designed to be performed through pain

This protocol should NOT be used for insertional Achilles tendinopathy — the range of motion at the bottom of the heel drop compresses the tendon insertion against the heel bone, worsening insertional disease. Modified protocols that avoid end-range dorsiflexion are used instead.

Progressive resistance training using a calf raise machine or leg press — performed slowly (3 seconds up, 3 seconds down) with heavy load — has been shown to produce equivalent or superior outcomes to eccentric training for mid-portion tendinopathy and is better tolerated for insertional disease.

The load is progressed weekly, targeting the maximum load tolerable while keeping pain below 5/10.

For runners and athletes from Kattankulathur, Maraimalai Nagar, and the GST Road corridor, return to running is managed through a structured interval programme — beginning with walk-run intervals and progressively increasing running duration based on symptom response. Full training load is typically resumed at 16–20 weeks for mid-portion tendinopathy.

A Haglund's deformity is a bony prominence on the posterosuperior (top-back) corner of the heel bone. It is a structural variant — some people have it, others do not — but in those who do, it creates a mechanical impingement against the retrocalcaneal bursa and the Achilles tendon insertion during activities that bring the heel bone and tendon into compression.

Women who wear heeled footwear regularly — the heel counter of the shoe impinges on the bony prominence

Patients with insertional Achilles tendinopathy — the deformity worsens the tendon-bone compression

People with a high-arched (cavus) foot type — the shape of the foot tilts the heel bone to a position that worsens the bony impingement

Surgical reshaping of the Haglund's prominence (Haglund's resection or calcaneoplasty) is considered only after prolonged conservative and interventional management has failed. Dr. RRB will discuss the surgical pathway with appropriate patients and facilitate referral when indicated.

Why Patients from Kattankulathur, Maraimalai Nagar, Oragadam and Across the GST Road Corridor Choose Dr. RRB Pain Care:

PRP into the Achilles tendon and cortisone into the retrocalcaneal bursa are both procedures that must be performed with imaging guidance. Injecting cortisone near the Achilles tendon without imaging carries a documented risk of tendon weakening and rupture. At Dr. RRB Pain Care, every procedure is performed under real-time ultrasound — the tendon and bursa are clearly distinguished, and the needle is placed with confirmed precision.

You have pain at the back of your heel — not under it — that has been present for more than 4 weeks

Morning stiffness in the heel and back of ankle that is limiting your first steps of the day

You are a runner who has developed Achilles pain and cannot complete training without it worsening

You switched from heeled to flat footwear and developed back-of-heel pain in the following weeks

You have visible swelling at the back of the heel — particularly if it is warm and tender to touch

You feel a bony lump at the back of your heel that is being irritated by your footwear

You have been doing Achilles stretches or eccentric exercises for weeks and your pain is not improving — or is getting worse

Your orthopaedic surgeon or physiotherapist has suggested a steroid injection for the Achilles area — seek a second opinion to ensure imaging guidance is part of the plan

The longer Achilles tendinopathy is left without targeted treatment, the greater the degree of tendon degeneration. A tendon with advanced degeneration is at higher risk of partial or complete rupture — particularly if a poorly placed steroid injection is administered. Early specialist review gives you the most options and the best outcomes.

Plantar fasciitis causes pain on the bottom of the heel — specifically at the point where the plantar fascia attaches to the underside of the heel bone. The pain is worst with the first steps in the morning and after rest. Achilles tendinopathy causes pain at the back of the heel — either in the mid-portion of the Achilles tendon (2–6cm above the heel bone) or at the tendon's insertion onto the heel bone. Both involve the heel, but they are completely different structures with completely different treatment approaches. Treating plantar fasciitis when the true problem is Achilles tendinopathy — or vice versa — produces no improvement, because the wrong tissue is being addressed.

No — and this is one of the most important clinical points on this page. Eccentric calf loading (the Alfredson Protocol) is highly effective for non-insertional (mid-portion) Achilles tendinopathy. However, for insertional Achilles tendinopathy — the type affecting the point where the tendon meets the heel bone — eccentric exercises that bring the ankle into full dorsiflexion compress the tendon insertion against the heel bone and can significantly worsen the condition. Insertional tendinopathy requires a modified loading programme that avoids end-range ankle dorsiflexion. This is why confirming which type of tendinopathy is present before beginning rehabilitation is essential.

Mid-portion Achilles tendinopathy with a full eccentric loading programme typically shows significant improvement at 12 weeks — though the full healing process continues for 3–6 months. Insertional tendinopathy tends to respond more slowly and may require 4–6 months of consistent management. PRP therapy, where indicated, can accelerate this timeline significantly — most patients notice improvement within 4–6 weeks of an ultrasound-guided PRP injection, with continued improvement at 12 weeks as collagen remodelling progresses.