Posterior Heel Pain – pain at the back of the heel

Do you have pain at the back of the heel?

This is called Posterior Heel Pain and there are actually lots of different causes for pain in this area. There are some common signs and symptoms for each of them. Here we will go through each of them, from most common to least common, so you can work out which problem you might have!


Achilles Insertional Tendinopathy

An achilles insertional tendinopathy is the most common cause of pain at the back of the heel. This is an irritation of where the achilles tendon attaches onto the back of your heel (calcaneous). It is quite different to your usual achilles tendon pain which is typically felt higher up on the tendon, about 2-3cm above the calcaneous. Because the bone AND the tendon are involved, they can be tricky to treat and often take longer.

The symptoms will typically involve pain on initial weight-bearing in the morning, that warms up within 30mins. It may also warm up when beginning running/sport then come on again after a period of activity. They can often ache afterwards.

Unlike a traditional achilles problem, they won’t respond to eccentric calf raises off the edge of a step. You generally have to start with higher range work right up on your toes before slowly dropping down lower as the pain improves. In serious cases, a heel raise worn for a short period can also help settle it down before starting some strength work.


Posterior Ankle impingement

In athletes such as ballet dancers where activity requires frequent rising up onto the tip toes they could experience a syndrome called posterior ankle impingement. This is where both hard and soft tissue can get stuck or “pinched” at the back of the ankle.

Posterior ankle impingement occurs when excessive plantaflexion (pointing the foot) pinches the soft tissue or compresses the back of the joint resulting in a sharp pinching pain.

Os Trigonum: A common cause of pain at the back of the ankle

Os Trigonum at the back of the talus bone.

There are 2 anatomical variations that cause posterior ankle impingement.

  1. Prominent Posterior Talus. The talus is the main weight-bearing bone in your ankle. The back of this bone can grow in response to abnormal loading. If it grows too much it can start to irritate structures at the back of the ankle.
  2. Os Trigonum. If the prominent part of the talus grows enough and then breaks off, it becomes labeled as on Os Trigonum. About 20-30% of the population have an os trigonum, with obviously not everyone having symptoms. If however, it does start to cause symptoms, then surgery to remove the loose bone can be highly effective.


Both of these anatomical variations can be diagnosed with a plain x-ray.

Treatment will likely include strengthening of the deep muscles in the lower leg such as tibilalis posterior, flexor digitorium longus, flexor hallicus longus and the peroneals.


Severs disease

Sounds “severe” but it’s not! Severs disease an “apophysitis”, or an inflammation/irritation of where the achilles tendon attaches to the back of the heel. When we’re younger, our bones are a bit softer, so repetitive pulling of the achilles tendon on the bone can cause some pain.

Severs disease is more common in boys than girls, aged 8-14 yrs. The typical presentation is pain caused by running, jumping and the pain gets worse with more activity then settles with rest. It often coincides with a growth spurt. As the bones grow, our muscles and tendons can sometimes struggle to keep up, so they get tighter and start to pull on the attachment.

Treatment of Severs disease involves rest from running and jumping until the pain settles, then addressing any tightness and/or weakness of the calf muscles. Sometimes a gel heel cup in the shoe will help offload the attachment. In serious cases, a boot may be required to be worn for 2-4 weeks.


Sural nerve compression

Sural Nerve Impingement - Ankle, Foot and Orthotic Centre

There is a little nerve that runs in behind the heel and tracks towards the outside of the ankle called the Sural nerve. It can be irritated by inflammation from surrounding tissues and normally exists with one of the other pathologies mentioned above or can occur after an ankle sprain (click here for ankle sprain management tips)

The sural nerve will obviously give you nerve pain, which feels very different. Common symptoms of nerve pain are “burning”, “tingling” and “numbness”. We can test the nerve with a nerve tension test and this will reproduce the same pain you are having.

Treatment will normally involve addressing the other problems in the area as well as nerve glides which can help restore mobility to the nerve.

Haglunds Deformity

Haglunds Deformity is a growth at the back of the calcaneuous that causes pain and swelling in the bursa (retrocalcaneal bursitis) and the achilles tendon.

The bone grows due to repetitive stress over the years and can be aggravated by resting the heel on a table or from wearing shoes with a firm heel support.Haglund's Deformity – Pump Bump on Heel | Foot Health Facts - Foot Health Facts

Treatment involves anti-inflammatories, choosing footwear that doesn’t compress the back of the heel, calf and foot strengthening

and a heel raise to offload the tendon and bursa. In serious cases that fail to improve, surgery may be required to remove the bony enlargement.


Calcaneal bone stress/fracture

A bone stress injury or fracture of the heel is rare and makes it almost impossible to weight-bear.

Pain with weight-bearing, likely with a history of increased load or overload. This one is needed to be confirmed by MRI and you will likely end up with a very fashionable moon boot for 6-8 weeks.


If any of these sound like your pain, then please don’t hesitate to get it seen to quickly.

Thumb/Wrist Pain? It could be De Quervain’s Tenosynovitis.

De Quervain’s Tenosynovitis is a painful condition which affects the thumb muscles (Abductor Pollicis Longus and extensor Pollicis Brevis).

Commonly seen in females who are in the post-natal phase, it is caused by a rapid increase in load on the thumb muscles and tendons. This over-load is usually caused from repetitive feeding positions, lifting and holding of an new infant. It can also commonly occur in golfers.

Symptoms will include swelling and local tenderness over the tendons. It can also be a sudden sharp feeling, which is not ideal when holding a young child!


It is diagnosed by conducting a simple test called the Finkelstein test. The tests involve bending your thumb across the palm of your hand and then bending your fingers over the thumb. The wrist is then bent toward your little finger. If this reproduces the same pain you experience, it is likely De Quervains syndrome.

A physiotherapist will also conduct some tests on the joints around the thumb and wrist to exclude them as a source of the pain symptoms.


Successful treatment techniques include splinting/bracing of the wrist to off-load the thumb tendons, and then progressive weaning from the brace to reintroduce load in a monitored way.

Gradual strengthening of the tendon is highly important as increasing the tendons tolerance to load is the fundamental component of rehab. As with any tendon strength program, load needs to be slowly introduced as a sudden increase in strength exercises can easily overload and aggravate the tendon! If bracing is left on for too long the tendon will become weaker and hence when you remove the brace the pain will come back.

If you start treatment early, your symptoms should improve over the next 4-6 weeks. If your symptoms start during or after pregnancy your symptoms are likely to resolve once breast feeding has stopped.

Despite common belief, a corticosteroid injection is not the first line treatment. An injection should only be considered if bracing and physiotherapy has failed over a 4-6 week period.


  • ICE for pain relief

  • BRACE to off-load the tendon

  • STRENGTH to increase the tendons tolerance to load (likely the reason the thumb was sore in the first place).

  • CORTISONE injection only after 6 weeks if the above fails.

If you have any questions or if you think you may have De Quervain’s then please do not hesitate to get in touch with us here.


2 Easy Exercises for “Tennis Elbow” (Lateral Elbow Extensor Tendinopathy)

These 2 exercises are designed for people with quite severe lateral elbow pain that have difficulty gripping/lifting even light objects.

1) Isometric Wrist Extension with 1kg dumbbell.

Start with 3x10sec holds. If pain-free, progress to 3x30sec holds or increase the weight. If you can tolerate doing this every day for 1 week, progress to exercise no.2

2) Eccentric Wrist Extension

Do 3 sets of 15 reps with 1kg. If pain-free, add an extra 1kg. Complete this exercise every second day.

Tennis Elbow – Latest Evidence

What is Tennis Elbow?

Tennis elbow is defined as a cause of pain and tenderness in the outer part of the elbow (lateral epicondyle) where the tendons of the forearm muscles attach.

It is an overuse injury from repetitive or forceful/explosive movements involving eccentric motion and/or in which the wrist frequently deviates from a neutral position. This can be from training errors, inadequate equipment or poor environmental conditions.

Who can get Tennis Elbow?

Tennis elbow can affect anyone, however is more common in people between 30 and 60 years of age. It appears to be more severe and of longer duration in females. The most commonly affected arm is the dominant arm. It is commonly seen in office workers (repetitive typing) or manual labour workers (carpenters etc).

Signs and Symptoms of Tennis Elbow?

Pain and tenderness over the elbow bone (lateral epicondyle)

Pain with gripping, twisting, lifting.

Some cases may have nerve involvement – nerve pain and neck range of motion restrictions.

Do I need an X-ray or MRI?

A diagnosis can be made based on the history of the condition and a physical examination. X-rays may be used to help rule out other causes of elbow pain, such as arthritis. An ultrasound or magnetic resonance imaging (MRI) scan will show the degenerative changes or small tears in the tendon, but is rarely required.

Tennis Elbow Treatment

Evidence tells us that strength exercises are the most effective way of treating tennis elbow, with adjuncts of manual therapy (lateral elbow glides and C5 glides if radial nerve involvement. (L.Bisset et al 2015, Cleland et al 2013).

Strength exercises can not only help settle the pain, but also reduce the risk of the pain returning.


Each patient should be treated based on the history and the findings. Common treatments include:

  1. Load management: – Reducing or stopping the aggravating activity for a short period- Progressive loading and strengthening to improve load capacity
  2. Ergonomic advice (for example, the amount of time spent out of neutral wrist position is strongly associated with tennis elbow)
  3. Correction of biomechanics if required for return to sport.

Tips & Tricks:

  • Avoid the aggravating activities or positions that bring on your pain
  • Carry things with your palm up
  • Carry things close to the body
  • Load the tendon with exercises, but reduce manual labour
  • There should be no pain when performing exercises

Patients can also be reassured that some cases will improve without intervention and just information regarding modification of aggravating activities, ergonomic advice and reassurance that their condition will eventually settle.

Cortisone injections for tennis elbow… do they work?

Corticosteroid injections are NOT recommended. In a study by Vicenzino et al 2006, 198 participants got assigned to three groups (physiotherapy interventions, corticosteroid injections and ‘the wait and see approach’). The corticosteroid group had most reported recurrences at 72%.

Is there any evidence for any other treatment options?

Chiropractic manipulation

Can provide short term pain relief, however has no effect on long term outcome.


There is conflicting evidence for the effectiveness of bracing/taping compared with placebo or no treatment.

Acupuncture/dry needling

Conflicting evidence, but may be more effective than placebo and ultrasound at relieving pain and improving self-assessed treatment benefit in the short term.

Laser therapy

May be beneficial in short term compared with placebo, likely no difference between laser and other active interventions in the short or long term.


No more effective than placebo for pain relief or self-perceived global improvement in short term.

Shock wave therapy

Little or no benefit in reducing pain or improving function.

Platelet rich plasma injections

No benefit.

If you have any questions, or would like our help, please do not hesitate to get in touch at


1) Physiotherapy management of lateral epicondylalgia – Bisset, Vicenzino (2015)

•Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia – Paungmali, O’Leary, Souvlis, Vicenzino (2003)

2) Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia – Vicenzino, Paungmali, Buratowski, Wright (2001)

•Manipulation of the wrist for management of lateral epicondylitis: A randomized pilot study – Struijs, Damen, Bakker, Blankevoort, Assendelft, Van Dijk (2003)

3) Incorporation of Manual Therapy Directed at the Cervicothoracic Spine in Patients with Lateral Epicondylalgia: A Pilot Clinical Trial – Cleland, Flynn, Palmer (2013)

4) A randomized controlled trial of eccentric vs. concentric graded exercise in chronic tennis elbow (lateral elbow tendinopathy) – Peterson, Butler, Eriksson, Svardsudd (2014)

5) Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial – Bisset, Beller, Jull, Brooks, Darnell, Vicenzino (2006)

6) Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: A prospective randomized trial – Tyler, Thomas, Nicholas, Malachy, McHugh (2010)

7) Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy – Cook & Purdam (2009)


Top 4 Injury Prevention Exercises for Footballers (Video)

These exercises are designed to reduce the risk of suffering common footballing injuries.
The most common injuries, ranked in order are:
  1. Hamstring Tear
  2. Knee Ligament/Meniscus Injury
  3. Ankle Ligament Injury
  4. Groin Strain/Pain

To address the strength and control deficits that can increase the risk of these injuries, the following exercises should be completed at least twice a weak, at the END of a training session OR by themselves in a separate session.

  1. Nordic Hamstring Curl. Perform as slowly as possible. Do 3 sets of 8 reps.
  2. Copenhagen Adductor Exercise. Do 3 sets of 12 each leg.
  3. Lateral ankle/knee stability jumps. Do 3 sets of 8.
  4. Single leg Agility jumps over line. Do 3 sets of 20 each leg.

If you are interested in other, more in-depth information on injury prevention, then head over to our article from last year on the topic