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 at the back of the talus bone.
There are 2 anatomical variations that cause posterior ankle impingement.
- 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.
- 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. You can read more about it here https://www.peterlam.com.au/procedures/arthroscopy-of-the-ankle-and-foot/
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
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.
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.
B.H.Sc.Physio., Women’s Health, Cert.Spinal.Man.Tpy., APAM
She graduated from New Zealand’s Auckland University of Technology in 2012, with a Bachelor of Applied Health Science (Physiotherapy). She first gained experience in a private hospital and has since extended her interest into Musculoskeletal Physiotherapy, Women’s Health and Clinical Pilates.
