Foot Problems – Posterior Heel Pain (Pain at the Back of the Heel)

Pain in the back of the heel, and just above the heel, is usually caused by one of the following conditions: Haglund’s Deformity (“Pump Bump”): a bony enlargement of the upper/back portion of the heel. This enlarged bone rubs on the Achilles Tendon, just above its attachment to the heel, causing inflammation and pain.

• Retrocalcaneal Bursitis is an inflammation of the protective sack between the heel bone and the Achilles tendon.
• Calcification of the Achilles Tendon at its attachment to the heel.
• Achilles Tendonitis is an inflammation of the Achilles Tendon. The cause of all 4 of these conditions is a biomechanical problem of the foot (a defect in the foot’s structure or function).

Anatomy of the Back of the Heel:  The Achilles Tendon travels down from the lower portion of the calf, and attaches to the middle of the back of the heel (the posterior aspect of the heel). To prevent the top portion of the heel bone (the superior aspect) from rubbing against the Achilles Tendon, there exists a fluid-filled sac called the Retrocalcaneal Bursa. This bursa, or protective sac lies between the posterior-superior aspect of the heel and the Achilles Tendon, preventing the heel bone from rubbing against the soft tissue of the tendon. If the posterior-superior portion of the heel has an abnormally large bony prominence protruding from it (called a Haglund’s Deformity), in some instances it may rub against the Achilles Tendon. When this occurs, the bursa between the bone and the tendon will become inflamed, swollen, and painful. This condition is called Retrocalcaneal Bursitis. The presence of a Haglund’s Deformity does not insure that these problems will occur. In order for these problems to occur, the heel and foot must be tilted in such a way as to actually force this bony prominence into the bursa and tendon. The most common causes of the tilting of the heel are: When the arch is flat, the front of the heel bone is tilted lower than normal, while the back of the heel is tilted a bit higher. This may force the posterior-superior portion of the heel into the Retrocalcaneal Bursa and Achilles Tendon.

• High arches. When this occurs, the front of the heel bone is tilted upwards, while the back of the heel is tilted down and back. This may force the posterior-superior portion of the heel into the Retrocalcaneal Bursa and Achilles Tendon.

Pronation is a tilting or rolling out of the foot so that we are forced to walk with more of our weight on the inner aspect of the heel and foot. When this occurs, the Haglund’s Deformity presses with abnormal force against the inner portion of the Retrocalcaneal Bursa. Pronation frequently occurs in flat feet, increasing the occurrence of heel pain. This is the opposite of pronation. The foot rolls inward so that we are forced to walk with more of our weight on the outer aspect of the heel and foot. When this occurs, the Haglund’s Deformity presses with abnormal force against the outer portion of the Retrocalcaneal Bursa. Supination frequently occurs in high arched feet, increasing the occurrence of heel pain. (Pronation affects the feet much more frequently than supination). This condition may be due to: a genetic or congenital cause ( such as during development, lying in the uterus in such a way as to restrict the normal development of this tendon); injury to the tendon; a result of surgery on the leg; strokes; and other neuromuscular diseases. The results of a tight Achilles Tendon are: to pull up on the back of the heel, where it attaches, with such force as to raise the back of the heel up, and tilt it, forcing the heel into the Retrocalcaneal Bursa. At the same time, the increased pull of this shortened tendon may produce a generalized inflammation of the tendon at or near its attachment to the heel. Thus, the net effect is not only Retrocalcaneal Bursitis but also Insertional Achilles Tendonitis. The above process may be hastened if the heel counter of the shoe rubs against the skin on the back of our heels with too much pressure. Treatment: Long Term Treatment must be directed towards eliminating the abnormal tilting of the heel, regardless of its cause. If this is delayed, the usual results are:

• the pain and swelling become worse, chronic, and debilitating
• and eventually, painful calcifications and bone spur formations may occur on the back of the heel, along with tears in the Achilles Tendon. These are serious problems that may require surgical intervention

In order to eliminate abnormal heel tilt, the foot must be re-balanced. This is best accomplished by controlling and reducing the biomechanical foot defects that are causing the heel to tilt. The “Gold Standard” of medical care (that treatment most used by doctors and therapists) to help eliminate pain, inflammation, and swelling at the back of the heel is custom-made orthotics. To help to alleviate abnormal heel tilt and pain in the back of the heel. Stabilizing the heel will also help to reduce ankle sprains, plantar fasciitis, and heel spurs on the bottom of the heel. By adding appropriate lifts to the heel, our custom-made orthotics will help to eliminate the pain caused by a short Achilles Tendon.

• In addition, comfort is also provided to the arch, shins, knees, and lower back by the use of our “space-age” materials. These unique materials provide semi-flexible support to the arch by “giving” to absorb the shock of each step, rather than our foot absorbing the shock (orthotics act in the same way a shock absorber does on an automobile). When your weight is removed from the orthotic, the arch returns to its original height since the material we use has a built-in “memory.”The following product can be very effective in reducing pain in the back of the heel; however, it does not correct the underlying cause of this problem as custom-made orthotics do. Achilles Heel Guard – this product, more than any other, comfortably protects the back of the heel and the lower portion of the Achilles Tendon from shoe pressure and friction. It is the only product that protects these areas without slipping. It is composed of a comfortable elastic sleeve, with a long-lasting gel cushion designed to absorb pressure and friction, rather than allowing these forces to “work” on the skin and soft tissue. The gel cushion is thin enough to fit in any shoe, yet it is durable and will provide you with comfort for many months.
• The entire guard is washable, including the gel cushion.
• Size is determined by the circumference of your ankle. This is measured with a tape measure placed around the ankle.
• The following may give some immediate relief, but usually not permanent relief:
• wear open-back shoes with a higher heel. This will eliminate some pressure on the back of the heel. Applications of ice to the back of the heel may help to reduce inflammation and pain. You need to apply mild cooling; you do not want to freeze the area. If the area becomes too cold, it may increase the pain. Apply an ice pack over a sock, not directly against the skin. Use for 10 minutes at a time, several times a day. If the cold makes the pain worse, stop immediately. Diabetics and those with poor circulation should not use ice.
• gentle massage with a cold linament may help.
• if this is comfortable for you, sleep with your heel not touching the mattress. Before sleep, put a pillow under your calf, to help elevate the heel during sleep. This will help to keep pressure off of the heel.
• finally, if there is an open sore, ulcer, or infection present, or if you think that you may have a tear of the tendon, see your family doctor immediately!

A set of custom-made orthotics, designed specifically for this condition can help Achilles Heel Guard Podiatrists and orthopedic specialists use this product more than any other to comfortably protect the back of the heel and the lower portion of the Achilles Tendon from shoe pressure and friction. It is the only product that protects these areas without slipping. It is composed of a comfortable elastic sleeve, with a long-lasting gel cushion designed to absorb pressure and friction, rather than allowing these forces to “work” on the skin and soft tissue. The gel cushion is thin enough to fit in any shoe, yet it is durable and will provide you with comfort for many months. The entire guard is washable, including the gel cushion. Size is determined by the circumference of your ankle. This is measured with a tape measure placed around the ankle.