Pain at the Back of the Heel: Achilles Tendinopathy, Bursitis or a Tear?

Short answer: Pain behind the heel commonly arises from the Achilles tendon, but the precise site and onset matter. Pain several centimetres above the heel may fit midportion Achilles tendinopathy. Pain where the tendon attaches to the heel may be insertional tendinopathy, sometimes with nearby bone prominence or bursal irritation. Sudden pain with a snap, weakness or loss of push-off raises concern for a partial or complete tear. These problems should not all receive the same stretching, exercise, injection or footwear advice.

When pain behind the heel needs urgent assessment

Seek prompt medical assessment if:

• you felt or heard a sudden snap or pop at the back of the ankle;
• it felt as if someone kicked or struck your calf even though nobody did;
• you suddenly cannot push off, walk normally or rise onto the toes;
• there is a new gap, marked swelling or bruising along the tendon;
• the heel is hot, red, rapidly swelling or associated with fever, a wound or discharge;
• the foot becomes cold, pale, blue, severely numb or weak;
• one calf becomes unexpectedly swollen, warm or painful, especially with breathlessness or chest pain.

These features may require evaluation for Achilles rupture, fracture, infection, impaired circulation or a blood clot. A person may still be able to walk with an Achilles rupture, so walking does not safely exclude it. For a life-threatening emergency in Singapore, call SCDF 995.^[1]

What does the pain pattern suggest?

The pattern can guide assessment, but it does not establish a diagnosis by itself.

Common causes of pain at the back of the heel

Midportion Achilles tendinopathy

This typically affects the tendon above its heel attachment. Symptoms may follow an increase in running, hills, court sport, walking volume or repeated calf loading, but sedentary patients can also develop it. The tendon may feel thick or tender and may hurt when first walking, during push-off or after activity.

“Tendinitis” is a familiar term, but persistent tendon pain is not necessarily explained by simple ongoing inflammation. “Tendinopathy” better reflects a load-related tendon disorder with variable changes in tissue structure, pain sensitivity and capacity.

Insertional Achilles tendinopathy

Insertional pain occurs at the tendon’s attachment to the heel bone. It may be aggravated by uphill walking, stairs, deep squatting, rigid shoe counters or exercises that lower the heel below a step. Compression at the attachment matters, so a loading plan used for midportion symptoms may need modification.

Retrocalcaneal or superficial bursitis

A bursa is a small fluid-containing structure that reduces friction. One lies between the Achilles tendon and heel bone, while another superficial bursa can be irritated by footwear. Bursal pain may coexist with insertional tendinopathy, inflammatory disease or a prominent heel contour.

Haglund-type heel prominence

A bony prominence at the upper back of the heel may increase shoe pressure and local compression. Its presence on X-ray does not prove it is the only pain source. Symptoms, footwear response and surrounding tendon and bursa findings must be considered.

Partial or complete Achilles tear

A rupture can occur during acceleration, jumping or an unexpected step, but it may also occur with less dramatic activity in a vulnerable tendon. Risk can be influenced by age, previous symptoms, certain medical conditions and some medicines. A partial tear can resemble severe tendinopathy; a complete rupture may cause surprisingly limited pain after the initial event despite major weakness.

Other possible causes

Posterior ankle impingement, stress injury, arthritis, gout, infection, nerve irritation and pain referred from the leg or lower back can overlap with Achilles-region symptoms. Pain location is helpful, not conclusive.

How is Achilles-region pain examined?

The history should clarify:

• whether symptoms began suddenly or gradually;
• the exact painful point and whether it has moved;
• morning stiffness and response to warming up;
• recent changes in walking, running, hills, sport, work or footwear;
• whether there was a snap, bruising or immediate loss of strength;
• previous tendon pain, injections, injuries or rehabilitation;
• medical conditions and medicines relevant to tendon health;
• the patient’s work, sport, deadline and preferred treatment approach.

Examination may include walking, swelling, bruising, tendon contour and tenderness, ankle movement, calf strength, repeated heel raises and comparison with the other side. The Thompson calf-squeeze test can contribute to assessment for a rupture, but clinical findings must be interpreted together; a partial tear or unusual presentation may require imaging.

A clinician may also examine the plantar heel, ankle joint, bursae, nerves and lower leg. This reduces the risk of treating every posterior-heel symptom as the same tendon problem.

When are X-rays, ultrasound or MRI considered?

Typical gradual-onset Achilles tendinopathy can often be assessed clinically. Imaging is more useful when the diagnosis is uncertain, symptoms are atypical, a significant tear is possible, progress has stalled despite appropriate care, or a procedure or operation is being considered.

X-ray

An X-ray shows bone rather than the tendon in detail. It may be considered for insertional symptoms when bone prominence, calcification, arthritis, impingement or another bone problem could affect the plan.

Ultrasound

Ultrasound can examine tendon thickness, fibre continuity, selected tears, nearby bursae and movement in real time. It is accessible and dynamic, but findings depend on the clinical question and operator experience.

MRI

MRI can provide a broader view of the tendon, insertion, bone, bursae and surrounding structures. It may be considered for uncertain or complex symptoms, suspected partial tear, persistent pain despite an appropriate programme, or surgical planning. Imaging guidance for chronic ankle pain emphasises matching the test to the suspected condition.^[2]

A structurally abnormal-looking tendon may not be the only cause of pain, and scan changes can remain after symptoms improve. Imaging should therefore answer a decision question rather than serve as a severity score by itself.

Treatment options for Achilles tendinopathy

The right plan depends on whether pain is midportion or insertional, how irritable the tendon is, whether a tear has been excluded, previous treatment and the patient’s priorities.

Adjust loading rather than automatically stopping everything

Reducing or temporarily modifying the most provocative activities can settle a flare without complete inactivity. A runner might reduce hills and speed work; a worker may need shorter walking blocks or temporary task changes. The aim is to find a tolerable starting load and rebuild capacity.

Progressive tendon loading

Exercise-based tendon loading is a central treatment for many patients with Achilles tendinopathy. Options can include isometric, slow resistance, eccentric or combined calf loading. The label matters less than matching the dosage, movement range and progression to the patient’s presentation and goals. Contemporary clinical guidance supports tendon-loading exercise for midportion Achilles tendinopathy.^[3]

Insertional pain may initially require limiting deep dorsiflexion—for example, performing heel raises from the floor rather than dropping the heel below a step. A generic online programme that ignores pain location can be counterproductive.

Footwear, heel lifts and orthoses

A softer or open-backed shoe can reduce direct heel pressure. A temporary heel lift may reduce tendon compression or strain in selected patients, but it changes lower-limb mechanics and is not automatically a long-term solution. Orthoses may help a specific associated foot problem; they are not required for every Achilles complaint.

Medication

Simple analgesics or anti-inflammatory medicines may be considered for short-term symptom relief when medically appropriate. They do not restore tendon capacity, and persistent tendinopathy is not simply an inflammatory condition. Risks depend on medical history, other medicines and duration.

Manual therapy and symptom-relief modalities

Manual therapy, taping or other modalities may help selected mobility or pain problems and make rehabilitation more tolerable. They should be linked to measurable function rather than used as proof that the tendon has healed.

Shockwave therapy

Extracorporeal shockwave therapy may be discussed for selected persistent Achilles tendinopathy, often alongside load management and rehabilitation. Evidence and protocols vary by pain location and clinical presentation. NICE notes that the evidence on efficacy is inconsistent and recommends special arrangements for governance, consent and audit for refractory Achilles tendinopathy.^[4] It should not be applied over a suspected acute tear without appropriate assessment.

Injections and emerging treatments

Injection options sometimes discussed include corticosteroid around selected inflamed adjacent structures, platelet-rich plasma and other biologic or image-guided procedures. They are not interchangeable. Injection into or close to the Achilles tendon can carry important risks, including tendon injury; the exact target, evidence, uncertainty and aftercare must be explained.

Novel biologic products, needling procedures and other emerging options have variable evidence, product status and regulatory requirements. A treatment should not be chosen solely because it is newer, passive or marketed as regenerative.

Surgery

Surgery is generally reserved for selected persistent cases with a clear diagnosis after substantial non-surgical management, or for specific tears and structural problems. The procedure, recovery and rehabilitation differ between tendinopathy, insertional bone and bursa problems, partial tears and complete ruptures.

What if the Achilles tendon is torn?

A suspected rupture requires timely confirmation and protection. Treatment may be non-operative or surgical depending on the tear, time since injury, age, medical risks, activity demands and patient preferences. Both pathways require structured rehabilitation. The initial ankle position and timing of loading matter, so patients should not improvise aggressive stretching while awaiting assessment.

A partial tear should not automatically be managed as ordinary tendinopathy. The extent and location, strength loss and functional demands help determine protection and progression.

Which approach fits the patient’s situation?

“I need to stand or walk at work next week”

First establish whether this is gradual tendinopathy or an acute tear. For tendinopathy, temporary footwear changes, a selected heel lift, shorter walking blocks and a modified loading plan may help preserve function. Work restrictions or recovery within a fixed number of days cannot be guaranteed.

“I do not want exercises and prefer a passive treatment”

Footwear modification, selected supports, manual care or shockwave therapy may reduce symptoms for some patients. However, if inadequate tendon capacity is central to the problem, passive care alone does not prepare the calf and tendon for walking, stairs or sport. A small, targeted programme may be more practical than a long generic routine.

“I already tried physiotherapy and it did not work”

Reassessment should ask whether the correct structure and location were treated, whether a tear, bursa, bone or nerve problem was missed, and whether loading was too little, too much or progressed inappropriately. Further options may include revising the programme, imaging where it would change care, a selected adjunct or a surgical opinion. Repeating the identical failed plan is not the only non-surgical option.

“I want the fastest treatment or an injection”

Fast pain reduction and safe tendon recovery are not always the same goal. An injection may not rebuild capacity and may carry tendon-specific risks. The discussion should compare likely speed, durability, uncertainty, side effects, downtime and the rehabilitation still required.

“I want to return to running or sport”

Minimal pain during walking is not the same as readiness for repeated running, jumping or sprinting. Progress may include calf strength, repeated heel raises, energy-storage tasks, hopping and gradual sport exposure. Criteria should reflect the activity rather than time alone.

How should progress be monitored?

Useful measures include:

• morning stiffness and first-step pain;
• walking or standing time before symptoms increase;
• pain response during activity and the following day;
• single-leg heel-raise number, height and control;
• swelling and shoe-pressure tolerance;
• running, jumping or work-task capacity where relevant;
• confidence and ability to progress without recurrent flares.

A temporary increase in discomfort does not always mean damage, but sudden loss of strength, a new snap, marked bruising or rapidly worsening swelling requires reassessment.

Integrated doctor and physiotherapy management

The Pain Relief Clinic has in-house physiotherapists who can work with the licensed medical doctor for integrated management. This can help coordinate the diagnosis, need for imaging, symptom-control options, progressive tendon loading and return-to-work or sport planning.

Integrated care may be particularly useful after failed rehabilitation, when a partial tear or associated bursa or bone problem is possible, or when a patient is considering shockwave therapy, an injection or a surgical opinion. Physiotherapists practising in Singapore should be appropriately registered.^[5]

Insurance referrals and supporting paperwork

The clinic can assist with clinically appropriate referrals and supporting paperwork for insurance claims. Coverage, required documents, pre-authorisation and reimbursement depend on the patient’s policy and insurer. A referral, form or medical report does not guarantee approval or payment.

Before imaging or physiotherapy, patients may wish to check whether their policy requires a doctor’s referral, panel provider, pre-authorisation, itemised invoice or medical report.

Frequently asked questions

Is pain behind the heel always Achilles tendinopathy?

No. Bursitis, shoe-pressure irritation, bone prominence, tear, impingement, arthritis, gout, infection and nerve-related pain can overlap. The onset, precise location and examination matter.

Should I stretch a painful Achilles tendon?

Not automatically. Stretching may help selected calf or ankle restrictions, but deep ankle bending can compress an irritable insertional tendon. A suspected tear requires assessment rather than aggressive stretching.

Can I walk with Achilles tendinopathy?

Many patients can continue some walking if symptoms remain tolerable and settle predictably. The amount should be adjusted to the presentation. Sudden weakness or suspected rupture requires prompt assessment.

Does a thick Achilles tendon mean it will rupture?

No. Thickening can occur with tendinopathy and does not by itself predict rupture. Risk assessment includes symptoms, function, medical factors, medicines and any acute injury.

Is ultrasound or MRI better for Achilles pain?

Neither is universally better. Ultrasound is dynamic and useful for selected tendon and bursa questions. MRI gives a broader view of the tendon, bone and surrounding tissues. The best test is the one that answers the clinical question and may change care.

How long does Achilles tendinopathy take to improve?

Recovery varies with duration, location, severity, health factors, load demands and treatment consistency. Tendon rehabilitation commonly requires progressive work over time rather than a single quick treatment.

Arrange an assessment for pain behind the heel in Singapore

If pain at the back of your heel is persistent, limiting work or sport, or followed a sudden snap or loss of strength, an assessment can distinguish tendon, insertion, bursa, bone and other possible causes and consider whether rehabilitation, imaging, symptom-relief treatment or referral may be appropriate.

The Pain Relief Clinic
350 Orchard Road, #10-00 Shaw House
Singapore 238868
Telephone: +65 9068 9605

Not every investigation or treatment discussed on this page is required, offered or recommended by the clinic. Availability and permissible use of tests, medicines, devices, injections and emerging treatments in Singapore may change with evolving Ministry of Health, Health Sciences Authority and Singapore Medical Council requirements. Individual decisions require clinical assessment and should follow current Singapore regulations and professional guidance.

References

1. Singapore Civil Defence Force. Emergency Medical Services.
2. American College of Radiology. ACR Appropriateness Criteria: Chronic Ankle Pain.
3. Chimenti RL, Neville C, Houck J, et al. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2024. Journal of Orthopaedic & Sports Physical Therapy.
4. National Institute for Health and Care Excellence. Extracorporeal shockwave therapy for refractory Achilles tendinopathy. Interventional Procedures Guidance IPG571.
5. Allied Health Professions Council Singapore. Search the register.

Disclaimer: This information is provided for general reference only and should be used in consultation with your licensed medical doctor. It is not a diagnosis or a substitute for personalised medical advice. Seek urgent care for severe, rapidly worsening or warning-feature symptoms.

Reviewed by Dr Terence Tan — 13 September 2026