Pain behind the heel is incredibly common, and most people experience this at some point in their lives. The back of the heel is incredibly important, as this is where the leg turns into the foot, and motion at the leg has to transfer ninety degrees to become motion at the foot. When pain develops at this area, it can be very disabling.

The two areas of concern for physicians here are the Achilles tendon and the heel bone, called the calcaneus. The Achilles tendon has it's name derived from the fabled late bronze age Greek warrior Achilles. A divine intervention made him impervious to bodily harm, except behind the heels where he was grasped during the procedure that made him so well protected. This defect eventually allowed him to be felled by an arrow from the Trojan prince during the lengthy Trojan War, as it pierced his heel. This tendon is aptly named, as dysfunction of it can certainly affect the ability to walk of anyone who suffers from it's injury and will 'fell' one's activity quickly.

Pain behind the heel can usually be caused by inflammation of the Achilles tendon as well as inflammation due to extra bone growth in the heel bone. Achilles inflammation, or tendonitis, is quite common, and activity only worsens the condition. It develops for a wide variety of reasons. These include chronic stretching of the tendon from unbalanced motion, violent injuries forcing the foot upward, and blunt pressure on the back of the heel itself as when someone steps on another's heel. Sometimes even stepping off of a curb in a slightly twisted position can cause damage to the Achilles tendon, resulting in tendon swelling and inflammation. Essentially, microscopic tears begin in the thick substance of the tendon during these injuries, and eventually progress to larger tears as the stress on the tendon continues during activity. In the case of violent or blunt injury, the tendon may even partially rupture or tear outright. When combined with a spur or enlargement of the back of the heel bone, even simple shoe use can be painful as the heel rubs against the back of the shoe. The pain can feel dull, sharp and knife-like, throbbing, aching, or all of the above. This pain usually goes down with rest and inactivity, and resumes with simple motion at the ankle or full activity.

The bone that the Achilles tendon attaches to can contribute a great deal to the overall process as briefly mentioned above. Spurs can develop on the back of the heel bone due to traction of the Achilles tendon on the bone. When the Achilles tendon eventually becomes inflamed, these spurs provide a rough, irritating surface for the tendon to move over, and can make the inflammation worse. Additionally these spurs can also fracture away, creating even more pain. These spurs need to be distinguished from the more commonly referred to heel spur on the bottom of the heel, which incidentally are rarely ever the true cause for heel pain down below. Some people do not have spurs behind their heel bone at all, but rather an enlargement of the back of the bone's rounded top surface. This enlargement, called a Haglund's deformity or pump bump, also irritates the Achilles tendon just above where it attaches to the heel bone. This enlargement can be seen from birth, or sometimes the result of gradual irritation from specific heel sections of poorly fitting shoes. The end result of either of these two bone abnormalities is additional irritation of the Achilles tendon and additional pain.

If the Achilles tendon is damaged significantly enough, or if tendonitis continues untreated for awhile, the end result can be full rupture or tearing of the tendon. This type of injury is easily noticed...after an Achilles tendon rupture most people cannot walk.

Treatment of tendonitis generally centers around stretching of the Achilles tendon, along with icing, anti-inflammatory medication, ankle bracing, and physical therapy. A tight Achilles tendon makes recovery incredibly difficult, and stretching becomes the most important aspect of this treatment course. Stretches should be done gently, and not to a point of pain. Icing and anti-inflammatory medication relieve the inflamed tissue around and in the tendon, and bracing prevents excessive tendon pulling by locking the ankle relatively in place. All these components together will help to reduce pain and improve mobility, as well as foster full healing. When more structured recovery is needed, such as in an athlete who needs to recover quickly or in a slowly healing individual, physical therapy can be used. Physical therapy accomplishes numerous goals, including eventual inflammation reduction, improved flexibility, and better tendon strength. Requiring several individual treatments with several different techniques in each, physical therapy is an excellent tool towards recovery but requires effort and time on the part of the injured. Immobilization in a walking cast, or with a non-weight bearing cast with crutches may also be necessary in severe cases, or in those that do not improve through the normal techniques.

Unfortunately, many people ignore their pain until it is very advanced. Untreated Achilles tendonitis can lead to tendon degeneration and even rupture. This requires surgical repair in many cases. Achilles tendon ruptures that occur as the initial injury almost always need surgery to repair them, unless other medical conditions make surgery dangerous or ill-advised. Recovery generally consists of four weeks in a cast and crutches as the tendon adequately heals, followed by several more weeks in a walking boot to protect the weakened but healed tendon. When the bone spur or bone enlargement is causing most of the pain, and the treatment outlined above is not helping, surgery is needed to remove the excess bone to relieve irritation of the Achilles tendon. This procedure requires the most surgical recovery time and needs nearly 3 months rehabilitation prior to returning to activity as the Achilles tendon is usually removed off the heel bone to access the spur prior to being replaced back down on it with a special anchor.

As you can see, what can start off as a simple area of pain behind the heel can blossom into a significant injury. Be sure not to ignore this pain, especially if it lasts longer than two weeks. When caught early enough, this condition can be healed much more quickly (unless the tendon was ruptured to begin with as part of the injury). See your foot specialist if possible for early intervention, or your family doctor or local urgent care center otherwise for at least the initial phases of treatment.