Heel Pain When Running: Haglund's Syndrome Explained

Heel pain is the second most common running complaint after knee pain — and the one most often treated for the wrong thing. The reason: "heel pain" is an umbrella for at least four different problems that respond in completely opposite ways. If you stretch a heel spur that is actually an inflamed Achilles insertion, you will make it worse for weeks. This article shows how to work out within five minutes which structure is irritated, what actually has evidence behind it, and how to dose your return to running.

Four causes, one similar pain

The heel is a mechanically extreme region: running produces ground reaction forces of two to three times body weight, and the tendon insertion has to bundle them and transfer them into bone. Four structures can become irritated there:

• Plantar fasciitis / heel spur: pain underneath the sole, right at the plantar fascia origin on the heel bone. Hallmark: the first steps out of bed or after sitting for a while are worst, then it eases. A bony spur on an X-ray is often an incidental finding — not the source of pain.
• Haglund's syndrome: a bony prominence at the back and top of the heel where the Achilles inserts. It rubs against the shoe collar and irritates the bursa and the tendon insertion. Typical: pain at the back of the heel, worse in tight shoes and when running uphill.
• Insertional tendinopathy: degeneration of the Achilles exactly at the bone attachment — usually thickened, tender to pressure, stiff in the morning. It frequently accompanies Haglund's syndrome because the same mechanics load both structures.
• Fat pad loss: the heel pad cushions like a shock absorber. With age, after years of barefoot walking or after cortisone injections it thins out — then the whole heel hurts on impact, not just one spot.

This distinction is not academic hair-splitting. It decides whether you should stretch your calf or leave it alone, whether a heel wedge helps or a softer heel collar, and whether you are back to normal running in four weeks or four months. For the tendon itself, see Achilles tendon pain from running; for the underside variant, see plantar fasciitis in runners.

The self-test: where exactly does it hurt?

You do not need an ultrasound for a first classification — only a thumb and some honesty about the answer. Palpate the heel systematically, ideally seated with the foot relaxed:

• Point A — underneath, in the middle of the sole: tender right at the plantar fascia origin, pain with the first morning step. That points to plantar fasciitis. The pain often runs along the arch.
• Point B — at the back, above the tendon insertion: a bump you can feel, pain when squeezing the heel bone from both sides. It also fits that tight shoes, ski boots or cycling shoes feel unpleasant. This is the classic Haglund's test.
• Point C — exactly at the tendon insertion: a thickened tendon, morning stiffness, pain on the single-leg heel raise. This suggests insertional tendinopathy.
• The whole heel tender, no single point: more likely the fat pad or a bone stress reaction — medical assessment is mandatory before you keep running.

Second test: the single-leg heel raise on a flat surface. Pain high up on the tendon only: tendinopathy. Pain deep in the heel or midfoot: more likely bone or fascia. If terms such as drop, pronation or insertion angle are new to you, the German Peakora glossary explains them in one paragraph each.

Why the insertion gets overloaded

The cause is rarely "too much running" on its own, but a sum of four factors arriving together:

• Load spike: the most common trigger. A record week of volume, three hard runs in a row, a training camp with doubles. Tendon insertions tolerate increases of roughly 10 % per week — beyond that, remodelling falls behind. How to build up cleanly is covered in increase training volume.
• Insertion angle and foot position: a stiff ankle with limited dorsiflexion, a pronounced rearfoot varus or a cavus foot all raise shear forces at the insertion. Reduced ankle mobility — under 10 cm knee-to-wall distance in the knee-to-wall test — belongs in this chapter too.
• Footwear: a firm, high-rising heel collar is the main mechanical suspect with Haglund's, because it presses exactly on the bony prominence. With plantar fasciitis, by contrast, a very flat, soft shoe without any guidance often works against you.
• Calf strength and ankle stability: a weak calf cannot absorb impact energy, so it ends up in the insertion. This is where training does most — see foot strength for runners.

Acute phase: what helps in the first two weeks

In the irritated phase the goal is not stretching but reducing the stimulus while keeping everyday movement going:

• Cut load by 30–50 %, not to zero. Running stays allowed as long as the pain traffic light is green: below 4 out of 10 during the run and back to baseline the next morning. Complete rest tends to prolong symptoms, because the structure loses load tolerance.
• Drop hills and sprints. Uphill raises the insertion angle, downhill raises impact forces. Both are the wrong signal right now.
• Switch shoes rather than buy new ones. For two to three weeks use a model with a soft heel collar and 8–12 mm drop. With Haglund's, also bend the heel collar backwards by hand — if it pushes back hard, the shoe is unsuitable.
• Heel wedge or heel cup: a 6–10 mm wedge under the rearfoot measurably reduces tensile strain at the Achilles insertion. For plantar fasciitis, a well-shaped insole with arch support is the better-supported route.
• Cold after loading for 10–15 minutes eases symptoms but does not speed healing. Heat before running loosens a stiff morning heel.

What does not help in this phase: cortisone injections at the insertion. They suppress pain for weeks but degrade tendon quality — with insertional tendinopathy the recurrence rate afterwards is clearly higher. An NSAID for three to five days is defensible with severe irritation, but it is not a training permit; more on that in painkillers in endurance sport.

The effective lever: strength with a slow lowering phase

The strongest evidence for tendon insertion complaints comes from eccentric work — yielding slowly under load. The principle: you push up with both legs and lower on one leg over three to five seconds. The muscle works while it lengthens, and exactly that stimulus remodels tendon tissue.

• Eccentric heel raise, straight knee: 3 sets of 12–15 repetitions, 3–5 seconds lowering. Twice daily, every day — even if it still pulls a little. Pain up to 5 out of 10 during the exercise is explicitly permitted with tendinopathy and part of the concept.
• Eccentric heel raise, bent knee: same dose, targeting the deep calf (soleus). It carries most of the load in running.
• With Haglund's syndrome: the same stimulus, but with a shortened end position — do not go all the way into full plantarflexion, where the bone presses against the tendon. Work to about 90 % of range instead.
• Add isometrics: 5 × 30–45 seconds holds at mid-range as a low-pain variant for irritated days.
• Foot and toe strength: toe stands with a towel under the toes, short foot exercise, single-leg balance with eyes closed — 10 minutes, two to three times per week.

Plan on twelve weeks of consistency. That sounds long, but it is the realistic horizon for tendon tissue: collagen synthesis is slow, and quitting after four weeks — when pain fades but the structure is not yet load-tolerant — is the most common reason for relapse.

Return to running: the six-week structure

The progression follows no calendar but the 24-hour test: how you feel the next morning decides whether the last session fitted.

• Weeks 1–2: volume at 50–70 % of normal, everything easy, flat, even asphalt or treadmill. Strength programme daily. Goal: morning stiffness gets shorter.
• Weeks 3–4: volume to 80 %, first short strides (4 × 20 seconds) on flat ground, still no hills. Check whether the morning value stays stable.
• Weeks 5–6: normal volume, first hilly runs with controlled walking uphill if needed. One tempo run per week, not two.
• From week 7: re-entry into race pace and longer runs. Raise intensity before volume — not the other way round.

Two setbacks in a row at one step means: one step back, not back to zero. Anyone who stops completely at every worsening loses the load tolerance they are trying to build. How to break such plateaus systematically is covered in training plateau.

Common mistakes

• Treating the X-ray spur as the diagnosis. A spur is detectable in a large share of pain-free people. You treat the pain, not the image.
• Aggressive stretching with Haglund's. Strong calf stretching presses the tendon against the bony prominence. Stretching is fine with plantar fasciitis, counterproductive with Haglund's.
• Insoles as the first and only measure. They offload but build no capacity. Without strength work the pain returns at the next load spike.
• Returning to old volume too early, as soon as the pain is gone. Being pain-free is the start of the loading phase, not the end of it.
• New shoes as the solution. A shoe can amplify or soften a stimulus, but it never replaces load management.

When you must see a doctor

Most heel pain is manageable conservatively. Medical assessment is not optional with: pain at rest and at night, swelling without an obvious cause, fever, redness and heat (suspected infection), numbness or tingling into the sole, pain unchanged or worsening after four weeks of consistent treatment, and sudden sharp pain with inability to bear weight (suspected calcaneal stress fracture). Imaging should then be targeted: ultrasound for tendon and bursa, MRI for bone marrow oedema and stress reaction — plain X-ray alone does not answer most of these questions.

How Peakora catches heel pain early

The decisive factor in heel complaints is not treatment but the load management before it. The Peakora engine caps volume increases to a tolerable corridor, calculated from your acute and chronic training load (ACWR), and warns before a hard week turns into an irritation. The morning check-in with sleep, wellbeing and pain rating feeds straight into planning: if you flag a heel as problematic, the adaptive plan removes pace work, hills and intervals while holding volume — instead of sending you into the next flare-up with the scheduled interval session. After a break the engine rebuilds your return in stages with a weekly ceiling, and the load history makes visible whether you are genuinely progressing or just going in circles.

Frequently asked questions about heel pain