Calcaneal Bursitis

Author: Patrick M Foye, MD; Chief Editor: Consuelo T Lorenzo, MD more...

Background
Pain at the posterior heel or posterior ankle is most commonly caused by pathology at the posterior
calcaneus, the Achilles (calcaneal) tendon, or the associated bursae. The following bursae are
located just superior to the insertion of the Achilles tendon [1, 2, 3] :

Subtendinous calcaneal bursa - This bursa (also called the retrocalcaneal bursa), situated
anterior (deep) to the Achilles tendon, is located between the Achilles tendon and the calcaneus. [4]
Subcutaneous calcaneal bursa - Also called the Achilles bursa, it is found posterior
(superficial) to the Achilles tendon, lying between the skin and the posterior aspect of the distal
Achilles tendon.
Inflammation of one or both of these bursae can cause pain in the posterior heel and ankle regions. [5,
6]

Haglund deformity (prominence of the posterior superior calcaneus) is not a true synonym for
calcaneal bursitis, but it can be a closely associated condition.
For additional information, see Bursitis [Emergency Medicine], Bursitis [Orthopedic Surgery], and
Retrocalcaneal Bursitis.

Pathophysiology
Inflammation of the calcaneal bursae is most commonly caused by repetitive overuse and cumulative
trauma, as seen in runners wearing tight-fitting shoes. Such bursitis may also be associated with
conditions such as gout, rheumatoid arthritis, and seronegative spondyloarthropathies.
In some cases, subtendinous calcaneal bursitis is caused by bursal impingement between the
Achilles tendon and an excessively prominent posterior superior aspect of a calcaneus that has been
affected by Haglund deformity. With Haglund disease, impingement occurs during ankle dorsiflexion.
A study by Lohrer and Nauck indicated that retrocalcaneal bursa pressure rises in patients with
chronic retrocalcaneal bursitis, which in turn, the investigators suggested, can cause an impingement
lesion on the anterior Achilles tendon.[7]

Epidemiology
Frequency
United States
Calcaneal bursitis is seen somewhat frequently, particularly if the clinician has a predominantly
musculoskeletal practice.

Mortality/Morbidity
See the list below:

No mortality is associated with calcaneal bursitis.

Morbidity is associated with progressive pain and limping (antalgic gait) in patients who have
not received adequate treatment. If chronic inflammation also affects the distal Achilles tendon,
rupture of the tendon may occur.

Race
No race predilection has been documented.

Sex
Calcaneal bursitis is observed in men and women. However, some increased risk may be incurred by
women who wear high-heeled shoes.

Age

Calcaneal bursitis is commonly observed in middle-aged and elderly persons; the condition is also
seen in athletes of all ages

History
Obtaining a detailed history from the patient is important in diagnosing calcaneal bursitis. [8] The
following complaints (which the physician should ask about during the subjective examination) are
commonly reported by patients:

Posterior heel pain is the chief complaint in individuals with calcaneal bursitis.
Patients may report limping caused by the posterior heel pain.
Some individuals may also report an obvious swelling (eg, a pump bump, a term that
presumably comes from the swelling's association with high-heeled shoes or pumps).

The condition may be unilateral or bilateral.

Symptoms are often worse when the patient first begins an activity after rest.
Other inquiries that the physician should make include the following:

The clinician should ask about the patient's customary footwear (whether, for example, it
includes high-heeled shoes or tight-fitting athletic shoes).
o
The patient should be asked specifically about any recent change in footwear, such
as whether he/she is wearing new athletic shoes or whether the patient has made a transition
from flat shoes to high heels or vice versa. Individuals who have been accustomed to wearing
high-heeled shoes on a long-term basis may find that switching to flat shoes causes increased
stretch and irritation of the Achilles tendon and the associated bursae.

The specifics of a patient's activity level should be ascertained, including how far the patient
runs and, in particular, whether the individual is running with greater intensity than before or has
increased the distance being run.

The history of any known or suspected underlying rheumatologic conditions, such as gout,
rheumatoid arthritis, or seronegative spondyloarthropathies, should be obtained.

Physical
During the physical examination of a patient with calcaneal bursitis, the physician should keep the
following considerations in mind:

Swelling and redness of the posterior heel (the pump bump) may be clearly apparent.
The inflamed area, which may be slightly warm to the touch, is generally tender to palpation.
Careful examination can help the clinician to distinguish whether the inflammation is
posterior to the Achilles tendon (within the subcutaneous calcaneal bursa) or anterior to the tendon
(within the subtendinous calcaneal bursa). Differentiating Achilles tendinitis/tendinosis from bursitis
may be impossible. At times, the 2 conditions co-exist.
Isolated subtendinous calcaneal bursitis is characterized by tenderness that is best isolated
by palpating just anterior to the medial and lateral edges of the distal Achilles tendon.
Conversely, insertional Achilles tendinitis is notable for tenderness that is located slightly
more distally, where the Achilles tendon inserts on the posterior calcaneus.
A patient with plantar fasciitis has tenderness along the posterior aspect of the sole, but
he/she should not have tenderness with palpation of the posterior heel or ankle. [8]
A patient with a complete avulsion or rupture of the Achilles tendon demonstrates a palpable
defect in the tendon, weakness in plantarflexion, and a positive Thompson test on physical
examination. During the Thompson test, the examiner squeezes the calf. The test is negative if this
maneuver results in passive plantarflexion of the ankle, which would indicate that the Achilles
tendon is at least partially intact.

Causes
See the list below:

Overtraining in a runner (eg, excessive increases in miles or intensity)

Tight or poorly fitting shoes that, because of a restrictive heel counter, exert excessive
pressure on the posterior heel and ankle
Haglund deformity, causing impingement between the increased posterior superior calcaneal
prominence and the Achilles tendon during dorsiflexion
More recent research suggests that a misaligned subtalar joint axis (measured in terms of
joint inclination and deviation) in relation to the Achilles tendon can result in an asymmetrical force

load on the tendon, disrupting normal biomechanics. This altered joint axis is associated with an
increased risk for Achilles pathologies, including bursitis.[9]
These include the following:

Gout
Haglund deformity
Seronegative spondyloarthropathies
Stress fracture of the calcaneus
Sural neuritis
Medial calcaneal nerve impingement (branch of tibial nerve)
Achilles chondrocalcinosis
Calcaneal spur
Calcaneal osteochondroma

Differential Diagnoses

Achilles Tendon Injuries

Physical Medicine and Rehabilitation for Stress Fractures

Plantar Fasciitis

Rheumatoid Arthritis

Laboratory Studies
If the appearance of the bursitis cannot be explained by local factors (eg, ill-fitting shoes, excessive
running, high heels) or if there are systemic symptoms or signs of rheumatologic involvement, the
clinician should consider laboratory studies to evaluate for the possibility of gout (hyperuricemia),
rheumatoid arthritis (rheumatoid factor), and seronegative spondyloarthropathies (HLA B-27,
erythrocyte sedimentation rate, and/or C-reactive protein).
Also see related Medscape Resource Centers on Gout and Rheumatoid Arthritis.

Imaging Studies
Plain radiographs of the calcaneus may reveal Haglund deformity, which can be seen best on the
lateral view. In this view, the triad consistent with Haglund's disease is thickening of Achilles tendon
at insertion, retrocalcaneal bursitis, and retro-Achilles bursitis. [10]
Plain radiographs can also be used to evaluate for stress fracture of the calcaneus. If the plain
radiographs are negative for stress fracture but this injury possibility remains a significant diagnostic
consideration, a 3-phase bone scan or a computed tomography (CT) scan of the calcaneus should
be obtained.
Magnetic resonance imaging (MRI) scans may demonstrate bursal inflammation but probably do not
offer much more information than is apparent from careful physical examination. Theoretically, MRI
scans may help to determine whether the inflammation is in the subcutaneous calcaneal bursa, the
subtendinous calcaneal bursa, or the tendon itself, but such testing is generally unnecessary. [11, 12]
Hybrid imaging modalities, most specifically single-photon emission CT (SPECT)/CT, may assist with
early detection of bursitis by offering a precise, accurate, and highly localizing diagnostic image.
However, little research exists on the cost benefit of this modality, and therefore, this imaging
modality is not frequently used for this type of soft-tissue injury.[13]
Some clinicians have suggested that ultrasonography can be used in place of MRI in cases in which
imaging is desired to investigate pathology at the posterior heel. A recent study concluded that
extended field-of-view sonography (EFOVS) when combined with traditional gray-scale sonography
has similar sensitivity and specificity to MRI for diagnosing calcaneal bursitis in addition to more rapid
results, lower cost, and lack of contraindications.[14, 15, 16]

Procedures
Generally, no diagnostic procedures are required.

Histologic Findings
Bursal inflammation is present in patients with calcaneal bursitis, but obtaining a histologic specimen
from an actual patient would be extremely rare.

Rehabilitation Program
Physical Therapy
Gradually progressive stretching of the Achilles tendon may help to relieve impingement on the
subtendinous calcaneal bursa. Stretching of the Achilles tendon can be performed by having the
patient place the affected foot flat on the floor and lean forward toward the wall until a gentle stretch
is felt in the ipsilateral Achilles tendon. The stretch is maintained for 20-60 seconds and then is
relaxed. This technique is demonstrated in the following images.

Achilles stretch 1; whole-person view. The patient

stands with the affected foot flat on the floor and leans forward toward the wall until a gentle stretch is felt in the
ipsilateral Achilles tendon. The stretch is maintained for 20-60 seconds and then is relaxed.

Achilles stretch 1; cropped view showing

a close-up of the region affected by this type of stretch.

Another technique, a more advanced stretch that isolates the Achilles tendon, is shown in the
following images.

Achilles stretch 2; whole person view. This stretch, which is

somewhat more advanced than that shown in Images 1-2, isolates the Achilles tendon. It is held for at least 2030 seconds and then is relaxed.

Achilles stretch 2; close-up view.

To maximize the benefit of the stretching program, the patient should repeat the exercise for multiple
stretches per set, multiple times per day. Ballistic (ie, abrupt, jerking) stretches should be avoided in
order to prevent clinical exacerbation.
The patient should be instructed to ice the posterior heel and ankle in order to reduce inflammation
and pain. Icing can be performed for 15-20 minutes at a time, several times a day, during the acute
period, which may last for several days. Some clinicians also advocate the use of contrast baths,
ultrasound or phonophoresis, iontophoresis, or electrical stimulation for treatment of calcaneal
bursitis.
If the patient's activity level needs to be decreased as a result of this condition, alternative means of
maintaining strength and cardiovascular fitness (eg, swimming, water aerobics) should be suggested.

Medical Issues/Complications
See the list below:

Addressing footwear
Changing footwear may be the most important form of treatment for calcaneal
bursitis. The use of an open-backed shoe may relieve pressure on the affected region.
Individuals whose symptoms have been precipitated by a dramatic footwear
change, specifically, a switch from high-heeled shoes to flat shoes (or vice versa), may need to
temporarily use footwear with a medium heel height.
Athletes should be encouraged to change running shoes on a regular basis,
because the shoes' fit, as well as the support the shoes provide, may change over the course of
hundreds of miles of use.
Further modification of shoes
A portion of the heel counter can be cut away and replaced with a soft leather insert
to decrease friction at the site where the heel counter meets the skin.
Shoes without laces (eg, slip-on shoes, sandals) inherently fit closely onto the heel
and should be avoided.
Inserting a heel cup into the shoe may help to raise the inflamed region slightly
above the restricting heel counter. If this approach is implemented, a heel cup should also be
placed into the other shoe to avoid introducing a leg-length discrepancy.
Of note, a recent prospective, randomized-controlled study has called into question
the efficacy of orthotic insoles, however, suggesting that routine use of foot orthoses by healthy
men provide no significant preventive benefits against overuse injuries, including bursitis. [17]

o
o

Immobilization
The initial accommodation of the bursitis by the introduction of rest or of a decrease
in or modification of activity may suffice to reverse the bursitis and its symptoms.
If the symptoms are resistant to the above treatments, immobilization in a cast for 46 weeks should be considered.
Complications from calcaneal bursitis or its treatment
Progressive posterior heel and ankle pain
Rupture of the Achilles tendon, either secondary to chronic local
inflammation/degeneration or as a result of corticosteroid injection(s)
Some clinicians advocate the use of corticosteroid injection(s) into the affected
bursa, being careful to avoid injection within the Achilles tendon. [18] Because of the close proximity
of the Achilles tendon to the bursae, such injections should be considered only in severe,
recalcitrant cases. The authors of this article generally recommend against corticosteroid injection
in the vicinity of the Achilles tendon because of the potential risk of tendon rupture. However,
prospective, randomized studies have not been performed to establish whether steroid injections
cause such tendon ruptures. Instead, the association between steroid injections and subsequent
tendon ruptures is mostly based on retrospective case reports. Potentially, those cases that were
more likely to go on to rupture were also more likely to have a severe presentation that prompted
the steroid injections.
One case report demonstrated that subtendinous calcaneal bursitis can be not only
diagnosed but also treated with ultrasonography. Ultrasonographic guidance can be used to inject
the subtendinous calcaneal bursa with a combination of local anesthetic (eg, lidocaine, giving
relief within minutes and lasting several hours) and corticosteroid (eg, Kenalog, producing an
anti-inflammatory effect within 24-48 h and providing relief for weeks to months). The authors feel
that using ultrasonographic guidance can help to ensure reliable, accurate delivery of medication
into the bursa while avoiding intratendinous injection. [15]

Surgical Intervention
For patients who have persistent or progressive symptoms despite rigorous nonsurgical treatment,
the following surgical interventions are options:

Resection of Haglund deformity, removing the calcaneal superoposterior prominence

(ostectomy)
Excision of the painful bursa or bursae
Debridement of the Achilles insertion
In cases of Achilles tendon rupture or avulsion, surgical re-anastomosis is indicated.
Outpatient endoscopic removal of the inflamed bursal tissue and resection of the prominent
bone. [19]
A review study by Wiegerinck et al suggested that, based on patient satisfaction and complication
rates, endoscopic treatment of chronic retrocalcaneal bursitis is superior to open surgery. The review
included 15 trials (12 open-surgery studies and 3 endoscopic trials), which encompassed 547
procedures in 461 patients. The study also indicated that sufficient bone resection is required for a
good procedure outcome, regardless of the surgical technique used. [20]

Consultations
Patients requiring surgical intervention should be referred for surgical consultation to an orthopedic
surgeon who is experienced in foot and ankle surgery.

Other Treatment
As discussed above, corticosteroid injection in this region is not recommended because of the
potential risk of rupturing the Achilles tendon.
Microcurrent therapy may serve as another modality for managing heel pain. Using a numerical
rating scale for pain, a recent study showed that the addition of microcurrent therapy to traditional
treatments significantly reduced pain (pain rating reduction from 8.9 to 2.3) compared with traditional
treatments alone (pain rating reduction from 8.2 to 5.9). Improvement may be due to the induction of
secondary messengers, such as cyclic adenosine monophosphate (cAMP), which modulates
important processes for cellular viability.[21]

Medication Summary

For this musculoskeletal condition, medications are used primarily to decrease pain and
inflammation. Thus, the most commonly used medications are oral nonsteroidal anti-inflammatory
drugs (NSAIDs), which are employed in conjunction with the rest of the rehabilitation plan. [22]

Nonsteroidal anti-inflammatory drugs

Class Summary
Oral NSAIDs can help to decrease pain and inflammation. Various oral NSAIDs can be used, with the
choice of drug being largely a matter of convenience (how frequently doses must be taken to achieve
adequate analgesic and anti-inflammatory effects) and cost.
View full drug information

Ibuprofen (Motrin, Advil, Nuprin, Rufen)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing
prostaglandin synthesis. Various doses are available with and without a prescription.
View full drug information

Naproxen (Naprelan, Naprosyn, Aleve, Anaprox)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity
of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.
View full drug information

Ketoprofen (Actron, Orudis, Oruvail)

For relief of mild to moderate pain and inflammation.
Small dosages are initially indicated in small and elderly patients and in persons with renal or liver
disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution
and closely observe patient for response.
View full drug information

Flurbiprofen (Ansaid)
May inhibit cyclo-oxygenase enzyme, which in turn inhibits prostaglandin biosynthesis. These effects
may result in analgesic, antipyretic, and anti-inflammatory activities.

Nonsteroidal Anti-inflammatory Drug, Topical

View full drug information

Diclofenac topical
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing
prostaglandin synthesis.

Further Outpatient Care

See the list below:

The patient should return for re-evaluation every 4-6 weeks until the symptoms are resolved
or under adequate control.
These follow-up visits provide the clinician with an opportunity to monitor the efficacy of the
treatment plan and to make appropriate modifications if the patient's symptoms have not
adequately improved.

Deterrence
See the list below:

The patient should avoid footwear that fits tightly at the posterior heel.
High-heeled shoes should be avoided.

Complications
See the list below:

Chronic or progressive posterior heel pain

Limping (antalgic gait)

Achilles tendon rupture occurring secondary to chronic inflammation or perhaps resulting

from corticosteroid injection

Prognosis
See the list below:

Most patients respond well to a combination of local icing, oral anti-inflammatory

medications, Achilles tendon stretching, and footwear modification.
Surgical intervention may provide good results for patients in whom conservative treatment
has failed.

Patient Education
See the list below:

The patient should be educated in the proper performance of Achilles tendon stretching.
The patient should understand the rationale for appropriate footwear.
A patient who is considering corticosteroid injection must understand the potential risks and
benefits of this treatment.
For patient education resources, see the Foot, Ankle, Knee, and Hip Center, as well
as Bursitis.