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, 4] :
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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. [5]
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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. [6, 7] Similarly, patients with Achilles tendinopathy may also have a thickened subcutaneous bursa with increased blood flow in the bursa walls. Concurrent Achilles tendon and subcutaneous bursa pathology can be very painful, as the subcutaneous bursa is a well-innervated structure and may be responsible for a great deal of pain. [8]
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. [9]
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:
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No mortality is associated with calcaneal bursitis.
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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.
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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.
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Achilles stretch 1; cropped view showing a close-up of the region affected by this type of stretch.
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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 20-30 seconds and then is relaxed.
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Achilles stretch 2; close-up view.
