AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

Background

Pain at the posterior heel or ankle is most commonly caused by pathology at either the posterior calcaneus (at the calcaneal insertion site of the Achilles tendon) or at its associated bursae. Two bursae are located just superior to the insertion of the Achilles (calcaneal) tendon. Anterior or deep to the tendon is the retrocalcaneal (subtendinous) bursa, which is located between the Achilles tendon and the calcaneus. Posterior or superficial to the Achilles tendon is the subcutaneous calcaneal bursa, also called the Achilles bursa. This bursa is located between the skin and posterior aspect of the distal Achilles tendon. Inflammation of either or both of these bursa can cause pain at the posterior heel and ankle region.

Frequency

United States

Retrocalcaneal bursitis is fairly common.

Sport-Specific Biomechanics

Inflammation of the calcaneal bursae is most commonly caused by repetitive (cumulative) trauma or overuse, and the condition is aggravated by pressure, such as when athletes wear tight-fitting shoes. Retrocalcaneal bursitis may also be associated with conditions such as gout, rheumatoid arthritis, and seronegative spondyloarthropathies. In some cases, retrocalcaneal bursitis may be caused by bursal impingement between the Achilles tendon and an excessively prominent posterosuperior aspect of the calcaneus (Haglund deformity). In Haglund disease, impingement occurs during ankle dorsiflexion.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

History

• Posterior heel pain is the primary presenting chief complaint, and patients may report limping.
• Some individuals may also present with an obvious or noticeable swelling (eg, a "pump bump," presumably named in association with high-heeled shoes or pumps).
  
  
  • Ask the patient about footwear, such as high-heeled shoes or tight-fitting athletic shoes.
  • Specifically ask about any recent change in footwear (eg, new athletic shoes, transition from flat shoes to high heels or from road running shoes to racing flats or to cleats).
• Retrocalcaneal bursitis may be unilateral or bilateral.
• Individuals who are accustomed to wearing high-heeled shoes on a long-term basis may experience increased stretch and irritation of the Achilles tendon and its associated bursae when switching to flat shoes.
• Ask about the specifics of the patient's activity levels (eg, include the distances runners travel).
• Symptoms often worsen when the athlete is first beginning an activity after resting.
• Ask about previously known or suspected underlying rheumatologic conditions (eg, gout, rheumatoid arthritis, seronegative spondyloarthropathies).

Physical

• Swelling and redness of the posterior heel may be clearly apparent (eg, pump bump).
• The inflamed area may be slightly warm and tender to palpation.
• Careful examination can help the clinician distinguish whether the inflammation is posterior (superficial) to the Achilles tendon (within the subcutaneous bursa) or anterior (deep) to the Achilles tendon (within the subtendinous bursa).
• Tenderness caused by isolated subtendinous bursitis can best be isolated by palpation just anterior to both the medial and lateral edge of the distal Achilles tendon.
• Tenderness due to insertional Achilles tendinitis is located slightly more distal, where the Achilles tendon inserts onto the posterior calcaneus.
• Plantar fasciitis causes tenderness along the posterior aspect of the sole, but patients should not experience tenderness with palpation of the posterior heel or ankle.
• A patient with avulsion or rupture of the Achilles tendon demonstrates a palpable defect in the tendon and a positive Thompson test (ie, squeezing the calf fails to cause plantar flexion due to the loss of Achilles tendon continuity).

Causes

• Overtraining in an athlete, such as with excessive increases in running mileage
• Tight or poorly fitting shoes that produce excessive pressure at the posterior heel and ankle due to a restrictive heel counter
• Haglund deformity, which causes impingement between the increased posterosuperior calcaneal prominence and Achilles tendon during dorsiflexion

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

Other Problems to Be Considered

Stress fracture of the calcaneus
Rheumatoid arthritis
Gout
Seronegative spondyloarthropathies
Haglund deformity
Sural neuritis
Calcaneus bone injuries

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

Lab Studies

• If the bursitis cannot be explained by local factors (eg, poorly fitting shoes, increased running, high heels), or if systemic symptoms or signs of rheumatologic involvement exist, consider laboratory studies to evaluate the possibility of gout (hyperuricemia), rheumatoid arthritis (rheumatoid factor), and seronegative spondyloarthropathies (eg, human leukocyte antigen B-27 [HLA B-27], erythrocyte sedimentation rate [ESR], C-reactive protein).

Imaging Studies

• Plain radiographs of the calcaneus may reveal a Haglund deformity (increased prominence of the posterosuperior aspect of the calcaneus), which is observed best on the lateral view.
• Plain radiographs can be used to evaluate for stress fracture of the calcaneus. If the studies are negative for a stress fracture, but a stress fracture remains a significant diagnostic consideration, the clinician may wish to pursue 3-phase bone scanning or computed tomography (CT) scanning of the calcaneus.
• Magnetic resonance imaging (MRI) may demonstrate bursal inflammation, but this modality probably does not offer much more information than that found by careful physical examination. Theoretically, MRI could help the physician to determine whether the inflammation is within the subcutaneous bursa, the subtendinous bursa, or even within the tendon itself; however, such testing is generally not necessary.
• Ultrasonography may be a potentially useful tool for diagnosing pathologies of the Achilles tendon.¹ (See the Procedures section below.)

Procedures

• Some clinicians advocate the use of corticosteroid injection(s) into the affected bursa, with particular care to avoid injection within the Achilles tendon. Due to the close proximity of the Achilles tendon to the subtendinous and subcutaneous calcaneal bursae, such injections should be considered only in severe, recalcitrant cases.

  In general, the authors of this article recommend against corticosteroid injection in the vicinity of the Achilles tendon due to the potential risk of tendon rupture. However, prospective, randomized studies have not been performed to definitively establish a causal relationship between steroid injections and such tendon ruptures. Instead, the association between steroid injections and subsequent tendon ruptures is mostly based on retrospective case reports. Thus, the cases that were more likely to go on to rupture were potentially those in which a more severe presentation prompted the steroid injections in the first place.

• A case report by Sofka et al demonstrated that retrocalcaneal bursitis can be diagnosed and treated with ultrasonography.² This modality can be used to guide injection into the retrocalcaneal bursa of a combination of local anesthetic (eg, lidocaine, with relief within minutes and duration of several hours) with corticosteroid (eg, triamcinolone [Kenalog; Bristol-Myers Squibb Company, Princeton, NJ], with anti-inflammatory effect within 24-48 hours and a relief duration of weeks to months). The authors stressed that ultrasonographic guidance helps to ensure reliable and accurate delivery of medication into the bursa, while concurrently avoiding intratendinous injection. 
• The patient must be informed—and must be willing to incur the risk—that corticosteroid injections may precipitate Achilles tendon rupture. Corticosteroid injection in the vicinity of the Achilles tendon is not recommended.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

Acute Phase

Rehabilitation Program

Physical Therapy

The patient should be instructed to apply ice to the posterior heel and ankle in the acute period of the bursitis. Icing can be performed several times a day, for 15-20 minutes each. Some clinicians also advocate use of contrast baths.

Gradual progressive stretching of the Achilles tendon may help relieve impingement on the subtendinous bursa and can be performed in the following manner:

1. Stand in front of a wall, with the affected foot flat on the floor. Leans forward toward the wall until a gentle stretching is felt within the ipsilateral Achilles tendon.
2. Maintain the stretch for 20-60 seconds and then relax.
3. Perform the stretches with the knee extended and then again with the knee flexed.
4. To maximize the benefit of the stretching program, repeat the above steps for several stretches per set, several times daily. Avoid ballistic (ie, abrupt, jerking) stretches.

If it is necessary for the patient to decrease his or her activity level due to retrocalcaneal bursitis, alternative means of maintaining strength and cardiovascular fitness should be suggested, such as swimming, water aerobics, and other aquatic exercises.

Consultations

Other Treatment

Changing the patient's footwear may be the most important form of treatment. Use of an open-backed shoe may relieve pressure on the affected region. For individuals in whom symptoms were precipitated by a dramatic change from wearing high-heeled shoes to flat shoes (or vice versa), the temporary use of footwear that is a heel height somewhere in between may be necessary. Encourage athletes to change running shoes on a regular basis because the support and fit of their footwear may change over the course of hundreds of miles of use.

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 patient's skin. The patient should avoid shoes without laces, because the nature of such footwear is to fit closely onto the heel. Inserting a heel cup in the shoe may help to raise the inflamed region slightly above the shoe's restricting heel counter. A heel cup should also be placed in the opposite (contralateral) foot's shoe to avoid introducing a leg-length discrepancy.

Corticosteroid injection in this region is not recommended due to the potential risk of Achilles tendon rupture. In a 2004 animal study, Hugate et al demonstrated the adverse effects of local corticosteroid injections (both within the tendon substance and into the retrocalcaneal bursa) on the biomechanical properties of the Achilles tendon.³

Recovery Phase

Rehabilitation Program

Physical Therapy

The patient should continue to advance the physical therapy program outlined above (see Acute Phase), with a gradual increase of activities. The goal is for the patient to have a full return to his or her previous level of athletic function.

Medical Issues/Complications

• Progressive posterior heel and ankle pain, with resultant limping and decreased athletic performance or mobility

• Rupture of the Achilles tendon, either secondary to chronic local inflammation/degeneration or due to corticosteroid injection

• Immobilization: Consider partial immobilization in a walking boot or immobilization in a cast for 4-6 weeks if the patient's symptoms are resistant to the other treatments. 

Surgical Intervention

Consider surgical intervention for patients who have significant persistence or progression of symptoms, in spite of the nonsurgical treatment approaches listed above (see Acute Phase Physical Therapy and Other Treatment). Surgical management may include the following:

• Resection of a Haglund deformity (eg, removal of the calcaneal posterosuperior prominence through an ostectomy)
• Excision of the painful bursa(e)
• Debridement of the Achilles tendon insertion
• Repair of an Achilles tendon rupture or avulsion
• Outpatient endoscopic removal of the inflamed bursal tissue and resection of the prominent bone⁴

Consultations

An orthopedic surgeon who is experienced with foot and ankle surgery should be consulted for patients in whom conservative therapy has failed and who require surgical intervention.

Other Treatment (Injection, manipulation, etc.)

Corticosteroid injection in this region is not recommended due to the potential risk of rupture of the Achilles tendon.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The patient should continue with a home exercise program that is developed in conjunction with a physical therapist during the course of treatment.

Medical Issues/Complications

The patient should be alert for any early signs or symptoms that indicate recurrence of the retrocalcaneal bursitis, so that intervention can be provided as soon as possible, if necessary.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

Retrocalcaneal bursitis is a musculoskeletal condition; thus, medications are used primarily to decrease the associated pain and inflammation. The most common medications are oral nonsteroidal anti-inflammatory drugs (NSAIDs) that are used in conjunction with the rehabilitation program.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

Various oral NSAIDs can be used to decrease pain and inflammation, and the drug of choice (DOC) is largely a matter of convenience (eg, what is the best dosing frequency to achieve adequate analgesic and anti-inflammatory effects?), safety profile, and cost.

Drug Name	Ketoprofen (Orudis, Oruvail, Actron)
Description	For relief of mild to moderate pain and inflammation. Small dosages are initially indicated for small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response.
Adult Dose	25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric Dose	<3 months: Not established 3 months to 12 years: 0.1-1 mg/kg PO q6-8h >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and β-blockers; may decrease diuretic effects of furosemide and thiazides; may increase risk of methotrexate toxicity; phenytoin levels may be increased with concurrent administration. Monitor prothrombin time closely (instruct patients to watch for signs of bleeding).
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Category D in third trimester of pregnancy; caution in patients with CHF, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy.

Drug Name	Naproxen (Naprelan, Naprosyn, Anaprox)
Description	For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing cyclooxygenase activity, which results in a decrease of prostaglandin synthesis.
Adult Dose	500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric Dose	<2 years: Not established >2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and β-blockers; may decrease diuretic effects of furosemide and thiazides; may increase risk of methotrexate toxicity; phenytoin levels may be increased with concurrent administration. Monitor prothrombin time closely (instruct patients to watch for signs of bleeding).
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and levels usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

Return to Play

Athletes may be expected to return to play without restrictions after they demonstrate the following:

• Resolution of symptoms
• Resolution of previous physical examination findings (eg, limping, tenderness on palpation)
• Adequate performance of sports-specific practice drills without recurrence of symptoms or physical examination findings

Complications

• The posterior heel pain may become chronic or progressive, resulting in limping (antalgic gait) and decreased athletic performance.
• Achilles tendon rupture may occur secondary to chronic inflammation and/or due to corticosteroid injection.

Prevention

Patients should consider the following preventive measures:

• Wear properly fitting footwear, and change running shoes on a regular basis, depending on the amount of use.
• Avoid footwear that fits too tightly at the posterior heel.
• Avoid high-heeled shoes.
• Avoid corticosteroid injection by other clinicians, unless the risk of Achilles tendon rupture is fully understood.

Prognosis

• Most patients respond well to a combination of local icing, oral medications, Achilles stretching, and modification of footwear.
• In general, patients with persistent symptoms despite nonsurgical measures (see Acute Phase Physical Therapy and Other Treatment) can expect improvement with any of the previously discussed surgical interventions (see Surgical Interventions).

Education

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education article Bursitis.

Patients should be thoroughly educated and informed about the following:

• The proper performance of Achilles tendon stretching
• The rationale for donning appropriate footwear
• The potential risks and benefits of corticosteroid injection for those who are considering receiving this treatment 
• The risks, benefits, and expected outcomes of surgical intervention for those in whom conservative therapy has failed

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

Medical/Legal Pitfalls

• In general, corticosteroid injection should be avoided due to the increased risk of Achilles tendon rupture with local injection at the posterior ankle.
• Failure to diagnose a calcaneal stress fracture can occur, particularly if bony tenderness is present at the mid calcaneal region rather than the more common location at the Achilles tendon and its associated bursae.
• Stress fractures may remain undiagnosed due to failure to consider further imaging, such as 3-phase bone scanning or CT scanning when plain radiographs appear normal.

Special Concerns

• Athletes are often very eager to continue or resume their usual exercise programs, sometimes too rapidly to allow for adequate physiologic and/or physical recovery.
• Alternative means of maintaining strength and cardiovascular fitness should be discussed with the patient, including water exercises such as swimming and pool aerobics.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

Greg Gazzillo, 4th year medical student, New Jersey Medical School–UMDNJ, Class of 2007, assisted with the 2006 revision of this manuscript.

Debra Ibrahim, 4th year medical student, New York College of Osteopathic Medicine, Class of 2008, assisted with the 2007 revision of this manuscript.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

1. Blankstein A, Cohen I, Diamant L, et al. Achilles tendon pain and related pathologies: diagnosis by ultrasonography. Isr Med Assoc J. Aug 2001;3(8):575-8. [Medline].
2. Sofka CM, Adler RS, Positano R, Pavlov H, Luchs JS. Haglund's syndrome: diagnosis and treatment using sonography. HSS Journal. Feb 2006;2(1):27-9. [Full Text].
3. Hugate R, Pennypacker J, Saunders M, Juliano P. The effects of intratendinous and retrocalcaneal intrabursal injections of corticosteroid on the biomechanical properties of rabbit Achilles tendons. J Bone Joint Surg Am. Apr 2004;86-A(4):794-801. [Medline].
4. Ortmann FW, McBryde AM. Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis. Foot Ankle Int. Feb 2007;28(2):149-53. [Medline].
5. Brinker MR, Miller MD. The adult foot. Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders Co; 1999:342-63.
6. Green SM, ed. Nonsteroidal anti-inflammatories. Tarascon Pocket Pharmacopoeia 2000. Loma Linda, Calif: Tarascon Publishing; 2000:11-2.
7. McGee DJ. Lower leg, ankle, and foot. Orthopedic Physical Assessment. 2^nd ed. Philadelphia, Pa: WB Saunders Co; 1992:448-515.
8. Mutlu H, Sildiroglu H, Pekkafali Z, Kizilkaya E, Cermik H. MRI appearance of retrocalcaneal bursitis and rheumatoid nodule in a patient with rheumatoid arthritis. Clin Rheumatol. Sep 2006;25(5):734-6; Epub 2005 Oct 13. [Medline].
9. Olsen NK, Press JM, Young JL. Bursal injections. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:36-43.
10. Snider RK, ed. Foot and ankle. Essentials of Musculoskeletal Care. 2^nd ed. Rosemont, Ill: American Academy of Orthopedic Surgeons; 1997:366-489.
11. Teebagy AK. Leg and ankle. In: Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in Primary Care. 3^rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999:241-7.
12. Young JL, Olsen NK, Press JM. Musculoskeletal disorders of the lower limbs. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996:783-812.

Article Last Updated: Oct 9, 2007