• Subcutaneous Calcaneal Bursitis
• Albert disease
• Calcaneus Altus
• Pump bump
• Winter heel
• Achillodynia
• Chronic retrocalcaneal bursitis
• subtendinous Bursitis

Anatomy at the Back of the Heel

To understand heel bursitis, it is helpful to be familiar with a few anatomical structures:

• The calcaneus is a large bone at the back of the foot, commonly known as the heel bone.
• The Achilles tendon is a long strip of fibrous tissue that connects the calf muscles to the back of the heel bone. The calf muscles include the gastrocnemius and soleus muscles.
• Enthesis is the medical term for the point at which any tendon or ligament inserts into a bone.
• The Achilles tendon enthesis is located at the back of the calcaneus.
• Bursae are thin, slippery, fluid-filled sacs that serve as both cushions and lubricant between tissues, usually between bone and soft tissue, such as a tendon or skin. A bursal sac is made up of a delicate, thin membrane called a synovial membrane. The membrane produces a fluid, called synovial fluid, that fills the sac.
• The retrocalcaneal bursa is located in between the heel bone and the Achilles tendon, just above the Achilles tendon enthesis.
• The calcaneal bursa is located in between the Achilles tendon and the skin at the back of the heel.

Bursitis can develop in either the retrocalcaneal bursa and the calcaneal bursa. It is possible for bursitis to develop in both bursae at the same time, making the pain and inflammation more difficult to treat.

Pathophysiology

• General
  • An overuse injury is commonly seen in middle-aged or older athletes
  • Inflammation of the bursa leads to heel and ankle pain, limiting function
  • Characterized by pain anterior to the Achilles tendon and superior to the calcaneus
• Etiology
  • Repetitive impingement of the bursa between the anterior aspect of the Achilles tendon and a bony posterosuperior calcaneal prominence

Associated Conditions

• Haglund Deformity

Pathoanatomy

• Retrocalcaneal Bursa
  • Lies between the Calcaneus anteriorly and the Achilles Tendon posteriorly
  • Separated from Achilles fat pad by synovial lining on superior aspect
  • The anterior wall is cartilaginous, posterior wall is tendinous

• Sports
  • Runners
  • Figure Skating
• Biomechanical
  • Hindfoot Varus
  • Rigid plantarflexed first ray
• Systemic
  • Gout
  • Rheumatoid Arthritis

Differential Diagnosis

• Fractures & Dislocations
  • Distal Tibia Fracture
  • Distal Fibular Fracture
  • Talus Fracture
  • Calcaneus Fracture
  • Subtalar Dislocation
  • Ankle Fracture (& Dislocation)
  • Peroneal Subluxation
• Muscle and Tendon Injuries
  • Peroneal Tendon Injuries
  • Achilles Tendonitis
  • Achilles Tendon Rupture
  • Posterior Tibial Tendon Dysfunction
  • Flexor Hallucis Longus Tendinopathy
• Ligament Injuries
  • Lateral Ankle Sprain
  • Medial Ankle Sprain
  • Syndesmotic Sprain
  • Chronic Ankle Instability
  • Intersection Syndrome Foot
• Bursopathies
  • Retrocalcaneal Bursitis
• Nerve Injuries
  • Peroneal Nerve Injury
  • Tarsal Tunnel Syndrome
• Arthropathies
  • Osteoarthritis of the Ankle
  • Osteochondral Defect Talus
• Pediatrics
  • Fifth Metatarsal Apophysitis (Iselin’s Disease)
  • Calcaneal Apophysitis (Sever’s Disease)
• Other
  • Haglunds Deformity
  • Posterior Ankle Impingement Syndrome
  • Sinus Tarsi Syndrome

Symptoms

In addition to pain, there are several other possible signs and symptoms of heel bursitis. A person with heel bursitis may notice one or more of the following:

Swelling at the back of the heel

Bursitis causes a bursa to fill with excess fluid. In retrocalcaneal bursitis, this excess fluid may cause visible swelling in the area just above the back of the heel bone.

The swelling caused by calcaneal bursitis—the form of heel bursitis associated with wearing tight shoes—may be more distinct, appearing as a hard lump behind the heel.

Stiffness

The swelling at the back of the heel may make it difficult to fully bend or straighten the ankle.

Skin redness

Both retrocalcaneal and calcaneal bursitis can cause the skin at the back of the heel to look red. This discoloration is more likely to occur in calcaneal bursitis because the calcaneal bursa is closer to the surface of the skin.

The skin at the back of the heel may also appear red skin if it has been irritated by ill-fitting shoes.

Skin warmth

If the skin at the back of the heel feels particularly hot to the touch, it may be a sign of septic bursitis. This condition is caused by an infection. Though uncommon, septic heel bursitis is a serious condition, and patients should seek medical care to ensure the infection does not spread or become chronic.

Fever or chills

A body-wide fever or chills is a sign of infection. When fever or chills appear with other heel bursitis symptoms, especially hot, red skin at the back of the heel, it may be a sign of septic bursitis. As stated above, people who suspect septic bursitis are advised to seek urgent medical care.

Treating heel bursitis can prevent the condition from becoming chronic and reduce the risk of other future problems. Septic bursitis should be treated immediately.

A health care provider can evaluate the affected foot and determine if symptoms are caused by bursitis or something else. When making a diagnosis, a health care provider may consider a patient’s medical risk factors and lifestyle, such as exercise routine.

Diagnosis

• History
  • Patients typically report posterior heel pain
  • Swelling may or may not be present
  • Typically worse during early exercise and improves during the workout
• Physical Exam: Physical Exam Ankle
  • Swelling at the bursa may be noted (i.e. ‘pump bump’)
  • Passive dorsiflexion often induces pain
  • Active plantarflexion reproduces pain
• Special Tests
  • Two Finger Squeeze Test: Pressure is applied with the fingers placed medially and laterally anterior to the Achilles tendon insertion

Radiographs

• Standard Radiographs Ankle
  • Typically normal
  • May show loss of retrocalcaneal recess

Ultrasound

• Best performed with the patient laying prone
  • Allows easy evaluation, comparison of both ankles
• Findings
  • Triangular hypoechoic lesion situated between the Achilles tendon and the calcaneus

MRI

• Not required to make a diagnosis
• Bursa will appear as an enlarged, fluid-filled structure
  • Low signal intensity on T1-weighted images
  • High signal intensity on fluid-sensitive images

Treatment

Nonpharmacological

• Rest. You may need to alter or limit activities that cause heel pain. These include high-impact activities like running.
• Prescription or over-the-counter medicines. This help reduces pain and swelling.
• Cold packs or heat packs. These may ease the pain.
• Shoe inserts or padding. Devices such as heel cups or pads for the back of your heel can ease discomfort when moving.
• Footwear. You should avoid wearing tight-fitting shoes or those that rub the back of your heel. Shoes with an open-back heel, such as clogs, may help.
• Stretching exercises. Gentle stretching movements can restore flexibility in your ankle and foot. They can also help with the pain.

Nonoperative

• Indications
  • Virtually all cases
• Ice Therapy
• Activity modification
• NSAIDS
• Heel Cup
  • Raises the heel, offloading the bursa and achilles tendon
• Physical Therapy
  • Emphasis on stretching the Achilles tendon
• Footwear modification
  • Shoes that are open backed may relieve pressure or tension
• Microcurrent therapy
  • One study suggested this was helpful as an adjunct when combined with standard therapy^[7]
• Corticosteroid Injection
  • Performed under ultrasound or fluoroscopic guidance
  • There is likely some risk to the Achilles Tendon, although this is not clearly established^[8][9]
  • Under fluoroscopy, patients reported a 50% reduction in pain^[10]

Operative

• Indications
  • Refractory to conservative management
• Technique
  • Bursectomy