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Calcaneal Bursitis Clinical Presentation

  • Author: Patrick M Foye, MD; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: Mar 16, 2016
 

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).
    • 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.
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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.
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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]
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Contributor Information and Disclosures
Author

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Coauthor(s)

Todd P Stitik, MD Professor, Department of Physical Medicine and Rehabilitation, Director, Outpatient Occupational/Musculoskeletal Medicine, Rutgers New Jersey Medical School

Todd P Stitik, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Physiatric Association of Spine, Sports and Occupational Rehabilitation, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, Association of Academic Physiatrists

Disclosure: Received honoraria from Allergan for speaking and teaching.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Additional Contributors

Daniel D Scott, MD, MA Associate Professor, Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine; Attending Physician, Department of Physical Medicine and Rehabilitation, Denver Veterans Affairs Medical Center, Eastern Colorado Health Care System

Daniel D Scott, MD, MA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, Academy of Spinal Cord Injury Professionals, National Multiple Sclerosis Society, Physiatric Association of Spine, Sports and Occupational Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Acknowledgements

Debra Ibrahim New York College of Osteopathic Medicine

Evish Kamrava St George's University School of Medicine

Jason Lee St George's University School of Medicine

Dev Sinha, MD American University of Antigua School of Medicine and Health Sciences

Craig Van Dien Rutgers New Jersey Medical School

References
  1. Brinker MR, Miller MD. The adult foot. Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders; 1999. 342-63.

  2. Foot and ankle. Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997. 366-489.

  3. McGee DJ. Lower leg, ankle, and foot. Orthopedic Physical Assessment. 2nd ed. Philadelphia, Pa: WB Saunders; 1992. 448-515.

  4. Kachlik D, Baca V, Cepelik M, et al. Clinical anatomy of the retrocalcaneal bursa. Surg Radiol Anat. 2008 Mar 11. [Medline].

  5. Teebagy AK. Leg and ankle. Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in Primary Care. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999. 241-67.

  6. Young JL, Olsen NK, Press JM. Musculoskeletal disorders of the lower limbs. Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders; 1996. 783-812.

  7. Lohrer H, Nauck T. Retrocalcaneal bursitis but not Achilles tendinopathy is characterized by increased pressure in the retrocalcaneal bursa. Clin Biomech (Bristol, Avon). 2014 Mar. 29 (3):283-8. [Medline].

  8. Aldridge T. Diagnosing heel pain in adults. Am Fam Physician. 2004 Jul 15. 70(2):332-8. [Medline]. [Full Text].

  9. Reule CA, Alt WW, Lohrer H, Hochwald H. Spatial orientation of the subtalar joint axis is different in subjects with and without Achilles tendon disorders. Br J Sports Med. 2011 Oct. 45(13):1029-34. [Medline].

  10. Ly JQ, Bui-Mansfield LT. Anatomy of and abnormalities associated with Kager's fat Pad. AJR Am J Roentgenol. 2004 Jan. 182(1):147-54. [Medline].

  11. Eshed I, Althoff CE, Feist E, et al. Magnetic resonance imaging of hindfoot involvement in patients with spondyloarthritides: comparison of low-field and high-field strength units. Eur J Radiol. 2008 Jan. 65(1):140-7. [Medline].

  12. Erdem CZ, Tekin NS, Sarikaya S, et al. MR imaging features of foot involvement in patients with psoriasis. Eur J Radiol. 2007 Nov 8. [Medline].

  13. Van der Wall H, Lee A, Magee M, Frater C, Wijesinghe H, Kannangara S. Radionuclide bone scintigraphy in sports injuries. Semin Nucl Med. Jan 2010. 40(1):16-30. [Medline].

  14. Reiter M, Ulreich N, Dirisamer A, et al. [Extended field-of-view sonography in Achilles tendon disease: a comparison with MR imaging]. Rofo. 2004 May. 176(5):704-8. [Medline].

  15. Sofka CM, Adler RS, Positano R, et al. Haglund's syndrome: diagnosis and treatment using sonography. HSS J. Feb 2006. 2(1):27-9.

  16. Reiter M, Ulreich N, Dirisamer A, Tscholakoff D, Bucek RA. Extended field-of-view sonography in Achilles tendon disease: a comparison with MR imaging. Rofo. 2004. 176:704-708.

  17. Mattila VM, Sillanpää PJ, Salo T, Laine HJ, Mäenpää H, Pihlajamäki H. Can orthotic insoles prevent lower limb overuse injuries? A randomized-controlled trial of 228 subjects. Scand J Med Sci Sports. 2011 Dec. 21(6):804-8. [Medline].

  18. Olsen NK, Press JM, Young JL. Bursal injections. Lennard TA, ed. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995. 36-43.

  19. 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. 2007 Feb. 28(2):149-53. [Medline].

  20. Wiegerinck JI, Kok AC, van Dijk CN. Surgical treatment of chronic retrocalcaneal bursitis. Arthroscopy. 2012 Feb. 28(2):283-93. [Medline].

  21. Aliyev R, Muslimov Q, Geiger G. Results of conservative treatment of achillodynia with application micro-current therapy. Georgian Med News. Oct 2010. 35-42. [Medline].

  22. Nonsteroidal anti-inflammatory drugs (NSAIDs). Green SM, ed. Tarascon Pocket Pharmacopoeia 2000. Loma Linda, Calif: Tarascon Pub; 2000. 11-2.

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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.
Achilles stretch 1; cropped view showing a close-up of the region affected by this type of stretch.
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.
Achilles stretch 2; close-up view.
 
 
 
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