eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions
Calcaneal Bursitis
Updated: May 4, 2008
Introduction
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 tendon1,2,3 :
- 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.
Related eMedicine topics:
Bursitis [Emergency Medicine]
Bursitis [Orthopedic Surgery]
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.
Frequency
United States
Calcaneal bursitis is seen somewhat frequently, particularly if the clinician has a predominantly musculoskeletal practice.
Mortality/Morbidity
- 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.
Clinical
History
Obtaining a detailed history from the patient is important in diagnosing calcaneal bursitis.7 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.
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.7
- 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
- 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 on Calcaneal Bursitis |
 Overview: Calcaneal Bursitis |
| Differential Diagnoses & Workup: Calcaneal Bursitis |
| Treatment & Medication: Calcaneal Bursitis |
| Follow-up: Calcaneal Bursitis |
| Multimedia: Calcaneal Bursitis |
| References |
| Next Page » |
References
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Reiter M, Ulreich N, Dirisamer A, et al. [Extended field-of-view sonography in Achilles tendon disease: a comparison with MR imaging]. Rofo. May 2004;176(5):704-8. [Medline].
Sofka CM, Adler RS, Positano R, et al. Haglund's syndrome: diagnosis and treatment using sonography. HSS J. Feb 2006;2(1):27-9.
Olsen NK, Press JM, Young JL. Bursal injections. In: Lennard TA, ed. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:36-43.
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].
Nonsteroidal anti-inflammatory drugs (NSAIDs). In: Green SM, ed. Tarascon Pocket Pharmacopoeia 2000. Loma Linda, Calif: Tarascon Pub; 2000:11-2.
Further Reading
Keywords
calcaneal bursitis, bursitis of the subtendinous or subcutaneous bursa of the calcaneal (Achilles) tendon, bursitis of the subtendinous or subcutaneous calcaneal bursa, bursitis of the subtendinous or subcutaneous retrocalcaneal bursa, exostosis, Haglund deformity, prominence of the posterior superior calcaneus, retrocalcaneal bursitis, pump bump
