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Calcaneal Bursitis Treatment & Management

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

Rehabilitation Program

Physical Therapy

Gradually progressive stretching of the Achilles tendon may help to relieve impingement on the subtendinous calcaneal bursa. Stretching of the Achilles tendon can be performed by having the patient place the affected foot flat on the floor and lean 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. This technique is demonstrated in the following images.

Achilles stretch 1; whole-person view. The patient 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-u Achilles stretch 1; cropped view showing a close-up of the region affected by this type of stretch.

Another technique, a more advanced stretch that isolates the Achilles tendon, is shown in the following images.

Achilles stretch 2; whole person view. This stretc 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. Achilles stretch 2; close-up view.

To maximize the benefit of the stretching program, the patient should repeat the exercise for multiple stretches per set, multiple times per day. Ballistic (ie, abrupt, jerking) stretches should be avoided in order to prevent clinical exacerbation.

The patient should be instructed to ice the posterior heel and ankle in order to reduce inflammation and pain. Icing can be performed for 15-20 minutes at a time, several times a day, during the acute period, which may last for several days. Some clinicians also advocate the use of contrast baths, ultrasound or phonophoresis, iontophoresis, or electrical stimulation for treatment of calcaneal bursitis.

If the patient's activity level needs to be decreased as a result of this condition, alternative means of maintaining strength and cardiovascular fitness (eg, swimming, water aerobics) should be suggested.

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Medical Issues/Complications

See the list below:

  • Addressing footwear
    • Changing footwear may be the most important form of treatment for calcaneal bursitis. The use of an open-backed shoe may relieve pressure on the affected region.
    • Individuals whose symptoms have been precipitated by a dramatic footwear change, specifically, a switch from high-heeled shoes to flat shoes (or vice versa), may need to temporarily use footwear with a medium heel height.
    • Athletes should be encouraged to change running shoes on a regular basis, because the shoes' fit, as well as the support the shoes provide, may change over the course of hundreds of miles of use.
  • Further modification of shoes
    • 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 skin.
    • Shoes without laces (eg, slip-on shoes, sandals) inherently fit closely onto the heel and should be avoided.
    • Inserting a heel cup into the shoe may help to raise the inflamed region slightly above the restricting heel counter. If this approach is implemented, a heel cup should also be placed into the other shoe to avoid introducing a leg-length discrepancy.
    • Of note, a recent prospective, randomized-controlled study has called into question the efficacy of orthotic insoles, however, suggesting that routine use of foot orthoses by healthy men provide no significant preventive benefits against overuse injuries, including bursitis.[17]
  • Immobilization
    • The initial accommodation of the bursitis by the introduction of rest or of a decrease in or modification of activity may suffice to reverse the bursitis and its symptoms.
    • If the symptoms are resistant to the above treatments, immobilization in a cast for 4-6 weeks should be considered.
  • Complications from calcaneal bursitis or its treatment
    • Progressive posterior heel and ankle pain
    • Rupture of the Achilles tendon, either secondary to chronic local inflammation/degeneration or as a result of corticosteroid injection(s)
    • Some clinicians advocate the use of corticosteroid injection(s) into the affected bursa, being careful to avoid injection within the Achilles tendon.[18] Because of the close proximity of the Achilles tendon to the bursae, such injections should be considered only in severe, recalcitrant cases. The authors of this article generally recommend against corticosteroid injection in the vicinity of the Achilles tendon because of the potential risk of tendon rupture. However, prospective, randomized studies have not been performed to establish whether steroid injections cause such tendon ruptures. Instead, the association between steroid injections and subsequent tendon ruptures is mostly based on retrospective case reports. Potentially, those cases that were more likely to go on to rupture were also more likely to have a severe presentation that prompted the steroid injections.
    • One case report demonstrated that subtendinous calcaneal bursitis can be not only diagnosed but also treated with ultrasonography. Ultrasonographic guidance can be used to inject the subtendinous calcaneal bursa with a combination of local anesthetic (eg, lidocaine, giving relief within minutes and lasting several hours) and corticosteroid (eg, Kenalog, producing an anti-inflammatory effect within 24-48 h and providing relief for weeks to months). The authors feel that using ultrasonographic guidance can help to ensure reliable, accurate delivery of medication into the bursa while avoiding intratendinous injection.[15]
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Surgical Intervention

For patients who have persistent or progressive symptoms despite rigorous nonsurgical treatment, the following surgical interventions are options:

  • Resection of Haglund deformity, removing the calcaneal superoposterior prominence (ostectomy)
  • Excision of the painful bursa or bursae
  • Debridement of the Achilles insertion
  • In cases of Achilles tendon rupture or avulsion, surgical re-anastomosis is indicated.
  • Outpatient endoscopic removal of the inflamed bursal tissue and resection of the prominent bone. [19]

A review study by Wiegerinck et al suggested that, based on patient satisfaction and complication rates, endoscopic treatment of chronic retrocalcaneal bursitis is superior to open surgery. The review included 15 trials (12 open-surgery studies and 3 endoscopic trials), which encompassed 547 procedures in 461 patients. The study also indicated that sufficient bone resection is required for a good procedure outcome, regardless of the surgical technique used.[20]

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Consultations

Patients requiring surgical intervention should be referred for surgical consultation to an orthopedic surgeon who is experienced in foot and ankle surgery.

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Other Treatment

As discussed above, corticosteroid injection in this region is not recommended because of the potential risk of rupturing the Achilles tendon.

Microcurrent therapy may serve as another modality for managing heel pain. Using a numerical rating scale for pain, a recent study showed that the addition of microcurrent therapy to traditional treatments significantly reduced pain (pain rating reduction from 8.9 to 2.3) compared with traditional treatments alone (pain rating reduction from 8.2 to 5.9). Improvement may be due to the induction of secondary messengers, such as cyclic adenosine monophosphate (cAMP), which modulates important processes for cellular viability.[21]

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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
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  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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