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Calcaneal Bursitis Workup

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

Laboratory Studies

If the appearance of the bursitis cannot be explained by local factors (eg, ill-fitting shoes, excessive running, high heels) or if there are systemic symptoms or signs of rheumatologic involvement, the clinician should consider laboratory studies to evaluate for the possibility of gout (hyperuricemia), rheumatoid arthritis (rheumatoid factor), and seronegative spondyloarthropathies (HLA B-27, erythrocyte sedimentation rate, and/or C-reactive protein).

Also see related Medscape Resource Centers on Gout and Rheumatoid Arthritis.

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Imaging Studies

Plain radiographs of the calcaneus may reveal Haglund deformity, which can be seen best on the lateral view. In this view, the triad consistent with Haglund's disease is thickening of Achilles tendon at insertion, retrocalcaneal bursitis, and retro-Achilles bursitis.[10]

Plain radiographs can also be used to evaluate for stress fracture of the calcaneus. If the plain radiographs are negative for stress fracture but this injury possibility remains a significant diagnostic consideration, a 3-phase bone scan or a computed tomography (CT) scan of the calcaneus should be obtained.

Magnetic resonance imaging (MRI) scans may demonstrate bursal inflammation but probably do not offer much more information than is apparent from careful physical examination. Theoretically, MRI scans may help to determine whether the inflammation is in the subcutaneous calcaneal bursa, the subtendinous calcaneal bursa, or the tendon itself, but such testing is generally unnecessary.[11, 12]

Hybrid imaging modalities, most specifically single-photon emission CT (SPECT)/CT, may assist with early detection of bursitis by offering a precise, accurate, and highly localizing diagnostic image. However, little research exists on the cost benefit of this modality, and therefore, this imaging modality is not frequently used for this type of soft-tissue injury.[13]

Some clinicians have suggested that ultrasonography can be used in place of MRI in cases in which imaging is desired to investigate pathology at the posterior heel. A recent study concluded that extended field-of-view sonography (EFOVS) when combined with traditional gray-scale sonography has similar sensitivity and specificity to MRI for diagnosing calcaneal bursitis in addition to more rapid results, lower cost, and lack of contraindications.[14, 15, 16]

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Procedures

Generally, no diagnostic procedures are required.

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Histologic Findings

Bursal inflammation is present in patients with calcaneal bursitis, but obtaining a histologic specimen from an actual patient would be extremely rare.

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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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