eMedicine Specialties > Sports Medicine > Foot and Ankle

Retrocalcaneal Bursitis: Differential Diagnoses & Workup

Author: Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service (www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Coauthor(s): Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation; Director, Outpatient Occupational/Musculoskeletal Medicine, UMDNJ-New Jersey School of Medicine; Scott F Nadler, DO, Assistant Director of Occupational/Musculoskeletal Medicine, Assistant Professor of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey, Director of Sports Medicine, University Hospital
Contributor Information and Disclosures

Updated: Mar 5, 2009

Differential Diagnoses

Achilles Tendon Rupture
Achilles Tendonitis
Plantar Fasciitis

Other Problems to Be Considered

Calcaneus bone injuries
Gout
Haglund deformity Rheumatoid arthritis
Seronegative spondyloarthropathies
Stress fracture of the calcaneus
Sural neuritis

Workup

Laboratory Studies

  • If the retrocalcaneal bursitis cannot be explained by local factors (eg, poorly fitting shoes, increased running, high heels), or if systemic symptoms or signs of rheumatologic involvement exist, consider laboratory studies to evaluate the possibility of gout (hyperuricemia), rheumatoid arthritis (rheumatoid factor [RF]), and seronegative spondyloarthropathies (eg, human leukocyte antigen [HLA] B-27, erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]).

Imaging Studies

  • Plain radiographs of the calcaneus may reveal a Haglund deformity (increased prominence of the posterosuperior aspect of the calcaneus), which is observed best on the lateral view.  
  • Imaging of patients with retrocalcaneal bursitis may have an absence of the normal radiolucency that is seen in the posteroinferior corner of Kager's fat pad. This may occur with or without an associated erosion of the calcaneus.6
  • Plain radiographs can be used to evaluate for stress fracture of the calcaneus. If the studies are negative for a stress fracture, but a stress fracture remains a significant diagnostic consideration, the clinician may wish to pursue 3-phase bone scanning or computed tomography (CT) scanning of the calcaneus.
  • Magnetic resonance imaging (MRI) may demonstrate bursal inflammation, but this modality probably does not offer much more information than that found by careful physical examination. Theoretically, MRI could help the physician to determine whether the inflammation is within the subcutaneous bursa, the subtendinous bursa, or even within the tendon itself; however, such testing is generally not necessary.
  • Ultrasonography may be a potentially useful tool for diagnosing pathologies of the Achilles tendon.7 (See the Procedures section below.)

Procedures

  • Some clinicians advocate the use of corticosteroid injection(s) into the affected bursa, with particular care to avoid injection within the Achilles tendon. Due to the close proximity of the Achilles tendon to the subtendinous and subcutaneous calcaneal bursae, such injections should be considered only in severe, recalcitrant cases. In general, the authors of this article recommend against corticosteroid injection in the vicinity of the Achilles tendon due to the potential risk of tendon rupture. However, prospective, randomized studies have not been performed to definitively establish a causal relationship between steroid injections and such tendon ruptures. Instead, the association between steroid injections and subsequent tendon ruptures is mostly based on retrospective case reports. Thus, the cases that were more likely to go on to rupture were potentially those in which a more severe presentation prompted the steroid injections in the first place.
  • A case report by Sofka et al demonstrated that retrocalcaneal bursitis can be diagnosed and treated with ultrasonography.8  This modality can be used to guide injection into the retrocalcaneal bursa with a combination of local anesthetic (eg, lidocaine, with relief within minutes and duration of several hours) and corticosteroid (eg, triamcinolone [Kenalog; Bristol-Myers Squibb Company, Princeton, NJ], with anti-inflammatory effect within 24-48 hours and a relief duration of weeks to months). The authors stressed that ultrasonographic guidance helps to ensure reliable and accurate delivery of medication into the bursa, while concurrently avoiding intratendinous injection. 
  • The patient must be informed — and must be willing to incur the risk — that corticosteroid injections may precipitate Achilles tendon rupture. Corticosteroid injection in the vicinity of the Achilles tendon is not recommended.

More on Retrocalcaneal Bursitis

Overview: Retrocalcaneal Bursitis
Differential Diagnoses & Workup: Retrocalcaneal Bursitis
Treatment & Medication: Retrocalcaneal Bursitis
Follow-up: Retrocalcaneal Bursitis
References
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References

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

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

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

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

  5. Teebagy AK. Leg and ankle. In: Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in Primary Care. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999:241-7.

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

  7. Blankstein A, Cohen I, Diamant L, et al. Achilles tendon pain and related pathologies: diagnosis by ultrasonography. Isr Med Assoc J. Aug 2001;3(8):575-8. [Medline]. [Full Text].

  8. Sofka CM, Adler RS, Positano R, Pavlov H, Luchs JS. Haglund's syndrome: diagnosis and treatment using sonography. HSS J. Feb 2006;2(1):27-9. [Medline]. [Full Text].

  9. Hugate R, Pennypacker J, Saunders M, Juliano P. The effects of intratendinous and retrocalcaneal intrabursal injections of corticosteroid on the biomechanical properties of rabbit Achilles tendons. J Bone Joint Surg Am. Apr 2004;86-A(4):794-801. [Medline].

  10. 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].

  11. Anderson JA, Suero E, O'Loughlin PF, Kennedy JG. Surgery for retrocalcaneal bursitis: a tendon-splitting versus a lateral approach. Clin Orthop Relat Res. Jul 2008;466(7):1678-82. [Medline].

  12. Green SM, ed. Nonsteroidal anti-inflammatories. Tarascon Pocket Pharmacopoeia 2000. Loma Linda, Calif: Tarascon Publishing; 2000:11-2.

  13. Kachlik D, Baca V, Cepelik M, et al. Clinical anatomy of the retrocalcaneal bursa. Surg Radiol Anat. Jun 2008;30(4):347-53. [Medline].

  14. Mutlu H, Sildiroglu H, Pekkafali Z, Kizilkaya E, Cermik H. MRI appearance of retrocalcaneal bursitis and rheumatoid nodule in a patient with rheumatoid arthritis. Clin Rheumatol. Sep 2006;25(5):734-6. [Medline].

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

  16. Suzuki T, Tohda E, Ishihara K. Power Doppler ultrasonography of symptomatic rheumatoid arthritis ankles revealed a positive association between tenosynovitis and rheumatoid factor. Mod Rheumatol. Feb 13 2009;epub ahead of print. [Medline].

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Further Reading

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Keywords

retrocalcaneal bursitis, calcaneal bursitis, pump bump (exostosis), bursitis of the subtendinous or subcutaneous retrocalcaneal bursa, bursitis of the subtendinous or subcutaneous calcaneal bursa, bursitis of the subtendinous or subcutaneous bursa of the calcaneal (Achilles) tendon, Haglund deformity, adhesive capsulitis

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Contributor Information and Disclosures

Author

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service (www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

Coauthor(s)

Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation; Director, Outpatient Occupational/Musculoskeletal Medicine, UMDNJ-New Jersey School of Medicine
Todd P Stitik, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Phi Beta Kappa, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Scott F Nadler, DO, Assistant Director of Occupational/Musculoskeletal Medicine, Assistant Professor of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey, Director of Sports Medicine, University Hospital
Scott F Nadler, DO is a member of the following medical societies: American College of Occupational and Environmental Medicine, American College of Sports Medicine, American Medical Association, Association of Academic Physiatrists, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
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