eMedicine Specialties > Sports Medicine > Foot and Ankle

Retrocalcaneal Bursitis

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

Introduction

Background

Pain at the posterior heel or ankle is most commonly caused by pathology at either the posterior calcaneus (at the calcaneal insertion site of the Achilles tendon) or at its associated bursae. Two bursae are located just superior to the insertion of the Achilles (calcaneal) tendon. Anterior or deep to the tendon is the retrocalcaneal (subtendinous) bursa, which is located between the Achilles tendon and the calcaneus. Posterior or superficial to the Achilles tendon is the subcutaneous calcaneal bursa, also called the Achilles bursa. This bursa is located between the skin and posterior aspect of the distal Achilles tendon. Inflammation of either or both of these bursa can cause pain at the posterior heel and ankle region.1,2,3,4,5

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education articles Bursitis and Tendinitis.

Related eMedicine topics:
Achilles Tendon Injuries and Tendonitis
Achilles Tendonitis
Bursitis

Frequency

United States

Retrocalcaneal bursitis is fairly common.

Sport-Specific Biomechanics

Inflammation of the calcaneal bursae is most commonly caused by repetitive (cumulative) trauma or overuse, and the condition is aggravated by pressure, such as when athletes wear tight-fitting shoes. Retrocalcaneal bursitis may also be associated with conditions such as gout, rheumatoid arthritis, and seronegative spondyloarthropathies. In some cases, retrocalcaneal bursitis may be caused by bursal impingement between the Achilles tendon and an excessively prominent posterosuperior aspect of the calcaneus (Haglund deformity). In Haglund disease, impingement occurs during ankle dorsiflexion.1,2,3,4,5

Clinical

History

  • In retrocalcaneal bursitis, posterior heel pain is the primary presenting chief complaint, and patients may report limping.
  • Some individuals may also present with an obvious or noticeable swelling (eg, a "pump bump," presumably named in association with the wearing of high-heeled shoes or pumps).
    • Ask the patient about footwear, such as high-heeled shoes or tight-fitting athletic shoes.
    • Specifically ask about any recent change in footwear (eg, new athletic shoes, transition from flat shoes to high heels or from road running shoes to racing flats or to cleats).
  • Retrocalcaneal bursitis may be unilateral or bilateral.
  • Individuals who are accustomed to wearing high-heeled shoes on a long-term basis may experience increased stretch and irritation of the Achilles tendon and its associated bursae when switching to flat shoes.
  • Ask about the specifics of the patient's activity levels (eg, include the distances runners travel).
  • Symptoms often worsen when the athlete is first beginning an activity after resting.
  • Ask about previously known or suspected underlying rheumatologic conditions (eg, gout, rheumatoid arthritis, seronegative spondyloarthropathies).

Physical

  • Swelling and redness of the posterior heel may be clearly apparent in patients with retrocalcaneal bursitis (eg, pump bump).
  • The inflamed area may be slightly warm and tender to palpation.
  • Careful examination can help the clinician distinguish whether the inflammation is posterior (superficial) to the Achilles tendon (within the subcutaneous bursa) or anterior (deep) to the Achilles tendon (within the subtendinous bursa).
  • Tenderness caused by isolated subtendinous bursitis can best be isolated by palpation just anterior to both the medial and lateral edge of the distal Achilles tendon.
  • Tenderness due to insertional Achilles tendinitis is located slightly more distal, where the Achilles tendon inserts onto the posterior calcaneus.
  • Plantar fasciitis causes tenderness along the posterior aspect of the sole, but patients should not experience tenderness with palpation of the posterior heel or ankle.
  • A patient with avulsion or rupture of the Achilles tendon demonstrates a palpable defect in the tendon and a positive Thompson test (ie, squeezing the calf fails to cause plantar flexion due to the loss of Achilles tendon continuity).

Causes

  • Overtraining in an athlete, such as with excessive increases in running mileage may lead to retrocalcaneal bursitis.
  • Tight or poorly fitting shoes that produce excessive pressure at the posterior heel and ankle due to a restrictive heel counter are another cause of retrocalcaneal bursitis.
  • Haglund deformity, which causes impingement between the increased posterosuperior calcaneal prominence and Achilles tendon during dorsiflexion, may lead to retrocalcaneal bursitis.

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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