Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Retrocalcaneal Bursitis Treatment & Management

  • Author: Patrick M Foye, MD; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Nov 26, 2014
 

Acute Phase

Rehabilitation Program

Physical Therapy

The patient with retrocalcaneal bursitis should be instructed to apply ice to the posterior heel and ankle in the acute period of the bursitis. Icing can be performed several times a day, for 15-20 minutes each. Some clinicians also advocate the use of contrast baths.

Gradual progressive stretching of the Achilles tendon may help relieve impingement on the subtendinous bursa and can be performed in the following manner:

  1. Stand in front of a wall, with the affected foot flat on the floor. Lean forward toward the wall until a gentle stretching is felt within the ipsilateral Achilles tendon.
  2. Maintain the stretch for 20-60 seconds and then relax.
  3. Perform the stretches with the knee extended and then again with the knee flexed.
  4. To maximize the benefit of the stretching program, repeat the above steps for several stretches per set, several times daily. Avoid ballistic (ie, abrupt, jerking) stretches.

If it is necessary for the patient to decrease his or her activity level due to retrocalcaneal bursitis, alternative means of maintaining strength and cardiovascular fitness should be suggested, such as swimming, water aerobics, and other aquatic exercises.

Consultations

 

Other Treatment

Changing the patient's footwear may be the most important form of treatment for retrocalcaneal bursitis. Use of an open-backed shoe may relieve pressure on the affected region. For individuals in whom symptoms were precipitated by a dramatic change from wearing high-heeled shoes to flat shoes (or vice versa), the temporary use of footwear that is a heel height somewhere in between may be necessary. Encourage athletes to change running shoes on a regular basis, because the support and fit of their footwear may change over the course of hundreds of miles of use.

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 patient's skin. The patient should avoid shoes without laces, because the nature of such footwear is to fit closely onto the heel. Inserting a heel cup in the shoe may help to raise the inflamed region slightly above the shoe's restricting heel counter. A heel cup should also be placed in the opposite (contralateral) foot's 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, suggesting that routine use of foot orthoses by healthy men provides no significant preventive benefits against overuse injuries, including bursitis.[19]

Corticosteroid injection into the retrocalcaneal bursa should be considered as long as the patient has consented regarding the theoretical risk of Achilles tendon rupture, particularly if image guidance is not used.

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.[20]

Next

Recovery Phase

Rehabilitation Program

Physical Therapy

The patient with retrocalcaneal bursitis should continue to advance the physical therapy program outlined above (see Acute Phase), with a gradual increase of activities. The goal is for the patient to have a full return to his or her previous level of athletic function.

Medical Issues/Complications

See the list below:

  • Progressive posterior heel and ankle pain, with resultant limping and decreased athletic performance or mobility
  • Rupture of the Achilles tendon, either secondary to chronic local inflammation/degeneration or due to non-image guided corticosteroid injection that is inadvertently placed into the Achilles tendon
  • Immobilization: Consider partial immobilization in a walking boot or immobilization in a cast for 4-6 weeks if the patient's symptoms are resistant to the other treatments.

Surgical Intervention

Consider surgical intervention for patients with retrocalcaneal bursitis who have significant persistence or progression of symptoms, in spite of the nonsurgical treatment approaches listed above (see Acute Phase Physical Therapy and Other Treatment). Surgical management may include the following:

  • Resection of a Haglund deformity (eg, removal of the calcaneal posterosuperior prominence through an ostectomy). Two surgical approaches have been described: a tendon-splitting approach and a lateral approach. A recent study showed that patients who underwent the tendon-splitting approach returned to normal function quicker than patients undergoing the lateral approach. [21]
  • Excision of the painful bursa(e)
  • Debridement of the Achilles tendon insertion
  • Repair of an Achilles tendon rupture or avulsion
  • Outpatient endoscopic removal of the inflamed bursal tissue and resection of the prominent bone [22]
  • A recently published review of the medical literature concluded that successful outcome of surgery for chronic retrocalcaneal bursitis is dependent on resecting an adequate amount of bone during the surgical treatment. The researchers also felt that the published evidence suggested (at least to some degree), that endoscopic surgery may have better outcomes than open surgical techniques in the treatment of retrocalcaneal bursitis. [23]

Consultations

An orthopedic surgeon who is experienced with foot and ankle surgery should be consulted for patients in whom conservative therapy has failed and who require surgical intervention for retrocalcaneal bursitis.

Other Treatment (Injection, manipulation, etc.)

Corticosteroid injection using ultrasound guidance to help ensure accurate and safe placement could be of significant benefit.

Previous
Next

Maintenance Phase

Rehabilitation Program

Physical Therapy

The patient should continue with a home exercise program that is developed in conjunction with a physical therapist during the course of treatment.

Medical Issues/Complications

The patient should be alert for any early signs or symptoms that indicate recurrence of the retrocalcaneal bursitis, so that intervention can be provided as soon as possible, if necessary.

Previous
 
 
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.

Leia Rispoli Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Varun Patibanda, MD Research Associate, Rutgers New Jersey Medical School

Varun Patibanda, MD is a member of the following medical societies: American Medical Association, New Jersey Society of Physical Medicine and Rehabilitation

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.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

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 Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, 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

Disclosure: Nothing to disclose.

Acknowledgements

Greg Gazzillo Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Debra Ibrahim New York College of Osteopathic Medicine

Disclosure: Nothing to disclose.

Evish Kamrava St George's University School of Medicine

Disclosure: Nothing to disclose.

Jason Lee St George's University School of Medicine

Disclosure: Nothing to disclose.

Dev Sinha American University of Antigua School of Medicine and Health Sciences

Disclosure: Nothing to disclose.

Craig Van Dien Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

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. Chu NK, Lew HL, Chen CP. Ultrasound-guided injection treatment of retrocalcaneal bursitis. Am J Phys Med Rehabil. 2012 Jul. 91(7):635-7. [Medline].

  7. 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. Oct 2011. 45(13):1029-34. [Medline].

  8. van Sterkenburg MN, Muller B, Maas M, Sierevelt IN, van Dijk CN. Appearance of the weight-bearing lateral radiograph in retrocalcaneal bursitis. Acta Orthop. 2010 Jun. 81(3):387-90. [Medline].

  9. 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]. [Full Text].

  10. van Sterkenburg MN, Muller B, Maas M, Sierevelt IN, van Dijk CN. Appearance of the weight-bearing lateral radiograph in retrocalcaneal bursitis. Acta Orthop. Jun 2010. 81(3):387-90. [Medline].

  11. Wiegerinck JI, Zwiers R, van Sterkenburg MN, Maas MM, van Dijk CN. The appearance of the pre-Achilles fat pad after endoscopic calcaneoplasty. Knee Surg Sports Traumatol Arthrosc. 2014 Mar 1. [Medline].

  12. 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].

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

  14. 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 May. 176(5):704-8. [Medline].

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

  16. 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. 2004 Apr. 86-A(4):794-801. [Medline].

  17. Thomas JL, Christensen JC, Kravitz SR, Mendicino RW, Schuberth JM, Vanore JV, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg. 2010 May-Jun. 49(3 Suppl):S1-19. [Medline].

  18. Lohrer H, Raabe T, Nauck T, Arentz S. Minimally invasive retrocalcaneal bursa pressure measurement: development and pilot application. Arch Orthop Trauma Surg. May 2011. 131(5):719-23. [Medline].

  19. 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. Dec 2011. 21(6):804-8. [Medline].

  20. Aliyev R, Muslimov Q, Geiger G. Results of conservative treatment of achillodynia with application micro-current therapy. Georgian Med News. Oct 2010. (187):35-42. [Medline].

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

  22. 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].

  23. Wiegerinck JI, Kok AC, van Dijk CN. Surgical treatment of chronic retrocalcaneal bursitis. Arthroscopy. 2012 Feb. 28(2):283-93. [Medline].

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

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

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

  27. 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. 2006 Sep. 25(5):734-6. [Medline].

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

  29. 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. 2009. 19(3):235-44. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.