Retrocalcaneal Bursitis Treatment & Management

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.

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.

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

• 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.^[12]
• 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^[13]

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.

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.