Calcaneal Bursitis Clinical Presentation

Updated: Sep 12, 2019
  • Author: Patrick M Foye, MD; Chief Editor: Consuelo T Lorenzo, MD  more...
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Presentation

History

Obtaining a detailed history from the patient is important in diagnosing calcaneal bursitis. [9] The following complaints (which the physician should ask about during the subjective examination) are commonly reported by patients:

  • Posterior heel pain is the chief complaint in individuals with calcaneal bursitis.

  • Patients may report limping caused by the posterior heel pain.

  • Some individuals may also report an obvious swelling (eg, a pump bump, a term that presumably comes from the swelling's association with high-heeled shoes or pumps).

  • The condition may be unilateral or bilateral.

  • Symptoms are often worse when the patient first begins an activity after rest.

Other inquiries that the physician should make include the following:

  • The clinician should ask about the patient's customary footwear (whether, for example, it includes high-heeled shoes or tight-fitting athletic shoes).

    • The patient should be asked specifically about any recent change in footwear, such as whether he/she is wearing new athletic shoes or whether the patient has made a transition from flat shoes to high heels or vice versa. Individuals who have been accustomed to wearing high-heeled shoes on a long-term basis may find that switching to flat shoes causes increased stretch and irritation of the Achilles tendon and the associated bursae.

  • The specifics of a patient's activity level should be ascertained, including how far the patient runs and, in particular, whether the individual is running with greater intensity than before or has increased the distance being run.

  • The history of any known or suspected underlying rheumatologic conditions, such as gout, rheumatoid arthritis, or seronegative spondyloarthropathies, should be obtained.

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Physical

During the physical examination of a patient with calcaneal bursitis, the physician should keep the following considerations in mind:

  • Swelling and redness of the posterior heel (the pump bump) may be clearly apparent.

  • The inflamed area, which may be slightly warm to the touch, is generally tender to palpation.

  • Careful examination can help the clinician to distinguish whether the inflammation is posterior to the Achilles tendon (within the subcutaneous calcaneal bursa) or anterior to the tendon (within the subtendinous calcaneal bursa). Differentiating Achilles tendinitis/tendinosis from bursitis may be impossible. At times, the 2 conditions co-exist.

  • Isolated subtendinous calcaneal bursitis is characterized by tenderness that is best isolated by palpating just anterior to the medial and lateral edges of the distal Achilles tendon.

  • Conversely, insertional Achilles tendinitis is notable for tenderness that is located slightly more distally, where the Achilles tendon inserts on the posterior calcaneus.

  • A patient with plantar fasciitis has tenderness along the posterior aspect of the sole, but he/she should not have tenderness with palpation of the posterior heel or ankle. [9]

  • A patient with a complete avulsion or rupture of the Achilles tendon demonstrates a palpable defect in the tendon, weakness in plantarflexion, and a positive Thompson test on physical examination. During the Thompson test, the examiner squeezes the calf. The test is negative if this maneuver results in passive plantarflexion of the ankle, which would indicate that the Achilles tendon is at least partially intact.

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Causes

See the list below:

  • Overtraining in a runner (eg, excessive increases in miles or intensity)

  • Repetitive microtrauma and acute traumatic injury to the region [10]

  • Infections and inflammatory conditions such as gout and rheumatoid arthritis [10]  

  • Tight or poorly fitting shoes that, because of a restrictive heel counter, exert excessive pressure on the posterior heel and ankle

  • Haglund deformity, causing impingement between the increased posterior superior calcaneal prominence and the Achilles tendon during dorsiflexion

  • More recent research suggests that a misaligned subtalar joint axis (measured in terms of joint inclination and deviation) in relation to the Achilles tendon can result in an asymmetrical force load on the tendon, disrupting normal biomechanics. This altered joint axis is associated with an increased risk for Achilles pathologies, including bursitis. [11]

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