Rehabilitation Program
Physical Therapy
Gradually progressive stretching of the Achilles tendon may help to relieve impingement on the subtendinous calcaneal bursa. Stretching of the Achilles tendon can be performed by having the patient place the affected foot flat on the floor and lean forward toward the wall until a gentle stretch is felt in the ipsilateral Achilles tendon. The stretch is maintained for 20-60 seconds and then is relaxed. This technique is demonstrated in the following images.
Achilles stretch 1; whole-person view. The patient stands with the affected foot flat on the floor and leans forward toward the wall until a gentle stretch is felt in the ipsilateral Achilles tendon. The stretch is maintained for 20-60 seconds and then is relaxed.
Achilles stretch 1; cropped view showing a close-up of the region affected by this type of stretch.
Another technique, a more advanced stretch that isolates the Achilles tendon, is shown in the following images.
Achilles stretch 2; whole person view. This stretch, which is somewhat more advanced than that shown in Images 1-2, isolates the Achilles tendon. It is held for at least 20-30 seconds and then is relaxed.
To maximize the benefit of the stretching program, the patient should repeat the exercise for multiple stretches per set, multiple times per day. Ballistic (ie, abrupt, jerking) stretches should be avoided in order to prevent clinical exacerbation.
The patient should be instructed to ice the posterior heel and ankle in order to reduce inflammation and pain. Icing can be performed for 15-20 minutes at a time, several times a day, during the acute period, which may last for several days. Some clinicians also advocate the use of contrast baths, ultrasound or phonophoresis, iontophoresis, or electrical stimulation for treatment of calcaneal bursitis.
If the patient's activity level needs to be decreased as a result of this condition, alternative means of maintaining strength and cardiovascular fitness (eg, swimming, water aerobics) should be suggested.
Medical Issues/Complications
See the list below:
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Addressing footwear
Changing footwear may be the most important form of treatment for calcaneal bursitis. The use of an open-backed shoe may relieve pressure on the affected region.
Individuals whose symptoms have been precipitated by a dramatic footwear change, specifically, a switch from high-heeled shoes to flat shoes (or vice versa), may need to temporarily use footwear with a medium heel height.
Athletes should be encouraged to change running shoes on a regular basis, because the shoes' fit, as well as the support the shoes provide, may change over the course of hundreds of miles of use.
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Further modification of shoes
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 skin.
Shoes without laces (eg, slip-on shoes, sandals) inherently fit closely onto the heel and should be avoided.
Inserting a heel cup into the shoe may help to raise the inflamed region slightly above the restricting heel counter. If this approach is implemented, a heel cup should also be placed into the other 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, however, suggesting that routine use of foot orthoses by healthy men provide no significant preventive benefits against overuse injuries, including bursitis. [21]
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Immobilization
The initial accommodation of the bursitis by the introduction of rest or of a decrease in or modification of activity may suffice to reverse the bursitis and its symptoms.
If the symptoms are resistant to the above treatments, immobilization in a cast for 4-6 weeks should be considered.
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Complications from calcaneal bursitis or its treatment
Progressive posterior heel and ankle pain
Rupture of the Achilles tendon, either secondary to chronic local inflammation/degeneration or as a result of corticosteroid injection(s)
Some clinicians advocate the use of corticosteroid injection(s) into the affected bursa, being careful to avoid injection within the Achilles tendon. [22] Because of the close proximity of the Achilles tendon to the bursae, such injections should be considered only in severe, recalcitrant cases. The authors of this article generally recommend against corticosteroid injection in the vicinity of the Achilles tendon because of the potential risk of tendon rupture. However, prospective, randomized studies have not been performed to establish whether steroid injections cause such tendon ruptures. Instead, the association between steroid injections and subsequent tendon ruptures is mostly based on retrospective case reports. Potentially, those cases that were more likely to go on to rupture were also more likely to have a severe presentation that prompted the steroid injections.
One case report demonstrated that subtendinous calcaneal bursitis can be not only diagnosed but also treated with ultrasonography. Ultrasonographic guidance can be used to inject the subtendinous calcaneal bursa with a combination of local anesthetic (eg, lidocaine, giving relief within minutes and lasting several hours) and corticosteroid (eg, Kenalog, producing an anti-inflammatory effect within 24-48 h and providing relief for weeks to months). The authors feel that using ultrasonographic guidance can help to ensure reliable, accurate delivery of medication into the bursa while avoiding intratendinous injection. [20]
Surgical Intervention
For patients who have persistent or progressive symptoms despite rigorous nonsurgical treatment, the following surgical interventions are options:
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Resection of Haglund deformity, removing the calcaneal superoposterior prominence (ostectomy)
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Excision of the painful bursa or bursae
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Debridement of the Achilles insertion
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In cases of Achilles tendon rupture or avulsion, surgical re-anastomosis is indicated.
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Outpatient endoscopic removal of the inflamed bursal tissue and resection of the prominent bone. [25]
A review study by Wiegerinck et al suggested that, based on patient satisfaction and complication rates, endoscopic treatment of chronic retrocalcaneal bursitis is superior to open surgery. The review included 15 trials (12 open-surgery studies and 3 endoscopic trials), which encompassed 547 procedures in 461 patients. The study also indicated that sufficient bone resection is required for a good procedure outcome, regardless of the surgical technique used. [26]
Consultations
Patients requiring surgical intervention should be referred for surgical consultation to an orthopedic surgeon who is experienced in foot and ankle surgery.
Other Treatment
As discussed above, corticosteroid injection in this region is not recommended because of the potential risk of rupturing the Achilles tendon.
Microcurrent therapy may serve as another modality for managing heel pain. Using a numerical rating scale for pain, a 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. [27]
Other research indicates that low-dose radiation therapy may be helpful in reducing heel pain, with this modality having been associated with significant improvement in achillodynia. [28, 29]
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Achilles stretch 1; whole-person view. The patient stands with the affected foot flat on the floor and leans forward toward the wall until a gentle stretch is felt in the ipsilateral Achilles tendon. The stretch is maintained for 20-60 seconds and then is relaxed.
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Achilles stretch 1; cropped view showing a close-up of the region affected by this type of stretch.
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Achilles stretch 2; whole person view. This stretch, which is somewhat more advanced than that shown in Images 1-2, isolates the Achilles tendon. It is held for at least 20-30 seconds and then is relaxed.
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Achilles stretch 2; close-up view.
