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). An underlying inflammatory arthritis should be considered in cases where the retrocalcaneal bursitis occurs bilaterally.^[10]

Physical Examination

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).

Differential Diagnoses

McGee DJ. Lower leg, ankle, and foot. Orthopedic Physical Assessment. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1992. 448-515.
Snider RK, ed. Foot and ankle. Essentials of Musculoskeletal Care. 2nd ed. Rosemont, Ill: American Academy of Orthopedic Surgeons; 1997. 366-489.
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.
Brinker MR, Miller MD. The adult foot. Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders Co; 1999. 342-63.
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.
Alfredson H, Spang C. Clinical presentation and surgical management of chronic Achilles tendon disorders - A retrospective observation on a set of consecutive patients being operated by the same orthopedic surgeon. Foot Ankle Surg. 2017 Jun 12. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Campanelli V, Piscitelli F, Verardi L, Maillard P, Sbarbati A. Lower extremity overuse conditions affecting figure skaters during daily training. Orthop J Sports Med. 2015 Jul. 3 (7):2325967115596517. [QxMD MEDLINE Link].
Desai SS, Wong TT, Crockatt WK, Tedesco LJ, Trofa DP, Popkin CA. The 'Bauer bump:' ice hockey skates as a common cause of Haglund syndrome. Phys Sportsmed. 2022 May 27. 1-6. [QxMD MEDLINE Link].
Chu NK, Lew HL, Chen CP. Ultrasound-guided injection treatment of retrocalcaneal bursitis. Am J Phys Med Rehabil. 2012 Jul. 91(7):635-7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Ridley LJ, Han J, Ridley WE, Xiang H. Cockscomb appearance: Retrocalcaneal bursitis. J Med Imaging Radiat Oncol. 2018 Oct. 62 Suppl 1:127. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Chang CD, Wu JS. MR Imaging Findings in Heel Pain. Magn Reson Imaging Clin N Am. 2017 Feb. 25 (1):79-93. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Johnson MD, Alvarez RG. Nonoperative management of retrocalcaneal pain with AFO and stretching regimen. Foot Ankle Int. 2012 Jul. 33 (7):571-81. [QxMD MEDLINE Link].
Boone SL, Uzor R, Walter E, Elsinger E, Catanese D, Ye K, et al. Safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection for the treatment of retrocalcaneal bursitis. Skeletal Radiol. 2021 Dec. 50 (12):2471-2482. [QxMD MEDLINE Link].
Pękala PA, Henry BM, Pękala JR, Piska K, Tomaszewski KA. The Achilles tendon and the retrocalcaneal bursa: An anatomical and radiological study. Bone Joint Res. 2017 Jul. 6 (7):446-451. [QxMD MEDLINE Link].
Turmo-Garuz A, Rodas G, Balius R, Til L, Miguel-Perez M, Pedret C, et al. Can local corticosteroid injection in the retrocalcaneal bursa lead to rupture of the Achilles tendon and the medial head of the gastrocnemius muscle?. Musculoskelet Surg. 2014 Aug. 98 (2):121-6. [QxMD MEDLINE Link].
Goldberg-Stein S, Berko N, Thornhill B, Elsinger E, Walter E, Catanese D, et al. Fluoroscopically guided retrocalcaneal bursa steroid injection: description of the technique and pilot study of short-term patient outcomes. Skeletal Radiol. 2016 Aug. 45 (8):1107-12. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Paša L, Kužma J, Herůfek R, Prokeš J, Šprláková-Puková A. [Arthroscopic Treatment of Chronic Retrocalcaneal Bursitis - Endoscopic Calcaneoplasty]. Acta Chir Orthop Traumatol Cech. 2018. 85 (3):209-215. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Wiegerinck JI, Kok AC, van Dijk CN. Surgical treatment of chronic retrocalcaneal bursitis. Arthroscopy. 2012 Feb. 28(2):283-93. [QxMD MEDLINE Link].
Zhang C, Cao J, Yang L, Duan X. Surgical treatment for insertional Achilles tendinopathy and retrocalcaneal bursitis: more than 1 year of follow-up. J Int Med Res. 2021 Mar. 49 (3):300060521992959. [QxMD MEDLINE Link]. [Full Text].
Opdam KTM, Zwiers R, Vroemen J, Sierevelt IN, Wiegerinck JI, van Dijk CN. High patient satisfaction and good long-term functional outcome after endoscopic calcaneoplasty in patients with retrocalcaneal bursitis. Knee Surg Sports Traumatol Arthrosc. 2021 May. 29 (5):1494-1501. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Patrick M Foye, MD Director of Coccyx Pain Center, Professor 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

Disclosure: Nothing to disclose.

Coauthor(s)

Shiyu (Shirley) Liu, MD, MHS Pre-Intern, Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

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, Phi Beta Kappa, Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Ossur, Fidia.

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.

Gerard J D'Onofrio, MBA Rutgers New Jersey Medical School

Gerard J D'Onofrio, MBA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association for Physician Leadership, American College of Physicians, American Medical Association, Beta Gamma Sigma, Biomedical Entrepreneurship Network

Disclosure: Nothing to disclose.

Vidur Tangri, MD Pre-Intern, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School

Vidur Tangri, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Marielle Araujo, MD Pre-Intern, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School

Marielle Araujo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, New Jersey Society of Physical Medicine and Rehabilitation, New York Society of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Muqadas H Malik, MD Pre-Residency Intern, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

John Keno Rivera, MD Pre-Intern, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School

John Keno Rivera, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Acknowledgements

Greg Gazzillo Rutgers New Jersey Medical School