Retrocalcaneal Bursitis Clinical Presentation

Updated: Sep 12, 2019
  • Author: Patrick M Foye, MD; Chief Editor: Sherwin SW Ho, MD  more...
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Presentation

History

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  • 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. [7]

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Physical

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  • 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).

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Causes

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  • Overtraining in an athlete, such as with excessive increases in running mileage may lead to retrocalcaneal bursitis.

  • Tight or poorly fitting shoes that produce excessive pressure at the posterior heel and ankle due to a restrictive heel counter are another cause of retrocalcaneal bursitis.

  • Haglund deformity, which causes impingement between the increased posterosuperior calcaneal prominence and Achilles tendon during dorsiflexion, may lead to retrocalcaneal bursitis.

  • 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. [8]

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