Retrocalcaneal Bursitis

Updated: Oct 30, 2020
  • Author: Patrick M Foye, MD; Chief Editor: Sherwin SW Ho, MD  more...
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Overview

Practice Essentials

Pain at the posterior heel or ankle is most commonly caused by pathology at either the posterior calcaneus (at the calcaneal insertion site of the Achilles tendon) or at its associated bursae. Two bursae are located just superior to the insertion of the Achilles (calcaneal) tendon. Anterior or deep to the tendon is the retrocalcaneal (subtendinous) bursa, which is located between the Achilles tendon and the calcaneus. Posterior or superficial to the Achilles tendon is the subcutaneous calcaneal bursa, also called the Achilles bursa. This bursa is located between the skin and posterior aspect of the distal Achilles tendon. Inflammation of either or both of these bursa can cause pain at the posterior heel and ankle region. [1, 2, 3, 4, 5]

Patients with insertional Achilles tendinopathy often have thickened subcutaneous and retrocalcaneal bursae with higher blood flow in the bursa walls. These patients may also have Haglund deformities. [6]

For patient education resources, see the Foot, Ankle, Knee, and Hip Center, as well as Bursitis and Tendinitis.

See related Medscape Reference topics Achilles Tendon Injuries and TendonitisAchilles Tendonitis, and Bursitis.

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Etiology

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. [7]

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Epidemiology

United States data

Retrocalcaneal bursitis is fairly common. Campanelli et al performed a cross-sectional study that found retrocalcaneal bursitis (RCB) to be the most frequent lower extremity overuse condition in figure skaters. The researchers collected data on 95 figure skaters of various ages and skill levels throughout Italy. A 34% point prevalence of RCB was seen in skaters over 9 years old. Furthermore, elite skaters had an RCB prevalence of 49%, compared to just 23% in non-elite skaters. Half of skaters with reported RCB had the condition bilaterally with varying degrees of severity. RCB is a frequent chronic overuse condition experienced by athletes of all skill levels. [8]

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Sport-Specific Biomechanics

Inflammation of the calcaneal bursae is most commonly caused by repetitive (cumulative) trauma or overuse, and the condition is aggravated by pressure, such as when athletes wear tight-fitting shoes. Retrocalcaneal bursitis may also be associated with conditions such as gout, rheumatoid arthritis, and seronegative spondyloarthropathies. In some cases, retrocalcaneal bursitis may be caused by bursal impingement between the Achilles tendon and an excessively prominent posterosuperior aspect of the calcaneus (Haglund deformity). In Haglund disease, impingement occurs during ankle dorsiflexion. [1, 2, 3, 4, 5]

In the cross-sectional study by Campanelli et al, a risk factor analysis was conducted for figure skaters with RCB. It was found that in non-elite skaters RCB was associated with higher body weight. In addition, an association was found between non-elite skaters with RCB and lower bendability scores. The lower bendability score indicates more flexibility of the ankle within the skating boot. This association suggests that repetitive dorsiflexion in the boot may lead to the development of RCB. [8]

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Prognosis

Most patients with retrocalcaneal bursitis respond well to a combination of local icing, oral medications, Achilles stretching, and modification of footwear. In general, patients with persistent symptoms despite nonsurgical measures can expect improvement with any of the previously discussed surgical interventions.

Complications

The posterior heel pain may become chronic or progressive, resulting in limping (antalgic gait) and decreased athletic performance. Achilles tendon rupture may occur secondary to chronic inflammation and/or due to corticosteroid injection.

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Patient Education

Patients should be thoroughly educated and informed about the following:

  • The proper performance of Achilles tendon stretching

  • The rationale for donning appropriate footwear

  • The potential risks and benefits of corticosteroid injection for those who are considering receiving this treatment

  • The risks, benefits, and expected outcomes of surgical intervention for those in whom conservative therapy has failed

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