Acute Phase
Rehabilitation program
Physical therapy
The patient with retrocalcaneal bursitis should be instructed to apply ice to the posterior heel and ankle in the acute period of the bursitis. Icing can be performed several times a day, for 15-20 minutes each. Some clinicians also advocate the use of contrast baths.
Gradual progressive stretching of the Achilles tendon may help relieve impingement on the subtendinous bursa and can be performed in the following manner:
Stand in front of a wall, with the affected foot flat on the floor. Lean forward toward the wall until a gentle stretching is felt within the ipsilateral Achilles tendon.
Maintain the stretch for 20-60 seconds and then relax.
Perform the stretches with the knee extended and then again with the knee flexed.
To maximize the benefit of the stretching program, repeat the above steps for several stretches per set, several times daily. Avoid ballistic (ie, abrupt, jerking) stretches.
If it is necessary for the patient to decrease his or her activity level due to retrocalcaneal bursitis, alternative means of maintaining strength and cardiovascular fitness should be suggested, such as swimming, water aerobics, and other aquatic exercises.
Other treatment
Changing the patient's footwear may be the most important form of treatment for retrocalcaneal bursitis. Use of an open-backed shoe may relieve pressure on the affected region. For individuals in whom symptoms were precipitated by a dramatic change from wearing high-heeled shoes to flat shoes (or vice versa), the temporary use of footwear that is a heel height somewhere in between may be necessary. Encourage athletes to change running shoes on a regular basis, because the support and fit of their footwear may change over the course of hundreds of miles of use.
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 patient's skin. The patient should avoid shoes without laces, because the nature of such footwear is to fit closely onto the heel. Inserting a heel cup in the shoe may help to raise the inflamed region slightly above the shoe's restricting heel counter. A heel cup should also be placed in the opposite (contralateral) foot's shoe to avoid introducing a leg-length discrepancy. Of note, a prospective, randomized-controlled study has called into question the efficacy of orthotic insoles, suggesting that routine use of foot orthoses by healthy men provides no significant preventive benefits against overuse injuries, including bursitis. [24]
Conversely, a prospective study by Johnson and Alvarez showed a nonoperative treatment regimen utilizing orthotic devices to be beneficial in retrocalcaneal pain. The treatment program included use of an ankle foot orthosis (AFO), a retrocalcaneal orthosis, and stretching of the heel cords similar to what was outlined above. The treatment regimen lasted on average 163 days. Improvement was measured using the Foot Function Index (FFI) to assess pain affect on daily activities. At the conclusion of the treatment program, the FFI score showed a statistically significant improvement in function. Overall, of the 103 participants who completed the study, 88% had improvement in symptoms, which allowed them to defer surgical intervention. This was particularly impressive because prior to this treatment protocol the patients had been experiencing symptoms for an average duration of 15 months. Notably, however, there was no control group. [25]
Corticosteroid injections to the retrocalcaneal region may potentially make the adjacent tissues vulnerable as the weak margins are unable to contain the injected fluid. A study of 20 cadaveric Achilles tendons by Pekala et al found that in 100% of the specimens, the ink had extravasated to the adjacent tissues, demonstrating that steroid can infiltrate the Achilles tendon from the injected retrocalcaneal bursa. This extravasation of steroid may potentially result in weakening and possibly rupturing of the Achilles tendon. [26]
Similarly, a study of 3 cadaver legs by Turmo-Garuz et al found that contrast injection at the retrocalcaneal bursa under ultrasound guidance resulted in extravasation beyond the bursa in all 3 specimens. [27] The extent of the spread included the upper part of the Achilles tendon, the surrounding adipose tissue, and peritendinous arterioles and venules. The findings in both of these studies suggest the potential of an anatomical connection between the retrocalcaneal bursa and the Achilles tendon. The retrocalcaneal bursa has only a 200-micron thick fibrocartilaginous layer. It is hypothesized that chronic inflammation can damage this layer, allowing for increased permeability.
Corticosteroid injection into the retrocalcaneal bursa should be considered as long as the patient has consented regarding the theoretical risk of Achilles tendon rupture, particularly if image guidance is not used.
A study by Goldberg-Stein et al reported that 69% of the 30 patients examined with retrocalcaneal bursitis had greater than 50% reduction in pain score after a steroid/anesthetic lateral fluoroscopically guided retrocalcaneal bursa injection. [28]
Microcurrent therapy may serve as another modality for managing heel pain. Using a numerical rating scale for pain, a recent 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. [29]
In retrocalcaneal bursitis patients who fail to respond to conservative treatment (ie. change in footwear, adjustment of the heel), it is possible that these patients may have a secondary pathology. Paša et al studied 24 patients who did not get adequate relief from such conservative management, and found that 54% of them had a tear in the anterior Achilles tendon, which went undetected on the initial ultrasound examination. [30]
Recovery Phase
Rehabilitation program
Physical therapy
The patient with retrocalcaneal bursitis should continue to advance the physical therapy program outlined above (see Acute Phase), with a gradual increase of activities. The goal is for the patient to have a full return to his or her previous level of athletic function.
Medical issues/complications
Medical issues and complications can include the following:
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Progressive posterior heel and ankle pain, with resultant limping and decreased athletic performance or mobility
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Rupture of the Achilles tendon, either secondary to chronic local inflammation/degeneration or due to non-image guided corticosteroid injection that is inadvertently placed into the Achilles tendon
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Immobilization: Consider partial immobilization in a walking boot or immobilization in a cast for 4-6 weeks if the patient's symptoms are resistant to the other treatments.
Surgical intervention
Consider surgical intervention for patients with retrocalcaneal bursitis who have significant persistence or progression of symptoms, in spite of the nonsurgical treatment approaches listed above (see Acute Phase Physical Therapy and Other Treatment). Surgical management may include the following:
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Resection of a Haglund deformity (eg, removal of the calcaneal posterosuperior prominence through an ostectomy). Two surgical approaches have been described: a tendon-splitting approach and a lateral approach. A recent study showed that patients who underwent the tendon-splitting approach returned to normal function quicker than patients undergoing the lateral approach. [31]
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Excision of the painful bursa(e)
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Debridement of the Achilles tendon insertion
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Repair of an Achilles tendon rupture or avulsion
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Outpatient endoscopic removal of the inflamed bursal tissue and resection of the prominent bone [32]
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A recently published review of the medical literature concluded that successful outcome of surgery for chronic retrocalcaneal bursitis is dependent on resecting an adequate amount of bone during the surgical treatment. The researchers also felt that the published evidence suggested (at least to some degree), that endoscopic surgery may have better outcomes than open surgical techniques in the treatment of retrocalcaneal bursitis. [33]
Consultations
An orthopedic surgeon who is experienced with foot and ankle surgery should be consulted for patients in whom conservative therapy has failed and who require surgical intervention for retrocalcaneal bursitis.
Other treatment
Corticosteroid injection using ultrasound guidance to help ensure accurate and safe placement could be of significant benefit.
Maintenance Phase
Rehabilitation program
Physical therapy
The patient should continue with a home exercise program that is developed in conjunction with a physical therapist during the course of treatment.
Medical issues/complications
The patient should be alert for any early signs or symptoms that indicate recurrence of the retrocalcaneal bursitis, so that intervention can be provided as soon as possible, if necessary.
Surgical Care
Patients who receive arthroscopic intervention for the treatment of retrocalcaneal bursitis have reported significant improvement in pain and quality of life, as compared with their presurgical states. [34] This type of surgery has been shown to reduce calcaneal bone marrow edema and retrocalcaneal bursitis. Arthroscopic intervention is also a viable option for patients with degenerative Achilles tendon who cannot undergo steroid injections owing to the risk of rupture or other factors.
