We were on holiday. Walking around the concrete jungle of NYC when my partner’s heel blew up. There was this incredible sharp pain every step from where her heel rubbed against the back of her shoe. “You’ve got retrocalcaneal bursitis” I helpfully offered as a diagnosis, “we’ll need to get some different shoes”.
Well, turns out the cold winter in NYC and the shoes you need for retrocalcaneal bursitis don’t always go perfectly well together. Let me share a bit more podiatry knowledge here about the condition.
What is Retrocalcaneal Bursitis
Your retrocalcaneal bursa is a fluid filled sac located between the heel bone and Achilles tendon. It helps cushion the heel during walking and running.
However, if the bursa becomes inflamed, it can cause pain and swelling. The condition is called retrocalcaneal bursitis.
Symptoms of Retrocalcaneal Bursitis
The most common symptom of this condition is pain at the back of the heel bone near the achilles tendon attachment. The pain is usually sharp and it gets worse when pressed upon. Closed heel shoes, particularly those with a hard heel counter usually make the pain worse. This posterior heel pain often requires a clinical diagnosis from your podiatrist to differentiate between noninsertional achilles tendinopathy and insertional tendinosis.
For some, there will be no noticeable increase in symptoms and pain with activity. For others there can be a mild increase in pain as you spend more time on your feet.
Depending on how long the pain has been going on for, it might be quite mild and dull or incredibly sharp.
Bending and pointing your foot to end range (plantar flexion) will often trigger a flare in symptoms too.
While pain is almost always a symptom, swelling is only sometimes. In the early phases there’s often no swelling around the retrocalcaneal bursa. As the condition deteriorates the swelling can become very prominent making shoes with a heel counter impossible or painful to wear.
Causes of Retrocalcaneal Bursitis
Retrocantal bursitis is usually caused by too much compression on the bursa at the back of the heel bone. This stress can be from internal forces, external forces or a combination of both.
The internal forces which cause retrocalcaneal bursitis are usually compression of the bursa between the top of the heel bone, the calcaneus and the achilles tendon. If there is spurring of the heel bone up into the tendon this can make things even worse.
Some people have a prominent extra long “tail bone” on their talus as well. This is a bone that makes up the middle of the ankle joint. If there is an extended trigonal process of the talus this too can cause stress on the retrocalcaneal bursa and lead to pain.
Also, if you have a highly mobile heel bone that inverts or everts a lot during gait this can lead to increased compression on just one side of your bone and retrocalcaneal bursa.
The most common external force leading to retrocalcaneal bursitis is from the back of our shoes. Tight fitting boots and shoes or shoes with a very hard internal heel counter can press onto the retrocalcaneal bursa and lead to pain.
Ski boots, ice skates and roller blades all pose an elevated risk of causing retrocalcaneal bursitis due to their fit and function holding on tight to the back of our heel bones.
How Retrocalcaneal Bursitis is Diagnosed
Your podiatrist will usually establish a clinical diagnosis of retrocalcaneal bursitis and provide you with your treatment plan. In most cases imaging in the form or X-rays, ultrasound imaging or MRI (magnetic resonance imaging) is not required.
The clinical signs and symptoms as well as a thorough assessment involving palpation, muscle, joint and tendon assessment, gait assessment and footwear assessment will give you a diagnosis.
For those who have a few complex factors then an ultrasound or and MRI could be used. Both these modalities are able to clearly show if there is an inflamed retrocalcaneal bursa causing your pain.
Tendon injuries often present with similar pain patterns to bursitis symptoms however a thorough clinical examination by your podiatrist will give you a diagnosis. Sometimes there will be a combination and it’s quite common to suffer with both insertional achilles tendinopathy and retrocalcaneal bursitis at the same time.
Retrocalcaneal Bursitis Treatment
Once you and your podiatrist have established a diagnosis of retrocalcaneal bursitis you can begin treatment. By addressing the causative factors for your specific needs you’ll be able to successfully pilot a path away from your sore heel.
For many this will involve reducing the compression on the bursa and treating the inflammation. The inflammatory side of things can be treated with topical or oral anti-inflammatory medications. In rare cases a steroid injection may be considered however the side effects of tendon rupture and bone weakness locally need to be considered carefully due to the close proximity to both the biggest tendon in the body (the achilles) and the very hard working heel bone.
Reducing compression on the outside of the bursa will likely involve a shoe change. Avoiding hard heel or tight fitting shoes for a period of time is often required. While this might help your retrocalcaneal bursitis again we need to be careful to weigh up the risks to other areas as you lose that extra heel support.
Shoe inserts and orthotics might be indicated if your heel bone twists either inverting or everting a lot and putting pressure on your bursa. Often your podiatrist can create some temporary padding to deflect pressure away from your painful bursa and still allow you to wear your shoes or boots.
Two modalities that used to be used to treat retrocalcaneal bursitis that are no longer used are therapeutic ultrasound and calf stretches. Stretching exercises have been shown to not have any significant effect on the bursa and therapeutic ultrasound has no place in clinical practice for foot and ankle injury treatment in the 21st century.
Frequently Asked Questions
How do I know if my retrocalcaneal bursa is swollen?
If you can feel around the back part of your heel and there is a warm, swollen bump that does not feel as rock hard as bone then it’s likely your retrocalcaneal bursa is swollen. If the bump is as hard as bone then it’s more likely to be a bony condition known as a Haglund’s deformity.
Can retrocalcaneal bursitis be caused by wearing high heels?
Wearing a hard backed, high heeled shoe can cause retrocalcaneal bursitis. The high heel leads to greater ankle plantar flexion, pressing the heel bone up into the achilles tendon and the back of the ankle. The harder the back on your high heeled shoes can also increase the external compression as well.
Is it possible to get retrocalcaneal bursitis without having any other foot problems?
It’s absolutely possible for the very first and only foot problem you’ve ever suffered in your life is retrocalcaneal bursitis. If you have healthy feet with no other risk factors and then spend an increased amount of time with your heel bone squished into a hard backed shoe you can easily develop retrocalcaneal bursitis.
Do I need surgery?
Retrocalcaneal bursitis very rarely (zero times in this podiatrists career) requires surgical treatment. By modifying some behaviours, treating inflammation and changing shoes you can usually resolve retrocalcaneal bursitis. This will allow you to lead an active healthy life without the potential risks of surgery.
Are there exercises or physical therapy treatments I should try?
While there are not exercises that will treat an acutely inflamed bursa at the back of the heel, they may be beneficial to reduce the risk of recurrence. Exercises that build strength in the inverter and everter muscles of the foot and ankle are often prescribed in the sub acute phase of treatment. These calf muscles can be strengthened with appropriate calf raise exercise programs.
Do bone spurs cause retrocalcaneal bursitis?
Bony spurs can increase the compression on your bursa however they often do not need to be removed to get a great functional outcome. By modifying external compressive forces on your bursa you can often resolve bursitis whilst still having a heel spur present. While this used to be called conservative treatment, these days we prefer “active treatment”. You’re much more actively involved in your footwear selection, exercise and overall nonoperative treatment when we actively buy in.