Heel Bursitis Causes and Risk Factors

Identifying the underlying cause of heel bursitis can help determine the best treatment. For example, if the retrocalcaneal bursa is being irritated by a tight Achilles tendon, then the best treatment will be calf stretches to alleviate the tightness.

The possible causes and risk factors for heel bursitis relate to lifestyle, medical conditions, or other factors, such as a previous injury.

See What Is Bursitis?

Lifestyle Habits that Increase Risk for Heel Bursitis

Certain movements and everyday habits can cause the repetitive heel irritation that triggers bursitis. People with heel bursitis often report one or more of the following:

Using the ankle repetitively

Retrocalcaneal bursitis is often caused by frequent mini-traumas. These mini-traumas are often due to excessive:

• Walking
• Jumping
• Running

Running uphill, which causes the foot to flex considerably, can be especially irritating to the retrocalcaneal bursae.

Ramping up workouts too fast

Starting an exercise program without adequate stretching and muscle conditioning may lead to retrocalcaneal bursitis. Intense exercise can put strain on the calf muscles and the Achilles tendon, including the enthesis, where the tendon attaches to the heel. Strain on the Achilles tendon enthesis can put extra stress on the retrocalcaneal bursa and cause bursitis.

See Exercising with Arthritis

Wearing ill-fitting footwear

Shoes that dig into the back of the heel are the primary cause of calcaneal bursitis. Wearing poorly fitting or too-tight footwear can also cause the retrocalcaneal bursa to become irritated and inflamed.

Dancers and figure skaters—who may be subject to intense training and tight or unsupportive footwear—are at particular risk of heel bursitis. ¹ Williams CH, Jamal Z, Sternard BT. Bursitis. [Updated 2020 Dec 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513340/ One study of competitive figure skaters found 34% had retrocalcaneal bursitis and 30% had signs of calcaneal bursitis. ² 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;3(7):2325967115596517. Published 2015 Jul 28. PMID: 26674524 DOI: 10.1177/2325967115596517

Inflammatory Diseases that Increase Risk for Heel Bursitis

Retrocalcaneal bursitis is an inflammatory condition. It is more likely to develop when abnormally high inflammation levels are already present in the body. Certain inflammatory diseases, particularly these forms of arthritis, are associated with heel bursitis:

• Rheumatoid arthritis ³ Suzuki T, Hidaka Y, Seri Y. Retrocalcaneal Bursitis Precedes or Accompanies Achilles Tendon Enthesitis in the Early Phase of Rheumatoid Arthritis. Clin Med Insights Arthritis Musculoskelet Disord. 2018 Jun 5;11:1179544118781094. PMID: 29899668; DOI: 10.1177/1179544118781094 ^{, 4} InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Bursitis: Overview. 2018 Jul 26. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525773/
• Spondyloarthropathy, including ankylosing spondylitis ⁵ Olivieri I, Barozzi L, Padula A, De Matteis M, Pierro A, Cantini F, Salvarani C, Pavlica P. Retrocalcaneal bursitis in spondyloarthropathy: assessment by ultrasonography and magnetic resonance imaging. J Rheumatol. 1998 Jul;25(7):1352-7. PMID: 9676768.
• Gout ⁴ InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Bursitis: Overview. 2018 Jul 26. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525773/

These conditions may also raise the risk of problems with the Achilles tendon ⁵ Olivieri I, Barozzi L, Padula A, De Matteis M, Pierro A, Cantini F, Salvarani C, Pavlica P. Retrocalcaneal bursitis in spondyloarthropathy: assessment by ultrasonography and magnetic resonance imaging. J Rheumatol. 1998 Jul;25(7):1352-7. PMID: 9676768. ^{, 6} Suzuki T, Hidaka Y, Seri Y. Retrocalcaneal Bursitis Precedes or Accompanies Achilles Tendon Enthesitis in the Early Phase of Rheumatoid Arthritis. Clin Med Insights Arthritis Musculoskelet Disord. 2018 Jun 5;11:1179544118781094. doi: 10.1177/1179544118781094. PMID: 29899668; DOI: 10.1177/1179544118781094 and degenerative changes to the bone. ⁷ Ridley LJ, Han J, Ridley WE, Xiang H. Cockscomb appearance: Retrocalcaneal bursitis. J Med Imaging Radiat Oncol. 2018 Oct;62 Suppl 1:127. PMID: 30309192. doi: 10.1111/1754-9485.08_12786.

When an underlying condition triggers heel bursitis, both the bursitis and the underlying condition need to be treated.

Other Factors Increase the Risk for Heel Bursitis

In addition to lifestyle habits and inflammatory disease, many other factors can increase the risk for heel bursitis. These risk factors include:

Foot or ankle deformity

Bone abnormalities and other deformities increase the likelihood of developing retrocalcaneal bursitis. For example, a Haglund deformity—a bony prominence at the back of the heel’s calcaneus—can cause extra friction between the Achilles tendon and the bursa, leading to bursitis. ⁸ Vaishya R, Agarwal AK, Azizi AT, Vijay V. Haglund's Syndrome: A Commonly Seen Mysterious Condition. Cureus. 2016;8(10):e820. Published 2016 Oct 7. PMID: 27843738 doi:10.7759/cureus.820

Trauma to the back of the heel

Striking the back of the heel against a hard object or other trauma can injure the bursa and lead to bursitis. The injured bursa may become swollen with blood, synovial fluid, or a combination of the two.

When heel bursitis us caused by a trauma, the following steps occur:

• The damaged bursa fills with blood
• The blood irritates the bursa’s delicate lining, causing it to become inflamed
• While the blood in the bursa may be gradually reabsorbed into the body, the bursa’s lining stays inflamed. The inflamed lining produces excess synovial fluid
• The fluid fills the bursa, causing swelling and other heel bursitis symptoms

If a doctor uses a needle and syringe to draw fluid from a bursa after a trauma, the fluid may appear reddish or pink because of the presence of blood.

Infection (septic bursitis)

Heel bursitis can be caused by an infection in of the bursa. This condition is called septic bursitis. While anyone can develop septic bursitis, certain medical conditions, such as diabetes, alcoholism, and rheumatoid arthritis, increase the risk. ⁹ Lormeau C, Cormier G, Sigaux J, Arvieux C, Semerano L. Management of septic bursitis. Joint Bone Spine. 2019 Oct;86(5):583-588. Epub 2018 Oct 26. PMID: 31615686. DOI: 10.1016/j.jbspin.2018.10.006 ^{, 10} Khodaee M. Common Superficial Bursitis. Am Fam Physician. 2017 Feb 15;95(4):224-231. Updated September 13, 2020. Accessed January 25, 2021. PMID: 28290630. Medications that suppress the immune system may also increase risk.

See Septic Bursitis

History of inflammation of the bursa

Patients who have had heel bursitis in the past have an increased chance of getting it again.

There may be more than one reason why the heel bursa is inflamed. In these cases, treatment and prevention strategies should address all of the causes.