Pain and swelling at the back of the heel can be a sign of retrocalcaneal or calcaneal bursitis. The symptoms can make it uncomfortable or even difficult to walk.
Bursitis occurs when a small, liquid-filled sac called a bursa becomes inflamed. There are more than 140 bursae in the body, 1 Azar FM, Beaty JH, Canale TS, eds. Campbell’s Operative Othopaedics, 13th ed., vol 1, page 482. Philadelphia PA: Elsevier; 2017. 2 of which are located at the back of the heel. These bursae, called the retrocalcaneal and calcaneal bursae, are prone to bursitis.
This article discusses the symptoms, risk factors, diagnosis, and treatment for retrocalcaneal bursitis. Also discussed are the differences between retrocalcaneal and calcaneal bursitis as well as other possible causes of heel pain. Many of the symptoms and treatments for retrocalcaneal and calcaneal bursitis are the same.
What Causes Heel Bursa Pain?
Painful bursitis typically occurs when a bursa is repeatedly irritated and becomes inflamed. In the heel, this irritation is most likely due to:
- Certain activities, such as jumping, jogging, or walking long distances
- Wearing shoes that do not fit well
- Underlying health conditions, such as arthritis
- Anatomical abnormalities, such as bone spurs at the back of the heel
When inflamed, the normally thin bursa fills with fluid, causing the back of the heel to look swollen.
Anatomy at the Back of the Heel
To understand heel bursitis, it is helpful to be familiar with a few anatomical structures:
- The calcaneus is a large bone at the back of the foot, commonly known as the heel bone.
- The Achilles tendon is a long strip of fibrous tissue that connects the calf muscles to the back of the heel bone. The calf muscles include the gastrocnemius and soleus muscles.
- Enthesis is the medical term for the point at which any tendon or ligament inserts into a bone.
- The Achilles tendon enthesis is located at the back of the calcaneus.
- Bursae are thin, slippery, fluid-filled sacs that serve as both cushions and lubricant between tissues, usually between bone and soft tissue, such as a tendon or skin. A bursal sac is made up of a delicate, thin membrane called a synovial membrane. The membrane produces a fluid, called synovial fluid, that fills the sac.
- The retrocalcaneal bursa is located in between the heel bone and the Achilles tendon, just above the Achilles tendon enthesis.
- The calcaneal bursa is located in between the Achilles tendon and the skin at the back of the heel.
Bursitis can develop in either the retrocalcaneal bursa and the calcaneal bursa. It is possible for bursitis to develop in both bursae at the same time, making the pain and inflammation more difficult to treat.
See What Is a Bursa?
The purpose of the retrocalcaneal bursa is to reduce friction between the heel bone and the Achilles tendon. Retrocalcaneal bursitis is often associated with other problems in the heel, such as Achilles tendonitis and Haglund deformity.
A healthy retrocalcaneal bursa is typically about 1 to 2 cm in diameter and filled with 1 to 1.5 ml (or about ¼ tsp) of fluid. 2 Kachlik D, Baca V, Cepelik M, Hajek P, Mandys V, Musil V, Skala P, Stingl J. Clinical anatomy of the retrocalcaneal bursa. Surg Radiol Anat. 2008 Jun;30(4):347-53. Epub 2008 Mar 11. PMID: 18330489. DOI: 10.1007/s00276-008-0335-4 When inflamed, this bursa can swell to several times its normal size.
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Calcaneal Bursitis (Subcutaneous Calcaneal Bursitis)
The purpose of the calcaneal bursa is to reduce friction between the skin and Achilles tendon. This bursa may go by several names, including calcaneal, subcutaneous calcaneal, superficial calcaneal, or retroachilles bursa. Like the retrocalcaneal bursa, the calcaneal bursa is small but can cause a great deal of pain.
Calcaneal bursitis is almost exclusively associated with shoes that dig into the back of the heel. This condition can cause a hard, red bump to develop at the back of the heel.
How Long Does Heel Bursitis Last?
If treated, inflammation and pain at the back of the heel will usually go away in 2 or 3 weeks. Home treatment may include rest, a change in footwear, icing the back of the heel, and gentle stretches for the Achilles tendon. When icing, wrap the ice in a towel to prevent injury to the skin.
If symptoms are not notably better after 2 to 3 weeks of home treatment, then a visit to primary care physician, podiatrist, or orthopedist is advised. They may recommend physical therapy or shoe orthotics to reduce strain on the bursa. Additional therapies may be recommended if first-line treatments do not work.
If left untreated, heel bursitis may become chronic.
Musculoskeletal Conditions Associated with Heel Pain and Bursitis
Certain conditions can make it more likely that heel bursitis develops.
Many people who develop retrocalcaneal bursitis have a small bump at the top and back of the heel bone, just above the area where the Achilles tendon attaches. Doctors call this bump a Haglund deformity. It may also be referred to as a retrocalcaneal exostosis, Mulholland deformity, or ‘pump bump.'
Haglund deformity is a common cause of retrocalcaneal bursitis. 3 Tu P. Heel Pain: Diagnosis and Management. Am Fam Physician. 2018 Jan 15;97(2):86-93. PMID: 29365222. It can put extra strain on the Achilles tendon, causing irritation of the retrocalcaneal bursa. Over time, the irritation can lead to inflammation and bursitis.
Haglund deformity often develops in middle age and is most common in women. 4 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
Both heel bursitis and Achilles tendinopathy cause painful symptoms to appear at the back of the heel. It is possible to have both heel bursitis and Achilles tendinopathy. Sometimes, Achilles tendon problems trigger heel bursitis.
Read more about Achilles Tendon Conditions Signs and Symptoms on Sports-health.com
Children and adolescents who complain of persistent heel pain may have Sever disease. In this condition, a growth spurt results in extra strain on the area where the Achilles tendon attaches to the heel bone. The bone tissue becomes inflamed, resulting in pain.
Sever disease is generally not a serious condition and can usually be treated with rest and physical therapy.
Septic Bursitis in the Heel
While not common in the heel, septic bursitis is a serious condition that requires medical attention. It occurs when infectious bacteria or other microbes enter the bursa, typically through a cut or blister, though the point of entry is not always clear. The calcaneal bursa, which lies just below the skin, is more susceptible to septic bursitis than the retrocalcaneal bursa. 5 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
Septic bursitis may cause the skin at the back of the ankle to become red and feel hot. The person may experience chills or fever and may feel sick and tired.
See Septic Bursitis
Septic bursitis can usually be successfully treated with oral antibiotics. Without antibiotic treatment, the infection may become chronic or spread to other parts of the body, including the bloodstream, which can be life-threatening.
What Type of Doctor Treats Heel Bursitis?
Many doctors are qualified to diagnose and make treatment recommendations for heel bursitis. Examples include:
- Primary care providers, such as family medicine doctors and internists
- Doctors who specialize in sports medicine, such as physiatrists
A doctor may refer a patient to another specialist depending on the patient’s unique health circumstances.