Retrocalcaneal bursitis is a condition characterized by the inflammation of the bursa, located towards the back of the foot, just above the heel bone. Commonly, pain at the posterior heel or ankle is caused by pathology at either the posterior calcaneus (at the calcaneal insertion site of the Achilles tendon) or at its related bursa. The retrocalcaneal (subtendinous) bursa is a fluid-filled sac that cushions and lubricants the joints and prevents the bones from becoming injured due to friction. Typically, this condition takes place when your ankle is repetitively overused from running and jogging long distances, or from a foot injury. This condition can cause inflammation and irritation of bursa which results in pain and difficulty in moving. Here is provided causes, symptoms, treatment and flexibility exercises of Retrocalcaneal Bursitis.

Alternatively, retrocalcaneal bursitis is also known as Insertional heel pain. Sometimes, it is often mistaken for Achilles tendonitis. The condition mostly takes place in athletes who participate in frequent running or walking. Bursitis in the retrocalcaneal area of foot can be treated through a variety of ways, for example prescription medication and simple lifestyle remedies that can easily be accomplished at home. On the basis of symptoms and severity of the condition, patients and physicians should work together to determine the best treatment.

Causes of Retrocalcaneal Bursitis:

Between tendons and muscles sliding over bone, a bursa acts as a cushion and lubricant. In the body, bursas are present around most large joints, including the ankle.

Repeated or over use of the ankle can cause this bursa to become irritated and inflamed. Possible causes include excessive walking, running, or jumping.

In an athlete, overtraining such as with excessive raises in running mileage may cause retrocalcaneal bursitis.

Commonly, this condition is related with Achilles tendinitis.

People who just start aggressive exercise regimens or who suddenly increase their activity without proper conditioning are at risk for this condition.

Haglund deformity, which is responsible for impingement between the raised posterosuperior calcaneal prominence and Achilles tendon during dorsiflexion, may cause retrocalcaneal bursitis.

The condition can also be caused by wearing tight or poorly fitting shoes that generate excessive pressure at the posterior heel and ankle because of a restrictive heel counter.

In short, events that can cause retro-calcaneal bursitis include:

Hill running or stair climbing

Poor biomechanics

Quickly increasing mileage or speed

Starting up too quickly after a layoff

Tight muscle groups in the back of the leg

Irritation from the heel counter of a sports shoe

Overuse resulting from the natural lack of flexibility in the calf muscles

Trauma caused by sudden and/or hard contraction of the calf muscles when putting out extra effort such as in a final sprint

Symptoms of Retro-calcaneal bursitis:

Symptoms of retro-calcaneal bursitis include pain in the heel, especially with walking, running. When the area between the achilles tendon and the heel bone is touched, it will be tender. The pain is frequently exacerbated when you try to stand on the tips of your toes as well. The skin over the back of the heel may be warm and possibly also red. The area will also look and feel swollen and the pain may be worse with attempted toe rise (standing on tippy-toes). If you push down upon the affected heel, then it may feel spongy. Consult with your doctor to discuss the best possible course of treatment, if you experience any of these symptoms.

Exams and tests: (Diagnosis)

If you have symptoms of retrocalcaneal bursitis, then your health care provider will take a history. The physician will find out the location of the pain by examining your ankle and also look for tenderness and redness in the back of the heel.

When the doctor bends the ankle upward (dorsiflex), the pain may be worse as this may tighten the Achilles tendon over the inflamed bursa. Alternatively, the pain may be worse when you rise on your toes.

As a first-line diagnosis, imaging studies such as x-ray and MRI are not generally necessary. These studies may be recommended if initial treatment fails to improve the symptoms as MRI may show inflammation.

Treatment of Retro-calcaneal bursitis:

Retro-calcaneal bursitis can be treated depending on the phase of the condition, means treatment is carried out in two phase: acute phase and recovery phase.

Acute Phase

Physical Therapy:

Rest: Take rest from all activities that cause pain or limping.

Ice: To treat retrocalcaneal bursitis, the patient should apply ice to the posterior heel and ankle in the acute period of the bursitis as a physical therapy. Apply ice several times a day, for 15-20 minutes each. Some clinicians also suggest using contrast baths.

Compression: Wrap an elastic bandage from the toes to mid calf with the application of pressure. Wear this until swelling reduces. If your toes start to turn blue or feel cold, then loose the wrap.

To restore normal function, sit with your knee straight and hold the foot position as long as possible. Do as frequently as possible for the first 3-10 days. Flex your foot back towards your body.

Stretching exercises:

Exercise 1:

Start eccentric exercise program 7-10 days after pain has been subsided. Begin with toes pointed, giving resistance through the thera-band and slowly let your foot into dorsiflexion (heel down. toes up).

Frequency: 10 repetitions/exercise, 5-7 days per week progressing to 3 sets of 15.

Exercise 2:

Carry out a toe raise on a 4-6 inch box or step with both legs. Once on your toes, pick up the uninvolved leg and lower yourself slowly into dorsiflexion (heel down, toes up).

Frequency: 6-10 repetitions/exercise, 5-7 days per week.

Warning: There should be no pain when doing this exercise. So, if pain persists, then stop it.

Sometimes, gradual progressive stretching of the Achilles tendon may help to relieve impingement on the subtendinous bursa and can be carried out in the following manner:

First, stand in front of a wall with the affected foot flat on the floor. Bend 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.

Carry out the stretches with the knee extended and then again with the knee flexed.

Repeat the above steps for several stretches per set several times daily to maximize the benefit of the stretching program. Avoid ballistic (i.e., abrupt, jerking) stretches.

Alternative means of maintaining strength and cardiovascular fitness such as swimming, water aerobics, and other aquatic exercises should also be suggested, if it is necessary for the patient to reduce his or her activity level due to retrocalcaneal bursitis.

Other Treatment:

Altering the patient’s footwear may be the most important form of treatment for retrocalcaneal bursitis. Pressure on the affected region may be relieved by use of an open-backed shoe. The temporary use of high-heeled footwear in between may be necessary in those individuals in whom symptoms were precipitated by a dramatic change from wearing high-heeled shoes to flat shoes (or vice versa).

If the patient has consented about the theoretical risk of Achilles tendon rupture, then corticosteroid injection into the retrocalcaneal bursa should be considered.

Recovery Phase

Physical Therapy:

The patient having retrocalcaneal bursitis should continue to advance the physical therapy program outlined above, with a gradual increase of activities. The objective is for the patient to have a full return to his or her previous level of athletic function.

Medical Issues/Complications:

Burst of the Achilles tendon, either secondary to chronic local inflammation/degeneration or due to non-image guided corticosteroid injection that is unintentionally placed into the Achilles tendon

Progressive posterior heel and ankle pain, with resultant limping and reduced athletic performance or mobility

Immobilization: If the patient’s symptoms are resistant to the other treatments, then consider partial immobilization in a walking boot or immobilization in a cast for 4-6 weeks

Surgical Intervention:

Patients who have significant persistence or progression of symptoms, surgical procedure is carried out for retrocalcaneal bursitis. Surgical intervention may include the following:

Bursectomy, a surgical procedure used to remove an inflamed or infected bursa. During this procedure, a surgeon makes small incisions so that a camera, called an arthroscope, may be inserted into the joint. Another small incision is made so that surgical instruments can be inserted to remove the inflamed bursa

Excision of the painful bursa

Repair of an Achilles tendon rupture or avulsion

Debridement of the Achilles tendon insertion

Outpatient endoscopic removal of the inflamed bursal tissue and resection of the prominent bone

Other Treatment: (Injection, manipulation, etc.)

Corticosteroid injection using ultrasound guidance to help make sure accurate and safe placement could be of important benefit.

Medication:

Medications are used primarily to reduce the associated pain and inflammation.

Outlook (Prognosis):

With the proper treatment, the condition usually gets better in several weeks.

Possible Complications:

Complications are rare. If the bursitis is related with tendinitis, then tendon rupture is a possible complication. Tendon rupture may also take place with steroid injections, especially if they are given too frequently.

When to Contact a Medical Professional?

If your symptoms of retrocalcaneal bursitis do not improve with rest, then contact your health care provider for evaluation and treatment.

Prevention:

Maintain proper form while exercising, as well as good flexibility and strength around the ankle to help prevent this condition. Proper stretching of the Achilles tendon helps to prevent injury.