Insertional heel pain

Alternative names
Retrocalcaneal bursitis

Definition
Retrocalcaneal bursitis is an inflammation of the bursa at the back of the heel bone (calcaneus). This causes pain with up-and-down movements of the foot.

Causes, incidence, and risk factors

A bursa is a fluid-filled sac that acts as a cushion and a lubricant between tendons and muscles sliding over bone. There are bursas around most large joints in the body, including the ankle.

The retrocalcaneal bursa is located in the back of the ankle by the heel, where the large Achilles tendon connects the calf muscles to the heel bone (calcaneus).

Repetitive or over use of the ankle, for instance by doing excessive walking, running or jumping, can cause this bursa to become irritated and inflamed. This condition is commonly associated with Achilles tendonitis. Sometimes retrocalcaneal bursitis may be mistaken for achilles tendonitis.

Those at risk for this condition include people just starting aggressive exercise regimens or having some other sudden increase in activity without proper conditioning.

Symptoms

Symptoms of bursitis include pain in the heel, especially with walking, running, or when the area is touched. The skin over the back of the heel may be red and warm, and the pain may be worse with attempted toe rise (standing on tippy-toes).

Signs and tests

Your doctor will take a history to find out if you have the symptoms of retrocalcaneal bursitis. By examining your ankle, he or she can generally tell the location of the pain. The physician will look for tenderness and redness in the back of the heel.

The pain may be worse when the doctor bends the ankle upward (dorsiflex), as this may tighten the achilles tendon over the inflamed bursa. Alternatively, the pain may be worse with toe rise, as this puts stress on the attachment of the achilles tendon to the heel bone.

Imaging studies such as X-ray and MRI are not usually necessary at first. If initial treatment fails to improve the symptoms, these studies may be obtained. MRI may show inflammation.

Treatment

The initial treatment for retrocalcaneal bursitis is to avoid activities that cause pain and take non-steroidal anti-inflammatory medications (for example, ibruprofen). Your doctor may recommend icing the heel several times a day and may prescribe physical therapy to improve flexibility and strength around the ankle. Physical therapy serves two functions; it can help the bursitis improve and it can help prevent future recurrences.

Over-the-counter or custom heel wedges may help to decrease the stress placed on the attachment of the achilles tendon and the associated bursa.

If these interventions are ineffective, then some health care providers may inject a small amount of steroids into the bursa. If the condition is associated with Achilles tendonitis, then casting the ankle to prevent motion for several weeks can be effective. Very rarely, surgery may be necessary to remove the inflamed bursa.

Expectations (prognosis)

This condition has an excellent prognosis and usually resolves in several weeks once proper treatment is initiated.

Complications

Complications are uncommon. If the bursitis is associated with tendonitis, then tendon rupture is a possible complication. Steroid injections have also been associated with tendon rupture, especially if done too frequently.

Calling your health care provider

If you have heel pain or symptoms of retrocalcaneal bursitis and these symptoms do not improve with rest, contact your health care provider for proper evaluation and treatment.

Prevention

Maintain proper form when exercising, good flexibility, and strength around the ankle to help prevent this condition from arising.

Proper stretching of the achilles tendon helps prevent injury.

Johns Hopkins patient information

Last revised: December 2, 2012
by Arthur A. Poghosian, M.D.

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