Author: Chloe Wilson - BSc(Hons) Physiotherapy
Retrocalcaneal bursitis is inflammation of the retrocalcaneal bursa at the back of the heel. The retrocalcaneal bursa is a small fluid-filled sac that sits between the heel bone and the insertion of the Achilles tendon.
The bursa provides cushioning at the back of the heel allowing the Achilles tendon to glide smoothly over the heel bone (calcaneus).
Repetitive friction or pressure over the area causes irritation and inflammation of the bursa leading to pain and swelling at the back of the heel. Symptoms tend to be worse when running uphill or when standing on tiptoes.
Retrocalcaneal bursitis is often associated with heel bone spurs and is commonly misdiagnosed as Achilles tendonitis. It is the most common type of heel bursitis.
Here we will look at the common causes, symptoms, diagnosis and treatment options for retrocalcaneal bursitis and how to prevent it from coming back.
The retrocalcaneal bursa is a thin sac of fluid that provides cushioning at the back of the heel. It stops the Achilles tendon from rubbing on the underlying bone, allowing the tendon to glide smoothly as the foot moves up and down.
Anything which places pressure or friction on the retrocalcaneal bursa can cause it to become inflamed, leading to heel bursitis. The most common causes of retrocalcaneal bursitis are:
Frequent, repetitive activities such as jumping and running, particularly uphill, can irritate the bursa leading to micro-trauma and bursitis. Sudden increases in training or not adequately warming up before exercise increase the risk of developing retrocalcaneal bursitis.
People who frequently wear high heels are a greater risk of developing heel bursitis. This is because wearing high heels long-term can lead to shortening of the calf muscles and tightness in the Achilles tendon.
When you then wear flat shoes or go barefoot, there is increased tension through the tendon which can cause excessive pressure on the bursa leading to inflammation.
Wearing poorly-fitting or tight shoes that dig in to the back of the heel can irritate the bursa. This is a common cause of heel bursitis.
Tightness in the calf muscles can lead to increased tension on the Achilles tendon where it attaches to the heel bone. This places friction on the retrocalcaneal bursa and can cause it to become inflamed. Failing to stretch before playing sports increases the risk of retrocalcaneal bursitis.
This is where a bony lump forms on the back of the heel in response to friction. The bony prominence rubs on the bursa leading to retrocalcaneal bursitis.
You can find out more about the causes and symptoms in the Haglund’s Deformity section.
Retrocalcaneal bursitis has be linked with certain medical conditions including gout, arthritis and fibromyalgia.
Sudden impact through the back of the heel such as a fall or being kicked can lead to inflammation of the retrocalcaneal bursa.
Retrocalcaneal bursitis symptoms tend to come on gradually over time and get progressively worse, unless there has been a specific injury in which case they tend to develop rapidly. Common symptoms include:
The main symptoms of retrocalcaneal bursitis are pain and tenderness at the back of the heel. The pain tends to be worse when there is pressure through the back of the heel and as a result, wearing shoes is often uncomfortable.
The activities that tend to cause the most pain are walking or running uphill and standing on tiptoes as in these positions the bursa gets squashed.
You may notice some swelling at the top part of the back of the heel due to the inflammation of the bursa.
In some cases, the ankle joint can become slightly stiff. This is usually due to a combination of tightness in the calf muscles and Achilles tendon, inflammation and not using the foot as normal. As a result your foot may not move around as freely or as fully.
Treatment for retrocalcaneal bursitis looks to reduce the pain and swelling as well as the pressure on the bursa and can be divided into four stages
Phase 1: Looks to treat the pain and inflammation
Phase 2: Looks to restore range of movement and strength at the ankle
Phase 3: Looks to restore function – getting back to the activities you love
Phase 4: Looks at prevent the recurrence of retrocalcaneal bursitis
There will be so overlap in the phases with certain treatments being beneficial during more than one phase.
Resting for any aggravating activities such as running or sports is essential to allow the inflammation to settle down. Try to avoid any activities that exacerbate your symptoms for a few weeks. If you try to get back to activities too soon, the pain and inflammation will quickly return.
That doesn’t mean you should rest completely. Try different activities such as swimming or cycling and gentle ankle exercises to keep yourself fit and your muscles in good condition.
Applying ice regularly to the back of the heel is a great treatment for retrocalcaneal bursitis. It helps to reduce pain and inflammation, and should be applied several times a day.
Visit the ice treatment section to find out about the best ways to apply ice and how to use it safely and effectively – it’s not as simple as just popping a bag of frozen peas on!
You may find it helpful to take painkillers and/or anti-inflammatories to help settle down your symptoms. Always check with your doctor before taking any medications.
If there is tightness in the calf muscles and Achilles tendon, it can help to wear a heel wedge in your shoe. This is a simple wedge made of gel or felt to slightly raise your heel up to reduce the tension on the Achilles tendon.
In most cases, after a few weeks of regularly performing stretching exercises, you shouldn’t need to wear the heel wedge any more. Heel raises should be worn in both shoes so as not to introduce a difference in leg lengths which can lead to back and knee pain.
Your doctor may advise having a corticosteroid injection to treat heel bursitis. This involves injecting a solution of steroid and local anaesthetic into the bursa to help reduce the pain and inflammation.
It is important to take it easy for 3 days after an injection as it can temporarily weaken the Achilles tendon, making it prone to tearing. You can find out more about how injections work on our sister site.
Wear soft-backed, comfortable shoes that don’t rub or place pressure over the bursa at the back of the heel. It may help to wear a shoe with a slight heel to take the tension off the Achilles tendon, but remember to do your calf stretches to alleviate any tightness.
Wearing the right shoes will help both in phase 1 of treatment to reduce pain, and also phase 4 to help reduce the risk of recurrence.
It is highly unlikely that you would need surgery to treat retrocalcaneal bursitis, but if symptoms have failed to resolve with other treatment methods, or there are secondary problems such as bone spurs, then it may be advised.
Surgery involves removing the retrocalcaneal bursa (known as a bursectomy) and shaving off any underlying bone spurs.
Stretching the calf muscles and Achilles tendon will help to take the pressure off the bursa and are a vital part of heel bursitis bursitis treatment in phases 2 – 4 to help restore movement and function as well as reducing the chance of recurrence.
Each of the two calf muscles, gastrocnemius and soleus, should be stretched separately to ensure a full recovery. Stretches should be held for around thirty seconds each and repeated to give the muscles adequate time to stretch out.
You can find out the best ways to stretch and loads of top tips in the calf stretches section.
Exercises to strengthen the calf and ankle muscles will help to restore function and reduce the chance of recurrent, making them suitable in phases 3 and 4 of retrocalcaneal bursitis treatment.
Strengthening exercises should not be started until the pain is under control and full range of movement at the ankle has been restored. It is important to start slowly with low numbers of repetitions and low loading exercises so as not to flare up symptoms.
Visit the strengthening exercises section for a whole range of exercises that are suitable and guidance on how to progress them.
Phase 3 of retrocalcaneal bursitis treatment looks at getting back to full function and being able to return to your usual activities. When returning to sports it is important, as with exercises, to wait until any pain and swelling has completely resolved, which may take a few weeks and to start slowly. If you try and return to activities too quickly before the bursa has been able to fully heal, you will most likely cause a flare up of symptoms and have to start all over again.
Start by playing for shorter periods, or running shorter distances than usual and gradually build up. Ensure that you warm up and cool down before you exercise. Generally, if you overdo things, you won’t necessarily know about it immediately so don’t be tempted to rush. A good rule to follow is the 10% rule where you increase activity levels by no more than 10% each week, be that distance or time.
So how long does it take for heel bursitis to heal? The best way to make a full recovery from retrocalcaneal bursitis is to take it slowly, get the pain and inflammation under control. Then you can gradually start doing stretching and strengthening exercises, building them up appropriately.
Return to sports should not be rushed, but reintroduced slowly, gradually progressing activity levels. If you do this, you should make a full recovery within around three months.
Retrocalcaneal bursitis is not the only cause of pain at the back of the heel. Other common causes include Achilles tendonitis and Haglund’s deformity. Find out about these and other different causes, including how to tell the difference between them, in the heel pain section.