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Retrocalcaneal Bursitis

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Other Names

  • Subcutaneus Calcaneal Bursitis
  • Albert disease
  • Calcaneus altus
  • Pump bump
  • Winter heel
  • Achillodynia
  • Chronic retrocalcaneal bursitis
  • Subtendinous Bursitis
  • Achilles bursitis
  • Posterior heel bursitis
  • Retro-Achilles bursitis
  • Calcaneal bursitis
  • Bursitis of the retrocalcaneal bursa

Background

History

  • First described by Painter in 1898[1]

Epidemiology

  • The epidemiology of retroachilles bursitis is poorly described in the literature

Pathophysiology

Clinical image (A) and radiograph (B) of a patient with a retrocalcaneal bursitis. The retrocalcaneal recess is obliterated by a chronic inflamed bursa (arrow). C. Endoscopic view of a patient with a retrocalcaneal bursitis.[2]
Illustration of the retrocalcaneal bursa[3]
There is a fluid distended retrocalcaneal bursa with mild surrounding edema.[4]

General

  • Inflammation of the bursa between the Achilles tendon and the posterior calcaneus
  • Typically results as a result of repeated microtrauma to the bursa
  • Patients present with erythema and swelling of the region, tenderness to palpation
  • Diagnosis is clinical and confirmed with imaging
  • Management is nonsurgical including activity modification, NSAIDS and a walking boot

Etiology

  • Repetitive impingement of the bursa between the anterior aspect of the Achilles tendon and a bony posterosuperior calcaneal prominence[5]
  • This chronic microtrauma leads to inflammation of the bursa

Mechanism of Injury

  • General
    • Compression and chafing of the retrocalcaneal bursa during repetitive ankle motion
    • During dorsiflexion, the bursa becomes compressed between anterior surface of the Achilles tendon, posterior calcaneal tuberosity[6]
    • This repeated impingement causes inflammatory changes
  • Anatomic Factors[7]
    • Flat surface of the calcaneal tuberosity increases risk fourfold
    • Calcaneal slope above 25° increases risk 2.8-fold
    • Presence of Haglund deformity creates additional mechanical irritation
    • Increased Achilles tendon thickness and smaller bursal surface area also contribute to impingement by further narrowing the retrocalcaneal space

Associated Conditions

Anatomy of the Retrocalcaneal Bursa

  • Lies between the Calcaneus anteriorly and the Achilles Tendon posteriorly
  • Separated from Achilles fat pad by synovial lining on superior aspect[8]
  • Anterior wall is cartilaginous, posterior wall is tendinous

Risk Factors

Differential Diagnosis

Differential Diagnosis Ankle Pain

Clinical Features

Demonstration of the two finger squeeze test[10]

History

  • Patients typically report posterior heel pain
    • Worse with pressure from shoes
    • Relieved when walking barefoot
  • Swelling is often but not always present
  • Typically worse during early exercise and improves during the workout
  • Patients may report wearing ill fitting footwear

Physical Exam: Physical Exam Ankle

  • Swelling, erythema at the bursa and posteiror calcaneus may be noted (i.e. 'pump bump')
  • If haglund deformity present, there is a bony prominence of the superior aspect of the posterior calcaneus
  • Tenderness to direct palpation of the posterior heel
  • Passive dorsiflexion often induces pain
  • Active plantarflexion reproduces pain

Special Tests

  • Two Finger Squeeze Test: Pressure is applied with the fingers placed medially and laterally anterior to the Achilles tendon insertion

Evaluation

Ankle XR showing the retrocalcaneal recess has disappeared because of the less radiolucent fluid in the distended retrocalcaneal bursa[11]
Sonographic pattern of superficial retrocalcaneal bursitis. Longitudinal scans (A, B) show a hypertrophic superficial retrocalcaneal bursa (b) presenting as a hypoechoic ovoidal mass between the superficial retrocalcaneal fat pad (sRFP) and the more distal fibers of the Achilles tendon (AT). Transverse scans (C, D) show hyperechoic fibrotic septae (void arrowhead) as multiple bursal compartments (white asterisks).[12]

Radiographs

  • Standard Radiographs Ankle
    • Typically normal
    • May show loss of retrocalcaneal recess
  • Obliteration of the retrocalcaneal recess
    • radiolucent area at the posteroinferior corner of Kager's triangle
    • Sensitive at 79-83%, highly specific 98-100%[11]
  • Additional findings[13]
    • Prominent posterosuperior calcaneal tuberosity
    • Thickening of the distal Achilles tendon outline

Ultrasound

  • Can easily detect the retrocalcaneal bursa and fluid collection
    • Only 50% sensitivity compared to MRI for identifying retrocalcaneal bursitis[14]
  • Patient positioning
    • Best performed with the patient laying prone
  • Findings
    • Triangular hypoechoic lesion situated between the Achilles tendon and the calcaneus
    • Power doppler: increased blood flow around an abnormal bursa
  • Advantages[15]
    • Allows easy evaluation, comparison of both ankles
    • More rapid and cost-effective than MRI
    • Allows dynamic assessment
    • Guide interventional procedures
    • Perform serial follow up examinations

MRI

  • General
    • Not required to make diagnosis
    • Most comprehensive and accurate imaging modality
  • Normal bursa[16]
    • May contain detectable fluid (average 1 mm anteroposterior, 6 mm transverse, 3 mm craniocaudal)
    • Dimensions exceeding 1 mm anteroposteriorly, 11 mm transversely, or 7 mm craniocaudally indicate pathology
  • Findings[13]
    • Bursa will appear as an enlarged, fluid-filled structure
    • Low signal intensity on T1-weighted images
    • High signal intensity on fluid-sensitive images
  • Other potential findings[17]
    • Increased signal intensity and thickening of the Achilles tendon
    • Prominence of the posterior calcaneus tuberosity
    • Reactive marrow edema.

Classification

  • Not applicable

Management

Ankle Foot Orthosis

A. Injection of 10 mg triamcinolone acetonide into the retrocalcaneal bursa was sonograph-assisted using a lateral approach. B, C, D. Needle placement (*) and medication passage into the bursa.[18]

Nonoperative

  • Indications
    • Virtually all cases
  • Ice Therapy
  • Activity modification
  • NSAIDS
  • Physical Therapy
    • Emphasis on stretching the Achilles tendon
  • Microcurrent therapy
    • One study suggested this was helpful as an adjunct when combined with standard therapy[19]

Medical Equipment and DME

  • Footwear modification
    • Shoes that are open backed may relieve pressure or tension
    • Walking barefoot can also provide relief
  • Heel Cup
    • Raises the heel, offloading the bursa and achilles tendon
  • Ankle Foot Orthosis
    • When combined with stretching program, showed 88% success rate[20]

Procedural

  • Corticosteroid Injection
    • Performed under ultrasound or fluoroscopic guidance
    • There is likely some risk to the Achilles Tendon, although this is not clearly established[21][22]
    • Under fluoroscopy, patients reported a 50% reduction in pain[23]
    • Risk of Achilles tendon rupture following injection is approximately 1.8%, typically occurring 15-59 days post-injection in association with acute injury[24]

Operative

  • Indications
    • Refractory to conservative management
  • Technique
    • Bursectomy
    • Calcaneal resection

Rehab and Return to Play

Rehabilitation

  • Structured stretching program
    • Has the strongest evidence for success for achieving nonoperative success
    • Especially when combined with an AFO
  • Home stretching vs physical therapy[25]
    • Both approaches produced similar outcomes at 6 weeks and 1 year
  • Eccentric exercise program
    • For associated Achilles tendinopathy, eccentric training improves VISA-A scores from 60.7 to 89.4 at 1 year

Rehab Program PDFs

Return to Play/ Work

  • RTS continuum requires[26]
    • Restoration of pain-free function and sport-specific performance
    • Individualized assessment considering the athlete's sport, position, and timing in season
    • Ongoing communication between the team physician, athlete, certified athletic trainers, and rehabilitation team
    • Equipment modifications or bracing as necessary

Prognosis and Complications

Illustration of Achilles Tendon Rupture at the insertion or mid substance[27]

Prognosis

  • Conservative management
    • There is an 88% success rate in avoiding surgery using structured nonoperative protocols
    • Approximately 11-14% of patients progress to surgical intervention despite conservative treatment[24]
  • Short-term outcomes with conservative treatment
    • Significant improvement, with mean Foot Function Index scores improving from 48.4 to 18.6
    • Image-guided corticosteroid injections yield excellent or good short-term response in 63-69% of patients
  • Long-term surgical outcomes[28]
    • Excellent when conservative measures fail
    • Endoscopic calcaneoplasty demonstrates high patient satisfaction, good functional outcomes at a follow-up of 101 months
    • Traditional open surgical approaches also show favorable results
  • Negative prognostic indicators[24]
    • Bursal Doppler flow on ultrasound
    • Positive smoking status

Complications

  • Chronic pain
  • Inability to return to sport
  • Trouble running
  • Achilles Tendon Rupture
    • Occurs in approximately 1.8% of patients following corticosteroid injection

See Also

Internal

External

References

  1. ↑ Painter CF. Inflammation of the post-calcaneal bursa associated with exostosis. J Bone Joint Surg Am 1898;s1-11:169-180.
  2. ↑ van Sterkenburg, Maayke N., et al. "Appearance of the weight-bearing lateral radiograph in retrocalcaneal bursitis." Acta orthopaedica 81.3 (2010): 387-390.
  3. ↑ Chu NK, Lew HL, Chen CP. Ultrasound-guided injection treatment of retrocalcaneal bursitis. Am J Phys Med Rehabil. 2012 Jul. 91(7):635-7.
  4. ↑ Case courtesy of Badis M.A Al-Harbawi, Radiopaedia.org, rID: 68903
  5. ↑ van Sterkenburg, Maayke N., et al. "Appearance of the weight-bearing lateral radiograph in retrocalcaneal bursitis." Acta orthopaedica 81.3 (2010): 387-390.
  6. ↑ Lohrer, Heinz, and Tanja Nauck. "Retrocalcaneal bursitis but not Achilles tendinopathy is characterized by increased pressure in the retrocalcaneal bursa." Clinical Biomechanics 29.3 (2014): 283-288.
  7. ↑ 7.0 7.1 Wnuk-Scardaccione, Agnieszka, et al. "Surface shape of the calcaneal tuberosity and the occurrence of retrocalcaneal bursitis among runners." International Journal of Environmental Research and Public Health 18.6 (2021): 2860.
  8. ↑ Theobald P, Bydder G, Dent C, et al.: The functional anatomy of Kager’s fat pad in relation to retrocalcaneal problems and other hindfoot disorders. J Anat 2006; 208: 91–7
  9. ↑ Campanelli, Valentina, et al. "Lower extremity overuse conditions affecting figure skaters during daily training." Orthopaedic journal of sports medicine 3.7 (2015): 2325967115596517.
  10. ↑ Lohrer, Heinz, and Tanja Nauck. "Results of operative treatment for recalcitrant retrocalcaneal bursitis and midportion Achilles tendinopathy in athletes." Archives of orthopaedic and trauma surgery 134 (2014): 1073-1081.
  11. ↑ 11.0 11.1 Van Sterkenburg MN, Muller B, Maas M, Sierevelt IN, van Dijk CN. Appearance of the weight-bearing lateral radiograph in retrocalcaneal bursitis. Acta Orthop. 2010 Jun. 81(3):387-90.
  12. ↑ Ricci, Vincenzo, et al. "Superficial retrocalcaneal bursae and nerves: from anatomy to ultrasound‐guided procedures." Clinical Anatomy 38.1 (2025): 29-34.
  13. ↑ 13.0 13.1 Shah, Mohammad Taufik Bin Mohamed, and Bak Siew Steven Wong. "Clinics in diagnostic imaging (170)." Singapore Medical Journal 57.9 (2016): 517.
  14. ↑ Olivieri, I., et al. "Retrocalcaneal bursitis in spondyloarthropathy: assessment by ultrasonography and magnetic resonance imaging." The journal of Rheumatology 25.7 (1998): 1352-1357.
  15. ↑ Fessell, David P., et al. "US of the ankle: technique, anatomy, and diagnosis of pathologic conditions." Radiographics 18.2 (1998): 325-340.
  16. ↑ Bottger, Bradford A., et al. "MR imaging of the normal and abnormal retrocalcaneal bursae." AJR. American journal of roentgenology 170.5 (1998): 1239-1241.
  17. ↑ Wong, Gloria NL, and Tien Jin Tan. "MR imaging as a problem solving tool in posterior ankle pain: a review." European Journal of Radiology 85.12 (2016): 2238-2256.
  18. ↑ Checa, Angel, William Chun, and Ramesh Pappu. "Ultrasound-guided diagnostic and therapeutic approach to Retrocalcaneal Bursitis." The Journal of Rheumatology 38.2 (2011): 391-392.
  19. ↑ Aliyev, R., Q. Muslimov, and G. Geiger. "Results of conservative treatment of achillodynia with application micro-current therapy." Georgian Med. News. Oct 187 (2010): 35-42.
  20. ↑ Barske, Heather L., and Judith Baumhauer. "Quality of research and level of evidence in foot and ankle publications." Foot & Ankle International 33.1 (2012): 1-6.
  21. ↑ Pękala, P. A., et al. "The Achilles tendon and the retrocalcaneal bursa: An anatomical and radiological study." Bone & joint research 6.7 (2017): 446-451.
  22. ↑ Turmo-Garuz, A., et al. "Can local corticosteroid injection in the retrocalcaneal bursa lead to rupture of the Achilles tendon and the medial head of the gastrocnemius muscle?." Musculoskeletal surgery 98.2 (2014): 121-126.
  23. ↑ Goldberg-Stein, Shlomit, et al. "Fluoroscopically guided retrocalcaneal bursa steroid injection: description of the technique and pilot study of short-term patient outcomes." Skeletal radiology 45.8 (2016): 1107-1112.
  24. ↑ 24.0 24.1 24.2 Boone, Sean L., et al. "Safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection for the treatment of retrocalcaneal bursitis." Skeletal Radiology 50.12 (2021): 2471-2482.
  25. ↑ Cooper, Minton Truitt. "Common painful foot and ankle conditions: a review." Jama 330.23 (2023): 2285-2294.
  26. ↑ Herring, Stanley A., et al. "Initial assessment and management of select musculoskeletal injuries: a team physician consensus statement." Current Sports Medicine Reports 23.3 (2024): 86-104.
  27. ↑ Image courtesy of orthoinfo.aaos.org
  28. ↑ Ortmann, Fred W., and Angus M. McBryde. "Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis." Foot & ankle international 28.2 (2007): 149-153.
Created by:
John Kiel on 26 June 2019 19:42:55
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18 December 2025 00:48:42
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