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Bursae are fluid filled sacs providing shock absorption and lubrication between joints and tendons around the body. The retrocalcaneal bursa lies between the achilles tendon and the calcaneus (heel bone). Inflammation due to load or compressive stress can cause swelling, tenderness and pain at the back of the heel.

Signs & Symptoms

  • Pain: Discomfort in the back of the heel, particularly when walking, running, or pressing the area.
  • Swelling: Noticeable swelling around the heel, just in front of the Achilles tendon.
  • Tenderness: The area is often tender to the touch, especially when pinched from both sides.
  • Stiffness: Limited ankle movement, especially after periods of rest.
  • Redness and Warmth: The skin overlying the bursa may appear red and feel warm if inflammation is severe.
  • Aggravation with Activity: Activities involving the Achilles tendon, such as running or jumping, tend to worsen symptoms.

Causes and Contributing Factors

  1. Overuse Injuries: Repeated stress on the Achilles tendon from running, jumping, or other high-impact activities can irritate the bursa.
  2. Improper Footwear: Tight or poorly fitting shoes that press against the back of the heel can increase pressure on the bursa.
  3. Biomechanical Issues: Conditions such as flat feet, high arches, or abnormal gait can place extra stress on the heel and Achilles tendon.
  4. Systemic Conditions: Inflammatory conditions like rheumatoid arthritis or gout can predispose individuals to bursitis.
  5. Direct Trauma: A direct blow to the back of the heel can cause irritation and inflammation of the bursa.
  6. Age-Related Changes: Reduced elasticity of the Achilles tendon and surrounding tissues in older adults can increase susceptibility.

Prognosis

With appropriate treatment, most individuals recover fully from retrocalcaneal bursitis. Recovery time depends on the severity of the condition and adherence to management strategies. Mild cases whereby there is minimal swelling and pain is short-lasting, may resolve in a few weeks. More severe presentations and chronic cases might take several months as the pain is persistent, noticeably swollen and difficulty performing activities of daily living. Chronic or untreated bursitis can lead to complications, such as persistent pain or Achilles tendon issues.

Treatment

Physiotherapy and Rehabilitation

  1. Activity Modification:
    Reducing or avoiding activities that aggravate symptoms is essential. A gradual return to activity under the guidance of a physiotherapist can help prevent recurrence.
  2. Stretching Exercises:
    • Achilles Tendon Stretches: Stretching the Achilles tendon and calf muscles can relieve tension on the bursa.
    • Heel Cord Stretch: Place your hands against a wall, one foot in front of the other, and gently push the back heel towards the floor.
  3. Strengthening Exercises:
    • Calf Raises: Strengthening the calf muscles can improve support for the Achilles tendon.
    • Eccentric Heel Drops: Slowly lowering the heel over the edge of a step can help improve tendon and muscle resilience.
  4. Manual Therapy:
    Techniques such as soft tissue mobilisation can help reduce muscle tension and improve circulation around the bursa.
  5. Orthotics and Footwear Advice:
    Custom orthotics or heel lifts can reduce pressure on the bursa. A physiotherapist can also recommend appropriate footwear with adequate cushioning and heel support.
  6. Taping or Bracing:
    Using supportive taping techniques or braces can reduce strain on the Achilles tendon and heel.

Medical Management

  1. Anti-inflammatory Medications:
    Non-steroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and inflammation.
  2. Corticosteroid Injections:
    In cases of severe inflammation, a corticosteroid injection may be administered. However, caution is needed to avoid complications like achilles tendon rupture.

Additional Therapies

  1. Icing:
    Applying ice packs for 15–20 minutes several times a day can reduce inflammation and pain.
  2. Ultrasound Therapy:
    This physiotherapy modality can help decrease inflammation and promote healing.

Surgical Intervention

In rare cases, surgery may be required to remove the inflamed bursa or address underlying structural issues. Surgery is typically considered only after conservative treatments fail.

Information is provided for education purposes only. Always consult your physiotherapist or other health professional.

References:

  1. Pękala PA, Henry BM, Pękala JR, Piska K, Tomaszewski KA. The Achilles tendon and the retrocalcaneal bursa. Bone Joint Res. 2017;6(7):446-451. doi:10.1302/2046-3758.67.BJR-2016-0340.R1