Retrocalcaneal Bursitis: Causes, Symptoms and Care

Heel pain is one of the most frequent musculoskeletal problems, capable of severely limiting both normal daily activities and sports practice. Among the various pathologies that can affect this anatomical region, Retrocalcaneal Bursitis represents a particularly insidious and painful inflammatory condition. It is an inflammation affecting the synovial bursa located in the space between the anterior surface of the Achilles tendon and the posterior tuberosity of the calcaneal bone. Understanding the anatomy, biomechanics, and triggering causes of this disorder is fundamental for setting up an effective therapeutic and rehabilitation pathway, preventing the condition from becoming chronic and disabling.

What is Retrocalcaneal Bursitis: Anatomy and Pathophysiology

To understand the nature of the pathology, it is necessary to take a step back and analyze the anatomy of the hindfoot. Synovial bursae are small sacs filled with viscous fluid (synovial fluid) that act as cushioning pads within the human body. Their main purpose is to reduce friction and rubbing between different structures, such as bones, tendons and muscles, during movement.

For a complete overview, see the comprehensive guide to foot and ankle pain.

In the heel region, there are two main bursae:

• The retrocalcaneal bursa (or deep): Located between the Achilles tendon and the calcaneal bone. This is the structure involved in the pathology under examination.
• The subcutaneous calcaneal bursa (or superficial): Located between the skin and the posterior portion of the Achilles tendon.

During the gait cycle, running, or jumping, the Achilles tendon is subjected to immense traction forces. The retrocalcaneal bursa protects the tendon from rubbing against the calcaneal bone. However, when this area is subjected to repetitive mechanical stress, microtrauma, or abnormal compressions, the bursa reacts by becoming inflamed. The bursa walls thicken, synovial fluid production increases dramatically, and the sac swells, creating painful pressure within an already very restricted anatomical space. This pathophysiological process leads to significant functional limitation of the ankle and foot.

Causes and Risk Factors

Retrocalcaneal bursitis is inflammation of the fluid-filled sac between the Achilles tendon and heel bone, causing pain and swelling in the posterior heel during activity. The onset of this inflammatory condition is rarely linked to a single acute traumatic event. More frequently, it is the result of a combination of biomechanical, environmental, and lifestyle-related factors. The main causes and risk factors include:

• Functional Overload (Overuse): This is the most common cause, especially in athletes. Activities that require repeated calf contractions, such as running (particularly uphill), jumping, dancing, or tennis, subject the bursa to continuous stress. A sudden increase in training volume, intensity, or frequency is a classic triggering factor.
• Anatomical and Biomechanical Abnormalities:

• Haglund’s Syndrome (or Haglund’s Deformity): This consists of an abnormal bony prominence on the postero-superior part of the calcaneus. This bony projection acts as a spur that, during dorsiflexion of the ankle, mechanically compresses and irritates the retrocalcaneal bursa and the Achilles tendon.

• Foot hyperpronation: A foot that excessively collapses inward during gait alters the traction axis of the Achilles tendon, creating abnormal shear forces that irritate the bursa.

• Cavus foot: An excessively rigid and high plantar arch reduces the foot’s shock absorption capacity, transferring greater impact forces to the heel.
• Inadequate Footwear: Using shoes with a heel counter (the part of the shoe that wraps around the heel) that is too rigid, tight, or worn can exert direct pressure on the area, triggering inflammation. Even sudden switching from high-heeled shoes to flat shoes (or vice versa) alters tension on the tendon and bursa.
• Muscle Retraction and Stiffness: Excessively tight and inflexible calf musculature (gastrocnemius and soleus muscles) maintains the Achilles tendon in a state of constant traction, squeezing the bursa against the calcaneal bone even at rest.
• Systemic Factors: Although less frequent, some systemic pathologies of rheumatological or metabolic nature, such as rheumatoid arthritis, gout, or ankylosing spondyloarthritis, can predispose to inflammation of synovial bursae throughout the body, including the retrocalcaneal bursa.

Symptoms and Clinical Signs

The symptom profile is generally very clear, although it may vary in intensity depending on the phase (acute or chronic) of inflammation. The main symptoms include:

• Localized pain: The cardinal symptom is acute and sharp pain, or dull and throbbing, localized exactly in the posterior part of the heel, deeply, just in front of the Achilles tendon insertion.
• Pain on palpation: Applying pincer-like pressure with two fingers (thumb and index) on the sides of the Achilles tendon, just above its insertion on the calcaneus, elicits acute pain. This is a distinctive clinical sign.
• Swelling and Edema: The area appears visibly swollen. To touch, one can perceive a spongy or fluctuating consistency on the sides of the tendon, due to fluid accumulation inside the bursa.
• Redness and Heat: In the most acute phases, the overlying skin may appear erythematous (reddened) and warm to touch, clear signs of the ongoing inflammatory process.
• Morning stiffness: The patient often reports severe stiffness and pain with the first steps after getting out of bed in the morning, or after a prolonged period of inactivity (for example, getting up from a chair after working at the computer). The pain tends to decrease slightly after the first few minutes of walking, then worsen again if activity is prolonged.
• Pain under stress: Pain typically worsens walking uphill, climbing stairs, running, or standing on tiptoes. All these actions require strong calf contraction that squeezes the inflamed bursa.
• Limping: In severe cases, pain forces the patient to alter their gait pattern (antalgic limp) to avoid loading weight on the affected heel.

Diagnosis: How to Recognize Retrocalcaneal Bursitis

An accurate and timely diagnosis is the essential prerequisite for successful treatment. The diagnostic process is primarily based on clinical examination, supported by instrumental investigations to confirm the suspicion and, especially, to rule out other pathologies with similar symptoms (differential diagnosis).

The clinical examination includes a thorough anamnesis (patient’s clinical history, sports habits, footwear used) and objective examination. The professional will evaluate foot posture, plantar arch, ankle mobility, and calf flexibility. Specific palpatory tests will be performed to localize the exact origin of pain.

Differential diagnosis is crucial. It is necessary to distinguish this pathology from:

• Insertional Achilles tendinopathy: Often coexists with bursitis, but requires partially different rehabilitation approaches.
• Subcutaneous bursitis: More superficial and visible, often caused only by shoe friction.
• Plantar fasciitis: Pain is typically localized under the heel, not behind it.
• Calcaneal stress fracture: Suspectable in case of drastic increases in training loads, requires specific radiological investigations.

Regarding diagnostic imaging:

• Musculoskeletal ultrasound: This is the first-line examination, considered the “gold standard” for this pathology. It is dynamic, non-invasive, and allows clear visualization of bursa wall thickening, any liquid effusion (hyperemia on color doppler), and the state of the Achilles tendon.
• X-ray (RX): Does not show soft tissues like the bursa, but is fundamental for evaluating the bony component. It allows identification of the presence of Haglund’s deformity (bone spur) or intratendinous calcifications.
• Magnetic Resonance Imaging (MRI): Reserved for more complex cases, resistant to conservative treatment, or when more serious associated lesions of the tendon or bone are suspected.

Conservative and Physiotherapy Treatment

The treatment of choice is conservative and physiotherapeutic. The approach must be multimodal and progressive, adapting to the clinical phase the patient is in. The goal is not only to extinguish inflammation, but to correct biomechanical causes to prevent recurrences.

Acute Phase: Pain and Inflammation Management

In this phase, which generally lasts from 3 to 7 days, the primary objective is to reduce painful symptoms and intrabursal effusion.

• Relative Rest: Immediate suspension of sports or work activities that evoke pain (running, jumping). Complete bed rest is not indicated, but load modulation is necessary.
• Cryotherapy (Ice): Ice applications for 15-20 minutes, 3-4 times daily, to exploit the vasoconstrictor and analgesic effect.
• Heel Lift (Heel Pad): Temporary insertion of a small lift (1-1.5 cm) in both shoes reduces Achilles tendon tension and, consequently, mechanical pressure on the retrocalcaneal bursa.
• Instrumental Physical Therapies: In this phase, high-tech therapies are extremely useful for accelerating the anti-inflammatory process. High-power Laser Therapy (Nd:YAG) has excellent anti-edematous and biostimulating effects. Tecar Therapy, used in athermic mode (without heat), promotes lymphatic drainage of the effusion.
• Pharmacological Therapy: Under strict medical advice, the use of NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) topically or systemically can help control the acute phase.

Sub-acute Phase: Mobility and Flexibility Recovery

Once acute pain is reduced, attention shifts to restoring correct hindfoot biomechanics.

• Manual Therapy and Deep Transverse Massage: Myofascial release techniques targeted at calf muscles (gastrocnemius and soleus) to reduce tensions that affect the tendon.
• Joint Mobilization: Restoration of correct gliding (joint play) of the tibiotalar and subtalar joints, often blocked due to pain and antalgic posture.
• Focused Shock Waves (ESWT): If the condition tends to become chronic or in the presence of Haglund’s syndrome, shock waves represent excellent therapy. They stimulate neoangiogenesis (formation of new blood vessels), break up any micro-calcifications, and trigger a powerful tissue regenerative process.

Strengthening Phase and Return to Activity

The final phase involves reconditioning the structure to withstand sports or work loads again.

• Load Management: Gradual reintroduction of activities. The tendon and bursa must be gradually reaccustomed to mechanical stress, constantly monitoring pain response (which should never exceed a score of 3 on a scale from 0 to 10 during or after exercise).
• Therapeutic Exercise: This is the pillar of this phase (detailed in the next section).

Recommended Therapeutic Exercises

Therapeutic exercise must be personalized and supervised. A common mistake is performing exercises suitable for mid-tendon Achilles tendinopathy on an insertional problem like bursitis, worsening the situation.

Stretching Exercises

The purpose is to lengthen the posterior muscle chain to reduce traction on the calcaneus.

• Gastrocnemius Stretching: Standing facing a wall, place hands against it. Move the leg to be stretched back, keeping the knee completely straight and heel firmly on the ground. Bend the knee of the front leg until feeling moderate tension in the posterior calf. Hold for 30-45 seconds, repeat 3 times.
• Soleus Stretching: Same position as above, but this time slightly bend the knee of the back leg as well, always keeping the heel on the ground. The tension will shift lower, toward the Achilles tendon. Hold 30-45 seconds, 3 sets.

Eccentric and Isometric Strengthening Exercises

Strengthening is fundamental for improving the load capacity of the muscle-tendon complex.

• Crucial Clinical Attention: Unlike the classic Alfredson protocol for tendinopathies, in case of retrocalcaneal bursitis, heel lowering exercises (eccentric) should NOT be performed on a step going below the parallel level. Going below the step level causes maximum dorsiflexion that violently squeezes the bursa against the bone.
• Heel Drops on ground (Modified eccentric): Standing on the floor (not on a step). Rise on tiptoes using both legs. Lift the healthy leg and slowly descend (in 3-4 seconds) until returning the affected leg’s heel to contact with the floor. Repeat 3 sets of 10-15 repetitions.
• Isometric: In the initial phase, if movement causes pain, isometric holds are performed. Rise on tiptoes (on both legs) and maintain the maximum position for 30-45 seconds. Repeat 4-5 times. This has a strong analgesic effect on the tendon.

Proprioception Exercises

Improving ankle neuromotor control helps prevent distortional microtrauma and stabilizes the foot during gait.

• Single-leg balance: Balance on one leg (the affected one) for 30-60 seconds. To increase difficulty, close eyes or perform the exercise on an unstable surface (proprioceptive cushion or Freeman board).

Prevention and Lifestyle Modifications

Preventing the onset or recurrence of this pathology requires attention to various aspects of daily life and training:

• Footwear Choice: Avoid shoes with rigid heel counters that rub against the heel. Prefer footwear with a soft or slightly hollowed heel cup. For runners, evaluate the shoe drop (the difference between heel and forefoot): too low a drop (minimalist shoes) increases Achilles tendon work and stress on the bursa.
• Orthotic Insoles: In case of severe hyperpronation or cavus foot, a baropodometric evaluation and use of custom insoles can correct the biomechanical axis, reducing torsional stress on the hindfoot.
• Training Progression: Respect the “10% rule”: never increase weekly training volume or intensity by more than 10% compared to the previous week.
• Warm-up and Cool-down: Always dedicate adequate time to dynamic warm-up before sports activity and static stretching at the end.
• Body Weight Control: Being overweight exponentially increases mechanical load on foot structures with each step.

Frequently Asked Questions (FAQ)

Frequently Asked Questions

How long does it take to recover from retrocalcaneal bursitis?

Recovery time for retrocalcaneal bursitis varies significantly among individuals, depending on the severity of the inflammation and adherence to the treatment plan. With timely and targeted intervention, including physical therapy, significant improvement can often be observed within several weeks to a few months.

Can activities like running or sports be continued during treatment?

During the acute phase of retrocalcaneal bursitis, it is generally recommended to temporarily modify or cease activities that exacerbate pain, such as running or high-impact sports. A physical therapist can guide a gradual return to activity, ensuring proper load management to prevent re-injury and promote healing.

What is the difference between retrocalcaneal bursitis and Achilles tendinitis?

Retrocalcaneal bursitis involves inflammation of the bursa located between the Achilles tendon and the heel bone, causing pain at the back of the heel. In contrast, Achilles tendinitis refers to inflammation or degeneration of the Achilles tendon itself, which is the large tendon connecting calf muscles to the heel. While both conditions cause heel pain, their distinct anatomical locations require different diagnostic approaches and targeted treatments.

Are cortisone injections recommended for this problem?

Cortisone injections may be considered in some cases of retrocalcaneal bursitis to reduce severe pain and inflammation, particularly when conservative treatments have not provided sufficient relief. However, their use is typically reserved for specific situations due to potential risks and the importance of addressing underlying biomechanical causes through physical therapy.

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