Pain at the posterior heel or ankle is most commonly caused by pathology at either the posterior calcaneus (at the calcaneal insertion site of the Achilles tendon) or at its associated bursae. Two bursae are located just superior to the insertion of the Achilles (calcaneal) tendon. Anterior or deep to the tendon is the retrocalcaneal (subtendinous) bursa, which is located between the Achilles tendon and the calcaneus. Posterior or superficial to the Achilles tendon is the subcutaneous calcaneal bursa, also called the Achilles bursa. This bursa is located between the skin and posterior aspect of the distal Achilles tendon. Inflammation of either or both of these bursa can cause pain at the posterior heel and ankle region.1,2,3,4,5
For excellent patient education resources, visit eMedicine’s Foot, Ankle, Knee, and Hip Center. Also, see eMedicine’s patient education articles Bursitis and Tendinitis.
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Achilles Tendon Injuries and Tendonitis
Retrocalcaneal bursitis is fairly common.
Inflammation of the calcaneal bursae is most commonly caused by repetitive (cumulative) trauma or overuse, and the condition is aggravated by pressure, such as when athletes wear tight-fitting shoes. Retrocalcaneal bursitis may also be associated with conditions such as gout, rheumatoid arthritis, and seronegative spondyloarthropathies. In some cases, retrocalcaneal bursitis may be caused by bursal impingement between the Achilles tendon and an excessively prominent posterosuperior aspect of the calcaneus (Haglund deformity). In Haglund disease, impingement occurs during ankle dorsiflexion.1,2,3,4,5
In retrocalcaneal bursitis, posterior heel pain is the primary presenting chief complaint, and patients may report limping.
Some individuals may also present with an obvious or noticeable swelling (eg, a “pump bump,” presumably named in association with the wearing of high-heeled shoes or pumps).
Ask the patient about footwear, such as high-heeled shoes or tight-fitting athletic shoes.
Specifically ask about any recent change in footwear (eg, new athletic shoes, transition from flat shoes to high heels or from road running shoes to racing flats or to cleats).
Retrocalcaneal bursitis may be unilateral or bilateral.
Individuals who are accustomed to wearing high-heeled shoes on a long-term basis may experience increased stretch and irritation of the Achilles tendon and its associated bursae when switching to flat shoes.
Ask about the specifics of the patient’s activity levels (eg, include the distances runners travel).
Symptoms often worsen when the athlete is first beginning an activity after resting.
Ask about previously known or suspected underlying rheumatologic conditions (eg, gout, rheumatoid arthritis, seronegative spondyloarthropathies).
Swelling and redness of the posterior heel may be clearly apparent in patients with retrocalcaneal bursitis (eg, pump bump).
The inflamed area may be slightly warm and tender to palpation.
Careful examination can help the clinician distinguish whether the inflammation is posterior (superficial) to the Achilles tendon (within the subcutaneous bursa) or anterior (deep) to the Achilles tendon (within the subtendinous bursa).
Tenderness caused by isolated subtendinous bursitis can best be isolated by palpation just anterior to both the medial and lateral edge of the distal Achilles tendon.
Tenderness due to insertional Achilles tendinitis is located slightly more distal, where the Achilles tendon inserts onto the posterior calcaneus.
Plantar fasciitis causes tenderness along the posterior aspect of the sole, but patients should not experience tenderness with palpation of the posterior heel or ankle.
A patient with avulsion or rupture of the Achilles tendon demonstrates a palpable defect in the tendon and a positive Thompson test (ie, squeezing the calf fails to cause plantar flexion due to the loss of Achilles tendon continuity).
Overtraining in an athlete, such as with excessive increases in running mileage may lead to retrocalcaneal bursitis.
Tight or poorly fitting shoes that produce excessive pressure at the posterior heel and ankle due to a restrictive heel counter are another cause of retrocalcaneal bursitis.
Haglund deformity, which causes impingement between the increased posterosuperior calcaneal prominence and Achilles tendon during dorsiflexion, may lead to retrocalcaneal bursitis.