Pain at the posterior heel or posterior ankle is most commonly caused by pathology at the posterior calcaneus, the Achilles (calcaneal) tendon, or the associated bursae. The following bursae are
located just superior to the insertion of the Achilles tendon. Subtendinous calcaneal bursa. This bursa (also called the retrocalcaneal bursa), situated anterior (deep) to the Achilles tendon, is
located between the Achilles tendon and the calcaneus. Subcutaneous calcaneal bursa. Also called the Achilles bursa, it is found posterior (superficial) to the Achilles tendon, lying between the skin
and the posterior aspect of the distal Achilles tendon. Inflammation of one or both of these bursae can cause pain in the posterior heel and ankle regions.
There are several factors which can lead to a person developing retrocalcaneal bursitis. In athletes, especially runners, overtraining, sudden excessive increase in running mileage may lead to
retrocalcaneal bursitis. Tight or ill-fitting shoes can be another causative factor as they can produce excessive pressure at the back of the heel due to restrictive heel counter. A person with an
excessively prominent posterosuperior aspect of the heel bone (Haglund deformity) may also have a higher predisposition to retrocalcaneal bursitis. In such individuals, pain would be reproduced when
the ankle goes into dorsiflexion.
When the bursa becomes inflamed after an injury, symptoms usually develop suddenly. When the bursa develops without an injury, symptoms may develop gradually. With both posterior and anterior
Achilles tendon bursitis, symptoms usually include swelling and warmth at the back of the heel. A minimally red, swollen, tender spot develops on the back of the heel. When the inflamed bursa
enlarges, it appears as a red lump under the skin of the heel and causes pain at and above the heel. If posterior Achilles tendon bursitis becomes chronic, the swelling may become hard, fluid-filled,
and red or flesh-colored.
On physical examination, patients have tenderness at the site of the inflamed bursa. If the bursa is superficial, physical examination findings are significant for localized tenderness, warmth,
edema, and erythema of the skin. Reduced active range of motion with preserved passive range of motion is suggestive of bursitis, but the differential diagnosis includes tendinitis and muscle injury.
A decrease in both active and passive range of motion is more suggestive of other musculoskeletal disorders. In patients with chronic bursitis, the affected limb may show disuse atrophy and weakness.
Tendons may also be weakened and tender.
Non Surgical Treatment
In addition to R.I.C.E., there are a number of other treatments to reduce swelling and any associated pain or discomfort due to heel bursitis. Orthotics or change of footwear. Wearing an orthotic
device such as a heel insert can encourage better mechanics in the foot and reduce irritation of the retrocalcaneal bursa. Some people do not need special orthotics but simply need to stop wearing
shoes with rigid heel and ankle construction and instead wear more supportive, comfortable shoes. Shoes with an "Achilles notch," a groove in the collar at the back of the shoe to protect the
Achilles tendon, can be particularly helpful. (Almost all running shoes are designed with an Achilles notch.) Stretching and physical therapy. Stretching the Achilles tendon often helps alleviate
pain. Once the pain is resolved it is important for the patient to continue a regular stretching program. Regular stretching reduces the chance of recurrence.
You may be able to prevent bursitis from happening or coming back. Continue your home treatment with rest, ice, pain relievers, and gentle exercises. When you are ready to try the activity that
caused the pain, start slowly and do it for short periods or at a slower speed. Warm up before and stretch after the activity. Increase your activity slowly, and stop if it hurts. Use ice afterward
to prevent pain and swelling. Change the way you do activities with repeated movements that may strain your muscles or joints. For example if using a certain tool has caused bursitis, start switching
hands or change the grip size of your tool. If sitting for long periods has caused bursitis, get up and walk around every hour. If a certain sport is causing bursitis, consider taking lessons to
learn proper techniques. Have an expert check your equipment to make sure it's well suited to your size, strength, and ability. If certain activities at work may be causing bursitis, talk to your
human resources department about other ways of doing your job, equipment changes, or other job assignments. Protect your joints from pressure. Cushion knees or elbows on hard surfaces, and wear shoes
that fit you well and have good support.