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A bursa is a fluid-filled sac that acts as a cushion to reduce friction between tissues of the body such as tendons and bones. When a bursa becomes inflamed, the condition is known as bursitis.
At the back of the heel between the Achilles tendon and posterior superior aspect of the calcaneum (heel bone) is located the retrocalcaneal bursa. This acts as a cushion between the Achilles tendon and adjacent calcaneum. The bursa reduces friction by allowing the Achilles tendon to glide over the edge of the calcaneum.
MRI of the heel in a patient with retrocalcaneal bursitis
Irritation and inflammation of the bursa results in retrocalcaneal bursitis. This is one of several causes of heel pain as shown below.
An MRI of the hindfoot and the common causes of heel pain – note the site of retrocalcaneal bursitis
Retrocalcaneal bursitis is most often caused by excessive friction as a result of repetitive trauma or overuse. We define overuse as injury to a part of the body due to repetitive mechnical loading, not due to a fault in the body tissue, but rather excessive or rapid increase in loading beyond the bodies ability to repair in a given timeframe.
Retrocalcaneal bursitis can be caused or exacerbated by:
Some people have an anatomical variation in their heel bone which predisposes them to problems with the Achilles tendon and the retrocalcaneal bursa.
The normal calcaneum is typically rounded at the top (superior margin). In some patients there is a prominent spur which narrows the space between the back of the heel bone and the front of the Achilles tendon. Activities that involve moving the foot in a downward position narrow the space between the heel bone and tendon resulting in increased rubbing and friction.
The presence of a Haglund’s deformity narrows this space considerbly thereby casuing or exacerbating problems such as retrocalcaneal bursitis.
A – Normal x-ray of the foot and ankle , B – X-ray demonstrating a Haglund’s deformity – note reduced space between Achilles tendon (dotted line) and back of the heel bone (solid white line) Haglund deformity in shaded red area in enlarged box
Pain in the posterior heel area is the commonest symptom. The pain may be worse after activity and exercise for example at night or the next morning. Eventually the pain will become more severe and limit exercise and activity. Some patients may find themselves limping.
Patients with bilateral symptoms should be investigated for an underlying inflammatory arthritis.
Typically patients have tenderness on palpation in a focal areas just above the calcaneum and infront of the Achilles tendon.
Patients also typically have tight calf muscles. There may or may not be associated Achilles tendon problems.
Swelling may be a feature of this condition.
Usually the diagnosis can be made, based on the history and clinical examination.
Radiographs (x-rays) are a useful first line investigation to rule out any other problems in the hindfoot and to confirm the presence of a Haglund’s deformity.
Ultrasound is used to confirm the diagnosis, and to see if there is anything else that may be causing the symptoms. At the same time an ultrasound guided injection can be performed, see below.
Occasionally MRI is useful in confirming the diagnosis and ruling out other causes of heel pain. It provides excellent high definition static images.
It is requested in patients who have failed to respond to conservative treatment and are being prepped and worked up for surgery.
Most patients heal very well and quickly with proper management.
Patients with retrocalcaneal bursitis who ignore their symptoms or who are mismanaged may develop chronic swelling and pain.
Some patients despite non operative treatment continue to have symptoms.
Non-operative management for retrocalcaneal bursitis aims at relieving pain and return to full activity including sports whenever possible.
It should always be the first line of treatment. Options include:
A short period of rest or reduction from sports and exercise that bring on symptoms. Fitness can be maintained by other non impact activities such as swimming and pool based exercises.
Minimising pressure on the heel will ease the pain. Shoes with soft padding at the heel, using sandals and avoid heel straps. Avoid or minimise the time spent wearing high heels if not already doing so. Wearing shoes with soft heel counters.
Application of ice for regular periods during the acute stage of bursitis may alleviate painful symptoms.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with superficial calcaneal bursitis.
The use of paracetamol and other painkillers to help reduce pain levels.
Physiotherapy is important with this condition to hasten the healing process, ensure an optimal outcome and prevent recurrence.
Treatment may comprise:
The following exercises are recommended as part of any physiotherapy program:
Patients with resistent symptoms depsite treatment may benefit from a period of immobilisation in a cast or walking boot.
Patients who fail to benefit from conservative (non-operative) management and have MRI confirmation of active inflammation in the retrocalcaneal bursa will be offered surgical debridement as discussed below.
Steroid injections into the inflamed retrocalcaneal bursa under ultrasound guidance is sometimes indicated, especially when trying to avoid surgery. However it is not without risk, as there is a small risk of Achilles tendon rupture and damage to the tendon. The injection can also cause a flare in symptoms with increased pain for several days after the injection. Patients should be aware of this.
Surgical management is reserved for patients who have failed to respond to non operative treatment.
Patients should understand that the decision to undergo surgery should not be taken lightly.
Any intervention is considered in a step wise manner, with the least invasive procedure carried out first. A number of surgical options are available.
Patients with retrocalcaneal bursitis often have an associated Achilles tendon problem. For details regarding surgery for the various Achilles tendon problems please click here.
Removing the posterior superior prominence of the heel bone will remove pressure on the Achilles tendon and the bursa. This can be done through a small open incision or via an arthroscope (keyhole/minimally invasive surgery).
This can be done again as an open or arthroscopic technique and involves removing all of the inflamed bursa.
It should be borne in mind that complications can result from a condition with or without surgery.
Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.
Please read the information regarding what to expect post surgery on this website.
Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
Almost all surgical procedures for retrocalcaneal bursitis will be undertaken as a day case.
You will have a backslab applied post operatively for two weeks to allow the wounds and soft tissues to heal.
A picture of a backslab
Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.
You will be non weight bearing for 2 weeks post operatively. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time.
A picture demonstrating high elevation
Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.
To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.
To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.
You will be reviewed at the clinic and your backslab and dressings removed. Your wound will be checked and if completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling. You will require to wear a special walking boot for another 2 to 4 weeks when weight bearing. Please limit your activities within limits of pain and swelling.
Gentle range of motion exercises out of the boot can also commence at this stage.
Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 4 to 6 weeks before any driving is advisable.
You may be referred at this stage for physiotherapy for early rehabilitation and Achilles tendon strengthening exercises.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.
You will be able to start wearing normal footwear (swelling permitted). You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
X-rays may be arranged at this stage.
Final clinical examination. Discharge if satisfactory.
This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.
For removal of the bony prominence and the bursa expect the operation to last 45 to 60 minutes.
Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 4 to 6 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
Patients with retrocalcaneal bursitis may be expected to return to sports without restrictions once they have:
Excellent pain relief and return to sports by 3 to 6 months in approximately 90% of patients.
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