Retrocalcaneal bursitis

Anatomy and function

Bursae are small, fluid-filled sliding cushions. The retrocalcaneal bursa lies deep between the anterior edge of the Achilles tendon and the upper, posterior portion of the heel bone. It reduces friction during movements of the ankle and Achilles tendon, especially during dorsiflexion (tightening the foot).

It is important to differentiate it from the subcutaneous bursa above the Achilles tendon (subachillary bursitis). This lies more superficially under the skin and is more often irritated by direct pressure from behind (firm heel shaft, hard heel cap). The retrocalcaneal bursa, on the other hand, is more likely to be stressed by “pinching” between the heel bone and Achilles tendon as well as bony protrusions (Haglund).

• Location: between calcaneus and Achilles tendon (deep)
• Function: Reducing friction and protecting the tendon
• Neighboring structures: Achilles tendon attachment, heel bone, subcutaneous bursa (superficial)

Causes and risk factors

Retrocalcaneal bursitis usually arises from an interaction of mechanical overload and anatomical factors. Uphill runs, sprints, sudden increases in training, or shoes with hard heel cups increase pressure on the deep bursa. Restricted calf muscle length also promotes entrapment of the bursa in dorsiflexion.

• Haglund configuration (bony prominence at upper posterior calcaneus)
• Inappropriate footwear (hard heel cap, oppressive heel shaft)
• Rapid increase in training, running uphill, intensive jumping
• Shortened calf muscles (gastrocnemius/soleus), limited dorsiflexion
• Misalignments/movement patterns (e.g. overpronation)
• Rheumatic underlying diseases, gout or, rarely, infections
• Soft tissue irritation after twisting or bruising

Superficial subachillary bursitis has similar triggers, but is usually caused by external pressure. The bony shape of the heel bone often plays a role in retrocalcaneal bursitis.

Typical symptoms

The symptoms appear locally on the upper back of the heel bone, just in front of the Achilles tendon insertion. Pain increases with dorsiflexion, rolling, in tight shoes or during exercise. Morning start-up pain and tender swelling are common.

• Pressure pain deep in front of the Achilles tendon, often palpable
• Swelling/warmth in the back of the upper heel bone
• Pain during dorsiflexion and when pushing off while walking/running
• Discomfort in shoes with hard heel caps
• Sometimes a feeling of friction or noticeable “pinching”

Differential diagnoses

Not all posterior heel pain is retrocalcaneal bursitis. A careful clarification prevents incorrect treatment and unnecessary downtime.

• Subachillary bursitis (superficial bursitis under the skin)
• Insertional Achilles tendinopathy/partial tear
• Haglund configuration with mechanical irritation
• Reactive arthritis, gout (crystal-induced bursitis)
• Rare: infection of the bursa
• Stress reaction/stress fracture of the calcaneus (less common)

Diagnostics: Clinical and imaging

Diagnosis is based on history, clinical examination and, if necessary, imaging. Decisive indications are localized pressure pain deep in front of the Achilles tendon and pain provocation during dorsiflexion.

• Inspection: Swelling, redness, shoe pressure points
• Palpation: tender, deep region in front of the Achilles tendon
• Function: Pain during dorsiflexion/repulsion; Calf length test
• Shoe analysis: heel counter, fit, wear patterns

Sonography shows an enlarged, fluid-filled bursa, hyperemia on power Doppler, and relationship to the Achilles tendon. Radiographs may document a Haglund configuration or bony irregularities at the posterior calcaneus. An MRI is useful for unclear cases, differential diagnoses or surgical planning.

Laboratory tests may be considered if rheumatic or infectious causes are suspected. In the event of fever, severe redness/overheating or general symptoms, rapid medical evaluation is necessary.

Conservative therapy (first line)

Most cases can be managed conservatively. The aim is to reduce mechanical stimuli, dampen inflammation and build resilient structures - without additional compression of the Achilles tendon.

• Load control: temporary reduction/adjustment of running and jumping load, especially uphill
• Optimize shoes: soft/rounded heel cap, sufficient heel space, if necessary change to sports shoes with a moderate drop
• Temporary heel lift to relieve dorsiflexion compression; Use for a short time and taper off later
• cooling in acute phases; Topical NSAID gels can relieve symptoms (pay attention to tolerability)
• Physiotherapy: Mobility of the front line of the ankle, gentle calf stretches without painful compression, soft tissue-friendly manual techniques
• Active exercises: isometric and later eccentric-concentric calf exercises, adapted to pain and stage
• Taping/Padding: Pressure protection in the heel area (e.g. heel pad, foam ring)

Systemic painkillers/anti-inflammatories may be considered in the short term if no contraindications exist. An individual medical assessment is important. Shock wave therapy is primarily used for tendinous complaints; Evidence for pure bursitis is limited.

Gentle exercises to get you started

Exercises should be painless, controlled and without additional compression of the Achilles tendon. Increase slowly and stop if pain is clearly provoked.

If pain or uncertainty persists, exercises should be individually adapted in physiotherapy.

Injections and regenerative procedures

Ultrasound-targeted infiltrations into the bursa can be considered in selected cases if basic conservative measures are not sufficient. The focus is on protecting the Achilles tendon.

• Corticosteroid injections: can reduce inflammation in the short term; Strictly intrabursal and image-guided, as contact with the tendon can increase the risk of rupture. Indication reserved and rare.
• Local anesthetic: can help diagnostically (limit the source of pain).
• PRP/ACP: evidence is limited for retrocalcaneal bursitis; If there is accompanying tendinous pathology, the indication is considered individually.

We clarify benefits, risks and alternatives transparently. Injections do not replace structural rehabilitation and optimization of footwear and weight-bearing.

Surgical options (rare indication)

Surgery is rarely required. It should be considered if persistent symptoms persist for several months despite consistent conservative therapy and a pronounced Haglund configuration or persistent mechanical entrapment can be detected.

• Endoscopic or open bursectomy and bony removal (calcaneoplasty) in cases of pronounced bony prominence
• Simultaneous treatment of combined pathologies (e.g. insertional tendinopathy) according to individual planning
• Rehabilitation: gradual increase in load, physiotherapy, return to sport depending on the healing process

We carefully discuss the indication, benefits and risks and decide together. A reliable conservative treatment attempt is usually the first step.

Course and prognosis

Many patients respond to conservative measures within 2-12 weeks. If there are significant accompanying factors (Haglund, significant calf shortening, rheumatic disease), the recovery time may take longer. The decisive factors are dosage of load, a consistent exercise routine and technical adjustments to the shoes.

• Early relief often shortens the duration of the symptoms
• Shoe and technology advice reduces relapses
• Increase slowly: Build up training loads gradually
• Regular re-evaluation of symptoms and goals

Prevention: How to prevent it

• Matching shoes with a soft heel cap and sufficient heel space
• Warm up and progressive increase in training volume (rule of thumb: max. ~10% per week)
• maintain calf mobility and strength; regular, pain-free stretching
• Use mountain runs and sprints in a measured manner, check your technique
• Identify pressure points early and cushion them; Insoles/heel lifts are limited in time and targeted

When should you see a doctor?

• Severe pain, significant redness/warmth, fever or feeling sick
• Sudden giving way/“snapping” in the Achilles tendon with loss of function
• Persistent symptoms for 2-3 weeks despite rest and personal measures
• Uncertainty when building up stress, recurring problems or unclear findings

Your orthopedics in Hamburg: structured help for heel pain

In our orthopedic practice at Dorotheenstrasse 48, 22301 Hamburg, we offer a differentiated assessment of posterior heel pain. We combine careful examination, modern imaging if necessary and a therapy tailored to your needs with the aim of making everyday life and sport possible again in the long term - without unrealistic promises.

We coordinate load management, physiotherapy and technical shoe measures together and discuss transparently when additional measures such as injections might make sense. Feel free to ask us – we take the time to provide information and a realistic treatment plan.