Subachillary bursitis (superficial heel bursitis)

Anatomy: Where exactly is the affected bursa?

Bursae are thin-walled, fluid-filled pads that reduce friction between tissues. There are two relevant bursae on the posterior calcaneus:

• Bursa subachilla (subcutaneous calcaneal bursa): lies superficially between the skin/toe of the shoe and the Achilles tendon.
• Retrocalcaneal bursa (deep bursa): lies deeper between the Achilles tendon and the heel bone (calcaneus).

In subachillary bursitis, the superficial bursa becomes inflamed - often due to external pressure and friction. This must be distinguished from retrocalcaneal bursitis, which is more likely to be associated with bony protrusion (Haglund exostosis) and Achilles tendon attachment problems.

Typical symptoms

• Tenderness and swelling directly over the heel, above the edge of the shoe
• Redness, overheating, sometimes chafing blisters or irritated skin
• Increased pain due to firm or high-cut shoe caps (sports, safety or leisure shoes)
• Relief barefoot or in open/soft heel cups
• Sometimes morning start-up pain; If the inflammation is severe, there is also pain at rest

In contrast to Achilles tendonitis, the focus here is primarily on pressure and rubbing pain - less strain-dependent tendon pain.

Causes and risk factors

Subachillary bursitis is usually due to mechanical causes. Repeated friction or direct pressure irritates the bursa and leads to inflammation.

• Firm/hard shoe toes, narrow heel area, unsuitable sports shoes
• Sudden increase in training, uphill/sprint focus with increased heel irritation
• Foot and axle peculiarities: pronounced heel bump (Haglund), shortened calf muscles, high instep
• Previous irritation/blisters, local contusion
• Systemic factors: rheumatic diseases, gout (rare), metabolic disorders
• Occupational stress with safety boots or hard heel caps

It is important to differentiate between retrocalcaneal bursitis and Achilles tendon attachment irritation, as the focus of therapy differs.

Differentiation from other causes of heel pain

• Retrocalcaneal bursitis (deeper bursitis behind the Achilles tendon)
• Achilles tendinopathy (insertion tendinopathy)
• Haglund exostosis with mechanical conflict
• Skin lesions: blisters, calluses, pressure ulcers
• Infectious bursitis (rare): pronounced redness, overheating, possibly fever
• Rare: gout attack, rheumatic activity, cellulitis

Diagnosis: This is how subachillary bursitis is diagnosed

Diagnosis is based on history, physical examination and, if necessary, imaging.

Conservative treatment: step by step

The aim is to reduce irritation by adapting the load and protecting the bursa. In many cases, symptoms improve within weeks if triggering factors are corrected.

• Load adjustment: temporarily less running/jumping; Prefer activities without heel pressure (cycling, swimming).
• Shoe fitting: soft, low-cut or open heel counter; sufficient space in the heel; If necessary, alternative lacing techniques.
• Heel pad/donut pad: ring-shaped pads relieve the pressure point; Blister plasters as skin protection.
• Heel wedge (5-10 mm): reduces ankle dorsiflexion and mechanical conflict; only use temporarily.
• Cryotherapy: cool for 10-15 minutes several times a day (note skin protection).
• Anti-inflammatory measures: topical NSAID gels; If necessary, short-term oral NSAIDs after medical consideration (note stomach/kidneys).
• Physiotherapy: initially soothing, soft tissue-oriented techniques; later calf stretching, gentle strength building and coordination. Eccentric training of the calf muscles carefully and only after the acute irritation has subsided.
• Taping: Relief tapes to reduce friction/pressure.
• Insoles/orthotics: individually for axial or foot misalignments, possibly silicone heel cups.
• Everyday factors: suitable socks, no hard heel seam; Break in/replace shoes in a timely manner.

Shock wave therapy may be considered for concurrent Achilles tendinopathy; Evidence is limited for pure subachilleal bursitis. Decision made individually.

Injections and surgical options – when do they make sense?

In the majority of cases, conservative treatment is sufficient. Invasive measures are used cautiously and according to clear indications.

• Ultrasound-targeted infiltration: a low-dose corticosteroid/local anesthetic injection into the bursa may be considered in refractory cases. Important: strict demarcation from the Achilles tendon, as an injection hit into the tendon can increase the risk of rupture; therefore only targeted and rare.
• Puncture/aspiration: if infectious bursitis is suspected for microbiological diagnosis and pressure reduction; subsequent targeted antibiotic therapy if germs are detected.
• Surgical bursectomy: rarely necessary, especially a. in chronic cases >3–6 months despite therapy according to guidelines or in the case of mechanical conflict. If Haglund's exostosis occurs at the same time, bone removal can be considered. Procedure usually on an outpatient basis; Follow-up treatment with early functional recovery.

We provide transparent information about possible risks (infection, impaired wound healing, persistent symptoms). A promise of healing cannot be seriously given.

Course and prognosis

If the triggering stimulus (shoe pressure, training peaks) is consistently reduced and the heel is protected, symptoms often subside within 2-8 weeks. If a mechanical cause persists (e.g. pronounced Haglund prominence or permanently unsuitable footwear), relapses are more likely. A gradual increase in load reduces the risk of recurrence.

Prevention: How to protect your heel

• Choose shoes with a soft/adjusted heel cap, sufficient heel width and a good fit.
• Break in new shoes slowly; If necessary, an alternative pair can be changed during physical activity.
• Stretch calf muscles regularly; warm up before exercise.
• Increase training volume/intensity gradually (10% rule).
• socks without hard seams; Heel plasters for known pressure points.
• If symptoms of irritation recur, adjust the load early and seek advice.

When should you see a doctor?

• Severe, increasing swelling with pronounced redness/warmth
• Fever, general feeling of illness or an open sore in the heel area
• Persistent symptoms despite protection, shoe fitting and self-care for >2–3 weeks
• Recurrent episodes or suspected comorbidities (e.g. gout, rheumatism)

In Hamburg we advise you at Dorotheenstrasse 48, 22301 Hamburg - with a focus on conservative, cause-oriented therapies.

Subachillary bursitis vs. retrocalcanea: the most important differences

• Location: subachilla superficial between skin and Achilles tendon; retrocalcanea deep between tendon and heel bone.
• Trigger: subachilla often shoe pressure/friction; retrocalcanea more often bony prominence (Haglund) and tendon insertion problems.
• Findings: subachilla visible/palpable superficial swelling; retrocalcanea rather deep tenderness, often less visible redness.
• Therapy focus: subachilla—pressure relief/shoe adjustment; retrocalcanea—additional management of the bony/tendinous conflict.

This distinction influences the treatment strategy and explains why the correct diagnosis is crucial.

Self-help: What can you do immediately?

If the symptoms persist or warning signs occur, have the heel examined by a doctor.