Retrocalcaneal bursitis

Anatomy: What is the retrocalcaneal bursa?

Bursae are small, fluid-filled buffers between tendons, bones and skin. The retrocalcaneal bursa lies deep between the Achilles tendon and the upper posterior aspect of the heel bone. It reduces friction when rolling and dorsiflexion (lifting the foot).

Important: It must be distinguished from the superficial (subcutaneous) bursa, which lies between the skin and the Achilles tendon. Complaints can affect one or both bursas. A posterosuperior bony prominence on the heel bone (Haglund exostosis) can cause mechanical irritation to the bursa.

• Location: between Achilles tendon and heel bone
• Function: friction reduction and pressure relief
• Neighbors: Achilles tendon, Haglund region, superficial bursa

Causes and risk factors

The retrocalcaneal bursa can become inflamed from repeated mechanical irritation or pressure. Often there is a combination of anatomical factors and loading errors.

• Mechanical irritation due to Haglund exostosis (posterosuperior calcaneal prominence)
• Increased pulling forces due to shortened calf muscles/limited dorsiflexion (equinus)
• Misalignments and loads on the hindfoot (e.g. valgus), leg axis and gait factors
• Sporty overload (especially running, jumping, field sports), rapid increase in training, running uphill
• Unsuitable footwear (hard heel caps, tight heel cups)
• Accompanying Achilles tendon irritation at the insertion (insertion tendinopathy)
• Systemic factors: inflammatory rheumatic diseases, metabolic factors (e.g. gout) – less common

Symptoms: How do I recognize retrocalcaneal bursitis?

• Pain in the back heel, deep in front of the Achilles tendon
• Reinforcement under pressure from shoe toes, when running, climbing stairs or dorsiflexion
• Swelling/thickened tissue on the side of the Achilles tendon, sometimes redness and warmth
• Morning stiffness or start-up pain
• Involvement of the Achilles tendon is possible: tenderness at the tendon insertion

Warning signs that should be clarified: sudden shooting pain with a bang and loss of function (suspected Achilles tendon rupture), severe redness/overheating with fever (infection), extensive night pain without exertion (rare, but needs to be clarified).

Diagnostics in practice

The diagnosis is based on a structured conversation, clinical examination and – if appropriate – imaging procedures. The aim is to precisely assign the source of the pain and identify contributing factors.

• Clinic: Inspection for swelling/prominence, tenderness deep in front of the Achilles tendon, pain provocation during dorsiflexion
• Functional test: mobility of the ankle joint, calf length test, foot axis analysis
• Sonography (in practice): visualization of the bursa (effusion-filled, thickened), hypervascularization in power Doppler, assessment of the Achilles tendon
• Lateral x-ray (if Haglund is suspected): bony prominence, shape of the heel bone
• MRI (selective): in case of unclear diagnosis, suspicion of severe tendon involvement or surgical planning

Laboratory diagnostics are only indicated if systemic inflammation or crystal deposits (e.g. gout) are suspected.

Differential diagnoses

Back heel pain can have various causes. Careful differentiation is important in order to provide targeted treatment.

• Insertional Achilles tendinopathy (with/without calcifications)
• Superficial (subcutaneous) Achilles tendon bursitis
• Haglund exostosis/syndrome (combination of exostosis, bursitis and tendon irritation)
• Partial Achilles tendon lesion or rupture
• Inflammatory rheumatic involvement of the tendon/bursa
• Less common: infection, gout
• Other causes of heel pain: Baxter neuropathy (plantar), tarsal tunnel syndrome (neuropathic, medial), posterior ankle joint impingement

Conservative therapy: step by step

In the vast majority of cases, symptoms can be controlled conservatively. Treatment is based on pain, function and the triggering factors. A structured plan combines load control, targeted training, shoe/aid adjustment and – if necessary – additional measures.

Shock wave therapy (ESWT) may be considered for associated findings such as insertional Achilles tendon irritation. The evidence for pure bursitis is limited, but in practice ESWT can be discussed as an adjunctive option for pain relief.

Physiotherapy and exercises: safe and effective

The aim is to reduce irritation, improve tendon tolerance and relieve pressure on the bursa through optimized movement patterns. Exercises are dosed based on pain: mild, tolerable training pain is acceptable; Sharp or long-lasting pain indicates a need for adjustment.

• Isometric calf exercises: Stand on the forefoot for 5×45–60 seconds (neutral, not in maximum dorsiflexion), 1–2× daily
• Concentric-eccentric calf raises at the step, but with limited dorsiflexion (do not lower the heel too low) with insertional involvement
• Stretching calf muscles (gastrocnemius/soleus) moderately and with little pain, 3×30–45 seconds, 1–2× daily
• Proprioception/balance: one-legged stance, unstable surfaces – stability of the rear foot
• Hip/Core Muscles: Gluteal strengthening to improve leg axis control

Progression occurs every 1-2 weeks depending on the symptoms. Running and jumping are only increased when walking and climbing stairs are largely symptom-free.

Injections and regenerative procedures: with caution

Injection therapies may be reserved for individual cases when basic conservative measures have been exhausted. A careful risk-benefit assessment is crucial.

• Ultrasound-targeted injection into the retrocalcaneal bursa: can reduce inflammatory symptoms. Corticosteroids are used very cautiously, if at all, because incorrect placement near/into the Achilles tendon increases the risk of rupture. Only carried out accurately and with information.
• Hyaluronate or local anesthetic rinses are discussed in some cases; Evidence limited.
• PRP/ACP (autologous blood preparations): Data for pure bursitis is inconsistent and weaker than for tendinopathies. Can be considered in treatment-refractory situations – with no guarantee of effectiveness.

We will discuss with you transparently which options make sense in your case and which expectations are realistic.

When does an operation make sense?

Surgical measures are only considered if professional conservative therapy over several months does not bring sufficient improvement or if a pronounced bony prominence (Haglund's exostosis) permanently mechanically irritates the bursa.

• Endoscopic or open bursectomy (removal of the inflamed bursa)
• Calcaneoplasty/removal of Haglund's exostosis to reduce pressure
• If there is relevant tendon involvement: additional measures on the Achilles tendon (e.g. debridement, refixation) – individually planned

Interventions require structured follow-up treatment with temporary relief, gradual increase in load and physiotherapy. The goal and expected course are discussed in detail in advance.

Course and prognosis

Many patients report significant improvement within 6-12 weeks with consistent conservative therapy. With combined insertional Achilles tendon irritation, rehabilitation may take longer (several months).

• Early adjustment of footwear and load promotes healing.
• Stretching too aggressively into maximum dorsiflexion can irritate the bursa in the early phase - use it carefully.
• Relapses are possible if mechanical triggers (e.g. hard heel cups, training errors) persist - prevention is part of therapy.

What you can do yourself – prevention

• Avoid training mistakes: slow increases, especially in terms of running distance and altitude
• Maintain calf flexibility regularly without stretching into pain areas
• Suitable footwear: sufficient heel space, soft caps; change in time if worn out
• At the first signs of irritation: reduce strain, cool, check heel elevation
• Train hindfoot and leg axis control (strength/balance); Insoles if indicated

Your treatment in Hamburg-Winterhude

In our practice at Dorotheenstraße 48, 22301 Hamburg, you will receive a careful diagnosis with clinical examination and high-resolution sonography. We create an individual treatment plan with a clear priority on conservative measures, accompany the implementation (physiotherapy, exercise control, shoe/insole advice) and discuss additional options if necessary.

Request an appointment? Feel free to use Doctolib or write us an email – we will get back to you as soon as possible.