One of the most common causes of pain and swelling on the back of the heel is
retrocalcaneal bursitis. It occurs when the bursa attached deep between the heel bone
(calcaneus) and the Achilles tendon becomes inflamed. This small sac lined with a synovial
membrane serves to fluidify movements to help protect the tissues from friction. Athletes
who have to jump regularly or wear tight skates are often affected by this problem. Examples
include figure skaters, field hockey players and basketball players. This type of bursitis
normally occurs after a severe trauma, an injury to the tendon or repeated micro-injuries. It’s
important to follow the progression of the inflammation and symptoms and if the pain
persists or worsens, consult a podiatrist immediately.
How to Diagnose Bursitis Behind the Heel
The affected area may become warm, swollen and painful, especially with ankle movement.
The diagnosis is made through a clinical examination where a podiatrist will palpate the back
of the foot and ask questions about medical history and lifestyle habits related to the
If the condition is not visible or if there is any doubt, an ultrasound of the foot will show
enlargement of the bursa and synovial membrane and may even reveal various factors
contributing to the condition. Further investigation or puncture may be helpful to identify or
rule out another condition. This may include the following:
● Bacterial infection or an inflammatory condition affecting soft tissue (psoriatic arthritis,
rheumatoid arthritis or gout).
● Achilles tendinopathy, where the irritation and risk of tearing is not in the bursa, but
rather in the substance of the tendon or at the point of attachment of the calf behind
● Retroachilles bursitis, where the bursa involved is the one between the skin and the
Achilles tendon on the surface, rather than the one between the bone and the
tendon, which is deeper.
● Paratenonitis, which involves the protective covering of the Achilles tendon.
● Haglund-type morphology, where the heel bone is particularly prominent and causes
irritation of the Achilles tendon and the intervening bursa.
Knowing the exact cause(s) will make it easier to design the proper treatment plan and avoid
Treatments for Retrocalcaneal Bursitis
The basic recommendations for relief include reducing movement and compressive forces.
Rest and ice to reduce swelling are also part of the immediate solutions. These seemingly
simple basic practices must be done properly to avoid further irritation and to
strengthen/soften the structures in order to limit the recurrence of bursitis. If sufficient
flexibility is not achieved due to calf hypertonicity, a serial therapeutic taping protocol,
podiatric orthotics and elevated footwear should be considered.
If your case is considered acute and causes significant limitations, more aggressive medical
treatment will be recommended. This could include cortisone injections or a prescription for
non-steroidal anti-inflammatory drugs (NSAIDs), administered orally or by injection. If the
treatment involving cortisone infiltrations is recommended, you’ll need to wear an off-loading
boot or a rigid restrictive bandage to protect the Achilles tendon from rupture. If it’s a
bacterial infection, you’ll be prescribed an antibiotic. Finally, if you have calcifications, radial
shock wave therapy may be proposed.
Many high-level athletes must or wish to continue their activities at all costs. However,
recovery necessarily requires a period of rest and controlled movements. Therefore, whether
your bursitis is mechanical, traumatic or related to a pathology, not treating it properly and
believing that the condition is benign could lead to a loss of mobility. Beware that an
inflammed bursa doesn’t become an Achilles heel!