Retrocalcaneal Bursitis
Retrocalcaneal bursitis is the most common heel bursitis. Retrocalcaneal bursitis is the inflammation of the bursa located between the calcaneus and the anterior surface of the Achilles tendon[1].There are two bursae located just superior to the insertion of the Achilles (calcaneal) tendon. Inflammation of either or both of these bursa can cause pain at the posterior heel and ankle region.
Anterior or deep to the tendon is the retrocalcaneal (subtendinous) bursa, which is located between the Achilles tendon and the calcaneus.
Posterior or superficial to the Achilles tendon is the subcutaneous calcaneal bursa, also called the Achilles bursa. This bursa is located between the skin and posterior aspect of the distal Achilles tendon.
It is also known as Achilles tendon bursitis. It can often be mistaken for Achilles Tendinopathy or can also occur in conjunction with Achilles tendinopathy.
Symptoms
Pain at the back of the heel, especially when running uphill
Pain may get worse when rising on the toes (standing on tiptoes)
Tenderness at the back of heel
Swelling at the back of heel
Increase in pain in activities which load the calf
Causes
A retrocalcaneal bursa mat occur traumatically from a fall or a sport related impact contusion or it can also present as a gradual onset due to repetitive trauma to the bursa from activities including running or excessive loading.
Overtraining in an athlete
Tight or poorly fitting shoes that produce excessive pressure at the posterior heel
Altered joint axis
Inflammation of the calcaneal bursae is most commonly caused by repetitive (cumulative) trauma or overuse, and the condition is aggravated by pressure, such as when athletes wear tight-fitting shoes. Retrocalcaneal bursitis may also be associated with conditions such as gout, rheumatoid arthritis, and seronegative spondyloarthropathies. In some cases, retrocalcaneal bursitis may be caused by bursal impingement between the Achilles tendon and an excessively prominent posterosuperior aspect of the calcaneus (Haglund deformity). In Haglund disease, impingement occurs during ankle dorsiflexion.
Diagnosis
A good clinical practise includes evaluation of the tendon, bursa and calcaneum by, careful history, inspection of the region for bony prominence and local swelling as well as palpation of the area of maximal tenderness. Biomechanical abnormalities, joint stiffness and proximal soft tissue tightening can exacerbate an anatomical predisposition to retrocalcaneal bursitis, they warrant correction when present.
Plain radiographs of the calcaneus may reveal a Haglund deformity (increased prominence of the posterosuperior aspect of the calcaneus). However, on weight-bearing lateral radiographs, the retrocalcaneal recess often appears normal even in patients with retrocalcaneal bursitis, limiting its usefulness in making this diagnosis.Radiographs may be used as a diagnostic measure to support a clinician’s diagnosis of retrocalcaneal bursitis. Individuals with retrocalcaneal bursitis may have an absence of the normal radiolucency (ie, blunting) that is seen in the posteroinferior corner of the Kager fat pad, known as the retrocalcaneal recess or bursal wedge. This may occur with or without an associated erosion of the calcaneus.
Magnetic resonance imaging (MRI) may demonstrate bursal inflammation, but this modality probably does not offer much more information than that found by careful physical examination. Theoretically, MRI could help the physician to determine whether the inflammation is within the subcutaneous bursa, the subtendinous bursa, or even within the tendon itself; however, such testing is generally not necessary.
Ultrasonography may be a potentially useful tool for diagnosing pathologies of the Achilles tendon.