Bursa is a fluid filled sac of tissue that is often found around the bony prominences over which tendons and soft tissues rub. This therefore helps the tendons to glide with least amount of friction. Retrocalcaneal bursa is found behind the heel under the Achilles tendon. Retrotendoneal bursa is found on the back of the attachment of the tendon where the shoe rubs on the skin. This can cause swelling, pain and difficulty in footwear. Sometimes there is a bony prominence on the heel bone that predisposes to this condition (Haglund?s deformity). Treatment of this can be modification of footwear. However surgery is often required which involves excision of the bursa and also the bony prominence on the heel bone.
There are several factors which can lead to a person developing retrocalcaneal bursitis. In athletes, especially runners, overtraining, sudden excessive increase in running mileage may lead to retrocalcaneal bursitis. Tight or ill-fitting shoes can be another causative factor as they can produce excessive pressure at the back of the heel due to restrictive heel counter. A person with an excessively prominent posterosuperior aspect of the heel bone (Haglund deformity) may also have a higher predisposition to retrocalcaneal bursitis. In such individuals, pain would be reproduced when the ankle goes into dorsiflexion.
Symptoms include pain at the back of the heel, especially when running uphill or on soft surfaces. There will be tenderness and swelling at the back of the heel which may make it difficult to wear certain shoes. When pressing in with the fingers both sides are the back of the heel a spongy resistance may be felt.
Obtaining a detailed history from the patient is important in diagnosing calcaneal bursitis. The following complaints (which the physician should ask about during the subjective examination) are commonly reported by patients.
Other inquiries that the physician should make include the following. The clinician should ask about the patient's customary footwear (whether, for example, it includes high-heeled shoes or tight-fitting athletic shoes). The patient should be asked specifically about any recent change in footwear, such as whether he/she is wearing new athletic shoes or whether the patient has made a transition from flat shoes to high heels or vice versa. Individuals who have been accustomed to wearing high-heeled shoes on a long-term basis may find that switching to flat shoes causes increased stretch and irritation of the Achilles tendon and the associated bursae. The specifics of a patient's activity level should be ascertained, including how far the patient runs and, in particular, whether the individual is running with greater intensity than before or has increased the distance being run. The history of any known or suspected underlying rheumatologic conditions, such as gout, rheumatoid arthritis, or seronegative spondyloarthropathies, should be obtained.
Non Surgical Treatment
During the initial acute phase of the condition, patients should apply ice to the back of the heel for 15 to 20 minutes and follow the R.I.C.E.R regime. Avoid activities that cause pain. Gradual progressive stretching of the calf muscle and Achilles tendon is also advocated. Changing the footwear. Wearing an open-backed shoe may help relieve pressure on the affected region. For those whose symptoms were caused by a sudden change from wearing high-heeled shoes to flat shoes, the temporary use of footwear with a heel height in between may be helpful. Inserting a heel cup in the shoe may help to raise the inflamed region slightly above the shoe?s restricting heel counter and relieve the pain. It is advisable to also insert the heel cup into the other shoe to avoid any leg-leg discrepancies that can lead to other problems. Training frequency and intensity should be gradually progressed with adequate rest between trainings.
Maintain proper form when exercising, as well as good flexibility and strength around the ankle to help prevent this condition. Proper stretching of the Achilles tendon helps prevent injury.