CALCANEAL BURSITIS

CALCANEAL BURSITIS

Pain at the posterior heel or posterior ankle is most commonly caused by pathology at the posterior calcaneus, the Achilles (calcaneal) tendon, or the associated bursae.

The following bursae are located just superior to the insertion of the Achilles tendon:

• Subtendinous calcaneal bursa - This bursa (also called the retrocalcaneal bursa), situated anterior (deep) to the Achilles tendon, is located between the Achilles tendon and the calcaneus.

• Subcutaneous calcaneal bursa - Also called the Achilles bursa, it is found posterior (superficial) to the Achilles tendon, lying between the skin and the posterior aspect of the distal Achilles tendon.

Inflammation of one or both of these bursae can cause pain in the posterior heel and ankle regions.

Haglund deformity (prominence of the posterior superior calcaneus) is not a true synonym for calcaneal bursitis, but it can be a closely associated condition.

PATHOPHYSIOLOGY

Inflammation of the calcaneal bursae is most commonly caused by repetitive overuse and cumulative trauma, as seen in runners wearing tight-fitting shoes.

Such bursitis may also be associated with conditions such as gout, rheumatoid arthritis, and seronegative spondyloarthropathies.

In some cases, subtendinous calcaneal bursitis is caused by bursal impingement between the Achilles tendon and an excessively prominent posterior superior aspect of a calcaneus that has been affected by Haglund deformity.

With Haglund disease, impingement occurs during ankle dorsiflexion.

MORTALITY/MORBIDITY

• No mortality is associated with calcaneal bursitis.

• Morbidity is associated with progressive pain and limping (antalgic gait) in patients who have not received adequate treatment. If chronic inflammation also affects the distal Achilles tendon, rupture of the tendon may occur.

SEX

Calcaneal bursitis is observed in men and women. However, some increased risk may be incurred by women who wear high-heeled shoes.

AGE

Calcaneal bursitis is commonly observed in middle-aged and elderly persons; the condition is also seen in athletes of all ages.

CLINICAL

HISTORY

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:

• Posterior heel pain is the chief complaint in individuals with calcaneal bursitis.

• Patients may report limping caused by the posterior heel pain.

• Some individuals may also report an obvious swelling (eg, a pump bump, a term that presumably comes from the swelling's association with high-heeled shoes or pumps).

• The condition may be unilateral or bilateral.

• Symptoms are often worse when the patient first begins an activity after rest.

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.

PHYSICAL

During the physical examination of a patient with calcaneal bursitis, the physician should keep the following considerations in mind:

• Swelling and redness of the posterior heel (the pump bump) may be clearly apparent.

• The inflamed area, which may be slightly warm to the touch, is generally tender to palpation.

• Careful examination can help the clinician to distinguish whether the inflammation is posterior to the Achilles tendon (within the subcutaneous calcaneal bursa) or anterior to the tendon (within the subtendinous calcaneal bursa). Differentiating Achilles tendinitis/tendinosis from bursitis may be impossible. At times, the 2 conditions co-exist.

• Isolated subtendinous calcaneal bursitis is characterized by tenderness that is best isolated by palpating just anterior to the medial and lateral edges of the distal Achilles tendon.

• Conversely, insertional Achilles tendinitis is notable for tenderness that is located slightly more distally, where the Achilles tendon inserts on the posterior calcaneus.

• A patient with plantar fasciitis has tenderness along the posterior aspect of the sole, but he/she should not have tenderness with palpation of the posterior heel or ankle.

• A patient with a complete avulsion or rupture of the Achilles tendon demonstrates a palpable defect in the tendon, weakness in plantarflexion, and a positive Thompson test on physical examination. During the Thompson test, the examiner squeezes the calf. The test is negative if this maneuver results in passive plantarflexion of the ankle, which would indicate that the Achilles tendon is at least partially intact.

CAUSES

• Overtraining in a runner (eg, excessive increases in miles or intensity)

• Tight or poorly fitting shoes that, because of a restrictive heel counter, exert excessive pressure on the posterior heel and ankle

• Haglund deformity, causing impingement between the increased posterior superior calcaneal prominence and the Achilles tendon during dorsiflexion

DIAGNOSIS

LABORATORY STUDIES

• If the appearance of the bursitis cannot be explained by local factors (eg, ill-fitting shoes, excessive running, high heels) or if there are systemic symptoms or signs of rheumatologic involvement, the clinician should consider laboratory studies to evaluate for the possibility of gout (hyperuricemia), rheumatoid arthritis (rheumatoid factor), and seronegative spondyloarthropathies (HLA B-27, erythrocyte sedimentation rate, and/or C-reactive protein).

IMAGING STUDIES

• Plain radiographs of the calcaneus may reveal Haglund deformity, which can be seen best on the lateral view.

• Plain radiographs can also be used to evaluate for stress fracture of the calcaneus. If the plain radiographs are negative for stress fracture but this injury possibility remains a significant diagnostic consideration, a 3-phase bone scan or a computed tomography (CT) scan of the calcaneus should be obtained.

• Magnetic resonance imaging (MRI) scans may demonstrate bursal inflammation but probably do not offer much more information than is apparent from careful physical examination. Theoretically, MRI scans may help to determine whether the inflammation is in the subcutaneous calcaneal bursa, the subtendinous calcaneal bursa, or the tendon itself, but such testing is generally unnecessary.

• Some clinicians have suggested that ultrasonography can be used in place of MRI in cases in which imaging is desired to investigate pathology at the posterior heel, but further research in this area is needed.

TREATMENT

PHYSICAL THERAPY

Gradually progressive stretching of the Achilles tendon may help to relieve impingement on the subtendinous calcaneal bursa.

Stretching of the Achilles tendon can be performed by having the patient place the affected foot flat on the floor and lean forward toward the wall until a gentle stretch is felt in the ipsilateral Achilles tendon. The stretch is maintained for 20-60 seconds and then is relaxed.

To maximize the benefit of the stretching program, the patient should repeat the exercise for multiple stretches per set, multiple times per day. Ballistic (ie, abrupt, jerking) stretches should be avoided in order to prevent clinical exacerbation.

The patient should be instructed to ice the posterior heel and ankle in order to reduce inflammation and pain. Icing can be performed for 15-20 minutes at a time, several times a day, during the acute period, which may last for several days.

Some clinicians also advocate the use of contrast baths, ultrasound or phonophoresis, iontophoresis, or electrical stimulation for treatment of calcaneal bursitis.

If the patient's activity level needs to be decreased as a result of this condition, alternative means of maintaining strength and cardiovascular fitness (eg, swimming, water aerobics) should be suggested.

MEDICAL ISSUES/COMPLICATIONS

• Addressing footwear

  • Changing footwear may be the most important form of treatment for calcaneal bursitis. The use of an open-backed shoe may relieve pressure on the affected region.

  • Individuals whose symptoms have been precipitated by a dramatic footwear change, specifically, a switch from high-heeled shoes to flat shoes (or vice versa), may need to temporarily use footwear with a medium heel height.

  • Athletes should be encouraged to change running shoes on a regular basis, because the shoes' fit, as well as the support the shoes provide, may change over the course of hundreds of miles of use.

• Further modification of shoes

  • A portion of the heel counter can be cut away and replaced with a soft leather insert to decrease friction at the site where the heel counter meets the skin.

  • Shoes without laces (eg, slip-on shoes, sandals) inherently fit closely onto the heel and should be avoided.

  • Inserting a heel cup into the shoe may help to raise the inflamed region slightly above the restricting heel counter. If this approach is implemented, a heel cup should also be placed into the other shoe to avoid introducing a leg-length discrepancy.

• Immobilization

  • The initial accommodation of the bursitis by the introduction of rest or of a decrease in or modification of activity may suffice to reverse the bursitis and its symptoms.

  • If the symptoms are resistant to the above treatments, immobilization in a cast for 4-6 weeks should be considered.

• Complications from calcaneal bursitis or its treatment

  • Progressive posterior heel and ankle pain

  • Rupture of the Achilles tendon, either secondary to chronic local inflammation/degeneration or as a result of corticosteroid injection(s)

  • Some clinicians advocate the use of corticosteroid injection(s) into the affected bursa, being careful to avoid injection within the Achilles tendon. Because of the close proximity of the Achilles tendon to the bursae, such injections should be considered only in severe, recalcitrant cases. The authors of this article generally recommend against corticosteroid injection in the vicinity of the Achilles tendon because of the potential risk of tendon rupture. However, prospective, randomized studies have not been performed to establish whether steroid injections cause such tendon ruptures. Instead, the association between steroid injections and subsequent tendon ruptures is mostly based on retrospective case reports. Potentially, those cases that were more likely to go on to rupture were also more likely to have a severe presentation that prompted the steroid injections.

  • One case report demonstrated that subtendinous calcaneal bursitis can be not only diagnosed but also treated with ultrasonography. Ultrasonographic guidance can be used to inject the subtendinous calcaneal bursa with a commendation of local anesthetic (eg, lidocaine, giving relief within minutes and lasting several hours) combined with corticosteroid (eg, Kenalog, producing an anti-inflammatory effect within 24-48 h and providing relief for weeks to months).

SURGICAL INTERVENTION

For patients who have persistent or progressive symptoms despite rigorous nonsurgical treatment, the following surgical interventions are options:

• Resection of Haglund deformity, removing the calcaneal superoposterior prominence (ostectomy)

• Excision of the painful bursa or bursae

• Debridement of the Achilles insertion

• In cases of Achilles tendon rupture or avulsion, surgical re-anastomosis is indicated.

• Outpatient endoscopic removal of the inflamed bursal tissue and resection of the prominent bone.

MEDICATION

For this musculoskeletal condition, medications are used primarily to decrease pain and inflammation. Thus, the most commonly used medications are oral nonsteroidal anti-inflammatory drugs (NSAIDs), which are employed in conjunction with the rest of the rehabilitation plan.

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

Oral NSAIDs can help to decrease pain and inflammation. Various oral NSAIDs can be used, with the choice of drug being largely a matter of convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.

IBUPROFEN (Motrin, Advil, Nuprin, Rufen)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Various doses are available with and without a prescription.

Adult: 200-800 mg PO tid/qid

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

NAPROXEN (Naprelan, Naprosyn, Aleve, Anaprox)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.

Adult: 500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d

KETOPROFEN (Actron, Orudis, Oruvail)

For relief of mild to moderate pain and inflammation.

Small dosages are initially indicated in small and elderly patients and in persons with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.

Adult: 25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

FLURBIPROFEN (Ansaid)

May inhibit cyclo-oxygenase enzyme, which in turn inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.