Introduction
The most likely bursa around the heel that is responsible for heel pain is the retrocalcaneal bursa. This pain results when this bursa( sac like structure lined by a thin layer of synovial fluid, functions to reduce friction between surfaces) gets filled up with inflammatory fluid and results in Retrocalcaneal Bursitis. The location of the bursa is between the calcaneum and the anterior surface of the Achilles tendon. There are two bursae in this area.[2] Deep to the Achilles tendon lies the subtendinous or retrocalcaneal bursa. Superficial to the Achilles lies the subcutaneous calcaneal bursa (This bursa lies between posterior surface of the Achilles tendon and the skin). Inflammation of either of these bursae can lead to pain at the posterior heel and ankle region.
Relevant Clinical Anatomy And Pathogenesis
The retrocalcaneal bursa is housed over the posterio-superior prominence of the heel bone right under the Achilles tendon and it’s lateral expansions. The calcaneum, fibrocartilaginous walls of the retrocalcaneal burial and the insertion of the Achilles tendon form an ‘Enthesis Organ’. Conceptually, at the site of the Achilles tendon insertion, the bursae and the bone are so intimately linked that a small prominence of the calcaneum will greatly increase the chances of mechanical irritation of the bursa.
Etiology
- Ill-fitting footwear and especially switching to flat shoes after a prolonged period of using high heels can predispose individuals to Retrocalcaneal bursitis.
- Repetitive micro trauma to the bursa due to excessive loading as is seen athletes who tend to overtrain can be a predisposing factor.
- Haglund deformity
- Alteration of the joint axis
- Gout, rheumatoid arthritis and seronegative spondyloarthropathies
Sign and Symptoms
- Troubling pain at the back of the hill especially while walking or running uphill.
- Standing up on toes can aggravate the pain.
- Tenderness on palpation at the back of heel
- Swelling often associated with warmth and redness at the back of heel
- Aggravation of pain with calf loading activities.
Clinical Assessment and Investigations
Careful history and a thorough examination to look for local swelling, tenderness, evaluation of the tendon, detecting any bony prominence as well as locating the area of maximum tenderness with palpation.
Tightening of proximal soft tissue, stiffness in joint and any biomechanical abnormalities
Should be looked for as these can make one anatomically predisposed to retrocalcaneal bursitis.
X rays may show the presence of a bony prominence in the postern-superior aspect of the calcaneum. This is termed as the Haglund deformity .
The retrocalcaneal recess often looks normal on weight bearing lateral x rays making their use limited in aiding the diagnosis.
Patients may show the absence of normal radiolucency at the posteroinferior corner of the Kager fat pad, (blunting). There may be associated calcaneal erosion seen.
Musculoskeletal Ultrasound is a great tool in imaging the bursa, appreciating any bursal thickening, inflammation, health of the adjoining soft tissues and is also mighty helpful in carrying out Interventional Pain Management and Regenerative Procedures for the same.
Magnetic resonance imaging (MRI) can demonstrate bursal inflammation but does not offer much greater information helping in the diagnosis.
Differential Diagnosis
- Haglund Deformity
- Achilles Tendonitis
- Partial rupture of the Achilles tendon
- Plantar Fasciitis
- Posterior Ankle Impingement
Treatment
Physical Therapy
Icing of the heel and posterior part of ankle can be performed several times a day during active inflammation for stretches of 15-20 minutes.
Exercises involving the stretching of the Achilles tendon are advised. These can help in relieving the impingement on the subtendinous bursa.
Calf stretch Keeping the back leg straight with the heel placed on the ground one should lean forward against a wall. The front leg has a bend in the knee . To stretch the gastrocnemius complex(calf muscles) and the Achilles tendon, hips have to be pushed towards the wall in a controlled manner. Position is to be held for 10 seconds before relaxing. Excercise should be repeated around 20 times for each foot and this should give the adequate stretch in the calf muscles.
Electrical modalities have been tried but are not hugely advocated.
Corticosteroid Injection
Traditionally a lot of people have received blind corticosteroid injections by clinicians for this condition. In our practice, we advocate precise ultrasound guided injections for really painful bursitis. This makes sure that the site of the injection is the bursa avoiding steroid infiltration in nearby tissues.
Platelt Rich Plasma & Prolotherapy
For most cases of retrocalcaneal bursitis encountered at ALLEVIATE, we follow a Comprehensive Platelet Rich Plasma and Prolotherapy treatment for the same. Patient usually respond well to treatment in two to three sessions of the same. Though our treatment is coupled with a rigorous multidisciplinary approach focussing on excercise, physical therapy, nutrition and weight management as well.
Surgery
For extremely chronic and resistant cases a Bursectomy might be undertaken.( Rarely done)
