Calcaneal Bursitis.doc

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Calcaneal Bursitis Author: Patrick M Foye, MD; Chief Editor: Consuelo T Lorenzo, MD more

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Pain at the #osterior heel or #osterior ankle is most commonly caused $y #atholo"y at the #osteriorcalcaneus, the Achilles %calcaneal& tendon, or the associated $ursae The follo'in" $ursae arelocated (ust su#erior to the insertion of the Achilles tendon)*, +, - :

.u$tendinous calcaneal $ursa / This $ursa %also called the retrocalcaneal $ursa&, situated

anterior %dee#& to the Achilles tendon, is located $et'een the Achilles tendon and the calcaneus )0- .u$cutaneous calcaneal $ursa / Also called the Achilles $ursa, it is found #osterior

%su#erficial& to the Achilles tendon, lyin" $et'een the skin and the #osterior as#ect of the distalAchilles tendon

1nflammation of one or $oth of these $ursae can cause #ain in the #osterior heel and ankle re"ions )2,3-

4a"lund deformity %#rominence of the #osterior su#erior calcaneus& is not a true synonym forcalcaneal $ursitis, $ut it can $e a closely associated condition

For additional information, see!ursitis)Emer"ency Medicine-,!ursitis)5rtho#edic .ur"ery-, and

6etrocalcaneal !ursitis

Patho#hysiolo"y

1nflammation of the calcaneal $ursae is most commonly caused $y re#etiti7e o7eruse and cumulati7etrauma, as seen in runners 'earin" ti"ht/fittin" shoes .uch $ursitis may also $e associated 'ithconditions such as "out, rheumatoid arthritis, and serone"ati7e s#ondyloarthro#athies

1n some cases, su$tendinous calcaneal $ursitis is caused $y $ursal im#in"ement $et'een theAchilles tendon and an e8cessi7ely #rominent #osterior su#erior as#ect of a calcaneus that has $eenaffected $y 4a"lund deformity 9ith 4a"lund disease, im#in"ement occurs durin" ankle dorsifle8ion

A study $y Lohrer and auck indicated that retrocalcaneal $ursa #ressure rises in #atients 'ithchronic retrocalcaneal $ursitis, 'hich in turn, the in7esti"ators su""ested, can cause an im#in"ementlesion on the anterior Achilles tendon)-

E#idemiolo"y

Frequency

United States

Calcaneal $ursitis is seen some'hat fre


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Calcaneal $ursitis is commonly o$ser7ed in middle/a"ed and elderly #ersons; the condition is alsoseen in athletes of all a"es

4istory

5$tainin" a detailed history from the #atient is im#ortant in dia"nosin" calcaneal $ursitis )=- Thefollo'in" com#laints %'hich the #hysician should ask a$out durin" the su$(ecti7e e8amination& are

commonly re#orted $y #atients:

Posterior heel #ain is the chief com#laint in indi7iduals 'ith calcaneal $ursitis

Patients may re#ort lim#in" caused $y the #osterior heel #ain

.ome indi7iduals may also re#ort an o$7ious s'ellin" %e", a #um# $um#, a term that

#resuma$ly comes from the s'ellin">s association 'ith hi"h/heeled shoes or #um#s&

The condition may $e unilateral or $ilateral

.ym#toms are often 'orse 'hen the #atient first $e"ins an acti7ity after rest

5ther ins acti7ity le7el should $e ascertained, includin" ho' far the #atient

runs and, in #articular, 'hether the indi7idual is runnin" 'ith "reater intensity than $efore or hasincreased the distance $ein" run

The history of any kno'n or sus#ected underlyin" rheumatolo"ic conditions, such as "out,

rheumatoid arthritis, or serone"ati7e s#ondyloarthro#athies, should $e o$tained

Physical

Durin" the #hysical e8amination of a #atient 'ith calcaneal $ursitis, the #hysician should kee# thefollo'in" considerations in mind:

.'ellin" and redness of the #osterior heel %the #um# $um#& may $e clearly a##arent The inflamed area, 'hich may $e sli"htly 'arm to the touch, is "enerally tender to #al#ation Careful e8amination can hel# the clinician to distin"uish 'hether the inflammation is

#osterior to the Achilles tendon %'ithin the su$cutaneous calcaneal $ursa& or anterior to the tendon%'ithin the su$tendinous calcaneal $ursa& Differentiatin" Achilles tendinitis?tendinosis from $ursitismay $e im#ossi$le At times, the + conditions co/e8ist

1solated su$tendinous calcaneal $ursitis is characterized $y tenderness that is $est isolated

$y #al#atin" (ust anterior to the medial and lateral ed"es of the distal Achilles tendon Con7ersely, insertional Achilles tendinitis is nota$le for tenderness that is located sli"htly

more distally, 'here the Achilles tendon inserts on the #osterior calcaneus A #atient 'ith #lantar fasciitis has tenderness alon" the #osterior as#ect of the sole, $ut

he?she should not ha7e tenderness 'ith #al#ation of the #osterior heel or ankle )=-

A #atient 'ith a com#lete a7ulsion or ru#ture of the Achilles tendon demonstrates a #al#a$ledefect in the tendon, 'eakness in #lantarfle8ion, and a #ositi7e Thom#son test on #hysicale8amination Durin" the Thom#son test, the e8aminer s


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load on the tendon, disru#tin" normal $iomechanics This altered (oint a8is is associated 'ith anincreased risk for Achilles #atholo"ies, includin" $ursitis )@-

These include the follo'in":

out

4a"lund deformity

.erone"ati7e s#ondyloarthro#athies .tress fracture of the calcaneus

.ural neuritis

Medial calcaneal ner7e im#in"ement %$ranch of ti$ial ner7e&

Achilles chondrocalcinosis

Calcaneal s#ur

Calcaneal osteochondroma

Differential Dia"noses Achilles Tendon 1n(uries

Physical Medicine and 6eha$ilitation for .tress Fractures

Plantar Fasciitis

6heumatoid Arthritis

La$oratory .tudies

1f the a##earance of the $ursitis cannot $e e8#lained $y local factors %e", ill/fittin" shoes, e8cessi7erunnin", hi"h heels& or if there are systemic sym#toms or si"ns of rheumatolo"ic in7ol7ement, theclinician should consider la$oratory studies to e7aluate for the #ossi$ility of "out %hy#eruricemia&,rheumatoid arthritis %rheumatoid factor&, and serone"ati7e s#ondyloarthro#athies %4LA !/+,erythrocyte sedimentation rate, and?or C/reacti7e #rotein&

Also see related Medsca#e 6esource Centers on outand6heumatoid Arthritis

1ma"in" .tudiesPlain radio"ra#hs of the calcaneus may re7eal 4a"lund deformity, 'hich can $e seen $est on thelateral 7ie' 1n this 7ie', the triad consistent 'ith 4a"lund>s disease is thickenin" of Achilles tendonat insertion, retrocalcaneal $ursitis, and retro/Achilles $ursitis )*B-

Plain radio"ra#hs can also $e used to e7aluate for stress fracture of the calcaneus 1f the #lainradio"ra#hs are ne"ati7e for stress fracture $ut this in(ury #ossi$ility remains a si"nificant dia"nosticconsideration, a /#hase $one scan or a com#uted tomo"ra#hy %CT& scan of the calcaneus should$e o$tained

Ma"netic resonance ima"in" %M61& scans may demonstrate $ursal inflammation $ut #ro$a$ly do notoffer much more information than is a##arent from careful #hysical e8amination Theoretically, M61scans may hel# to determine 'hether the inflammation is in the su$cutaneous calcaneal $ursa, the

su$tendinous calcaneal $ursa, or the tendon itself, $ut such testin" is "enerally unnecessary)**, *+-

4y$rid ima"in" modalities, most s#ecifically sin"le/#hoton emission CT %.PECT&?CT, may assist 'ithearly detection of $ursitis $y offerin" a #recise, accurate, and hi"hly localizin" dia"nostic ima"e4o'e7er, little research e8ists on the cost $enefit of this modality, and therefore, this ima"in"modality is not fre


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4istolo"ic Findin"s

!ursal inflammation is #resent in #atients 'ith calcaneal $ursitis, $ut o$tainin" a histolo"ic s#ecimenfrom an actual #atient 'ould $e e8tremely rare

6eha$ilitation Pro"ram

Physical Therapyradually #ro"ressi7e stretchin" of the Achilles tendon may hel# to relie7e im#in"ement on thesu$tendinous calcaneal $ursa .tretchin" of the Achilles tendon can $e #erformed $y ha7in" the#atient #lace the affected foot flat on the floor and lean for'ard to'ard the 'all until a "entle stretchis felt in the i#silateral Achilles tendon The stretch is maintained for +B/3B seconds and then isrela8ed This techni


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Achilles stretch *; cro##ed 7ie' sho'in"a close/u# of the re"ion affected $y this ty#e of stretch

Another techni


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Achilles stretch +; close/u# 7ie'

To ma8imize the $enefit of the stretchin" #ro"ram, the #atient should re#eat the e8ercise for multi#lestretches #er set, multi#le times #er day !allistic %ie, a$ru#t, (erkin"& stretches should $e a7oided inorder to #re7ent clinical e8acer$ation

The #atient should $e instructed to ice the #osterior heel and ankle in order to reduce inflammationand #ain 1cin" can $e #erformed for *2/+B minutes at a time, se7eral times a day, durin" the acute#eriod, 'hich may last for se7eral days .ome clinicians also ad7ocate the use of contrast $aths,ultrasound or #hono#horesis, ionto#horesis, or electrical stimulation for treatment of calcaneal

$ursitis

1f the #atient>s acti7ity le7el needs to $e decreased as a result of this condition, alternati7e means ofmaintainin" stren"th and cardio7ascular fitness %e", s'immin", 'ater aero$ics& should $e su""ested

Medical 1ssues?Com#lications

.ee the list $elo':

Addressin" foot'earo Chan"in" foot'ear may $e the most im#ortant form of treatment for calcaneal

$ursitis The use of an o#en/$acked shoe may relie7e #ressure on the affected re"iono 1ndi7iduals 'hose sym#toms ha7e $een #reci#itated $y a dramatic foot'ear

chan"e, s#ecifically, a s'itch from hi"h/heeled shoes to flat shoes %or 7ice 7ersa&, may need to

tem#orarily use foot'ear 'ith a medium heel hei"hto Athletes should $e encoura"ed to chan"e runnin" shoes on a re"ular $asis,

$ecause the shoes> fit, as 'ell as the su##ort the shoes #ro7ide, may chan"e o7er the course ofhundreds of miles of use

Further modification of shoeso A #ortion of the heel counter can $e cut a'ay and re#laced 'ith a soft leather insert

to decrease friction at the site 'here the heel counter meets the skino .hoes 'ithout laces %e", sli#/on shoes, sandals& inherently fit closely onto the heel

and should $e a7oidedo 1nsertin" a heel cu# into the shoe may hel# to raise the inflamed re"ion sli"htly

a$o7e the restrictin" heel counter 1f this a##roach is im#lemented, a heel cu# should also $e#laced into the other shoe to a7oid introducin" a le"/len"th discre#ancy

o 5f note, a recent #ros#ecti7e, randomized/controlled study has called into


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1mmo$ilizationo The initial accommodation of the $ursitis $y the introduction of rest or of a decrease

in or modification of acti7ity may suffice to re7erse the $ursitis and its sym#tomso 1f the sym#toms are resistant to the a$o7e treatments, immo$ilization in a cast for 0/

3 'eeks should $e considered

Com#lications from calcaneal $ursitis or its treatmento

Pro"ressi7e #osterior heel and ankle #aino 6u#ture of the Achilles tendon, either secondary to chronic local

inflammation?de"eneration or as a result of corticosteroid in(ection%s&o .ome clinicians ad7ocate the use of corticosteroid in(ection%s& into the affected

$ursa, $ein" careful to a7oid in(ection 'ithin the Achilles tendon)*=- !ecause of the close #ro8imityof the Achilles tendon to the $ursae, such in(ections should $e considered only in se7ere,recalcitrant cases The authors of this article "enerally recommend a"ainst corticosteroid in(ectionin the 7icinity of the Achilles tendon $ecause of the #otential risk of tendon ru#ture 4o'e7er,#ros#ecti7e, randomized studies ha7e not $een #erformed to esta$lish 'hether steroid in(ectionscause such tendon ru#tures 1nstead, the association $et'een steroid in(ections and su$se


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For this musculoskeletal condition, medications are used #rimarily to decrease #ain andinflammation Thus, the most commonly used medications are oral nonsteroidal anti/inflammatorydru"s %.A1Ds&, 'hich are em#loyed in con(unction 'ith the rest of the reha$ilitation #lan )++-

onsteroidal anti/inflammatory dru"s

Class Suary

5ral .A1Ds can hel# to decrease #ain and inflammation arious oral .A1Ds can $e used, 'ith thechoice of dru" $ein" lar"ely a matter of con7enience %ho' fre


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Achilles tendon ru#ture occurrin" secondary to chronic inflammation or #erha#s resultin"

from corticosteroid in(ection

Pro"nosis

.ee the list $elo':

Most #atients res#ond 'ell to a com$ination of local icin", oral anti/inflammatory

medications, Achilles tendon stretchin", and foot'ear modification

.ur"ical inter7ention may #ro7ide "ood results for #atients in 'hom conser7ati7e treatment

has failed

Patient Education

.ee the list $elo':

The #atient should $e educated in the #ro#er #erformance of Achilles tendon stretchin"

The #atient should understand the rationale for a##ro#riate foot'ear

A #atient 'ho is considerin" corticosteroid in(ection must understand the #otential risks and

$enefits of this treatment

For #atient education resources, see the Foot, Ankle, nee, and 4i# Center, as 'ell

as!ursitis
http://www.emedicinehealth.com/collections/CO1549.asphttp://www.emedicinehealth.com/articles/4717-1.asphttp://www.emedicinehealth.com/articles/4717-1.asphttp://www.emedicinehealth.com/articles/4717-1.asphttp://www.emedicinehealth.com/collections/CO1549.asphttp://www.emedicinehealth.com/articles/4717-1.asp

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