A bursa is a fluid-filled sac that acts as a cushion to reduce friction between tissues of the body such as tendons and bones. When a bursa becomes inflamed, the condition is known as bursitis.

At the back of the heel there is a superficial (just under the skin) bursa which acts to cushion and reduce the friction in the underlying Achilles tendon. Irritation and inflammation of the bursa results in superficial calcaneal bursitis. This is one of several causes of heel pain as shown in the image below.

An MRI of the hindfoot and the common causes of heel pain – note the site of superficial calcaneal bursitis

Superficial calcaneal bursitis is often caused by excessive friction on the skin overlying the Achilles tendon. This can be caused by:

• Wearing poorly fitted shoes (for example tight)
  
• Wearing high heels
• Overuse activities involving repetitive calf contractions
  • Walking or running excessively or sudden increase in activity
  • Rowing
  • Dancing
• Direct trauma to the bursa

Pain and swelling are the most common symptoms of superficial calcaneal bursitis.

Pain

Tenderness directly over the bursa. May be worse after activity and exercise for example at night or the next morning. Eventually the pain will become more severe and limit exercise and activity. Some patients may find themselves limping.

Swelling

Posterolateral heel swelling. Can become very swollen and red. Wearing shoes may become very difficult due to pressure and pain.

Clinical picture of a patient with an inflamed superficial calcaneal bursa

Usually the diagnosis can be made, based on the history and clinical examination.

Radiographs

Radiographs (x-rays) are a useful first line investigation to rule out any other problems in the hindfoot.

Ultrasound

Ultrasound is used to confirm the diagnosis, and to see if there is anything else that may be causing the symptoms for example retrocalcaneal bursitis.

MRI

Occasionally MRI is useful in confirming the diagnosis and ruling out other causes of heel pain. It provides excellent high definition static images.

Most patients heal very well and quickly with proper management.

Patients with superficial calcaneal bursitis who ignore their symptoms or who are mismanaged may develop chronic swelling and pain.

Clinical picture of the foot in a patient with severe superficial calcaneal bursitis

Non-operative management for superficial calcaneal bursitis aims at relieving pain and return to full activity including sports whenever possible.

It should always be the first line of treatment. Options include:

Activity modification and time

A short period of rest from sports and exercise that bring on symptoms. Fitness can be maintained by other non impact activities such as swimming and pool based exercises.

Footwear modification

Minimising pressure on the heel will ease the pain. Shoes with soft padding at the heel, using sandals and avoid heel straps. Avoid or minimise the time spent wearing high heels if not already doing so.

Ice

Application of ice for regular periods during the acute stage of bursitis may alleviate painful symptoms.

Non steroidal anti-inflammatories

The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with superficial calcaneal bursitis.

Analgesics

The use of paracetamol and other painkillers to help reduce pain levels.

Physiotherapy

Physiotherapy is important with this condition to hasten the healing process, ensure an optimal outcome and prevent recurrence.

Treatment may comprise:

• Exercises to improve strength, flexibility and balance
• Education
• Activity modification advice
• Biomechanical correction
• A graduated return to activity and exercise program

Patients who fail to benefit from conservative (non-operative) management, may benefit from an ultrasound guided steroid injection.

Steroids reduce inflammation. The aim of the injection would be to reduce the inflammation in the bursa and ease symptoms.

Prior to the injection the bursa may be aspirated (fluid drained).

The outcome of the injection may be:

• No pain relief
• Temporary pain relief
• Permanent pain relief

Surgical management is reserved for patients who have failed to respond to non operative treatment. Surgery for this condition is extremely rare.

Patients should understand that the decision to undergo surgery should not be taken lightly.

Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.

Please discuss with your surgeon Mr Malik for further information.

It should be borne in mind that complications can result from a condition with or without surgery.

Potential complications of non-operative treatment include:

• Worsening pain
• Increasing bump at the back of the heel
• Infection of the bursa