What is the management of retrocalcaneal bursitis?

Management of Retrocalcaneal Bursitis

Begin with conservative management including rest, ice, NSAIDs, and activity modification, avoiding corticosteroid injections in the retrocalcaneal bursa due to risk of Achilles tendon rupture. 1, 2

Initial Conservative Treatment (First-Line)

• Rest and activity modification to reduce pressure on the affected area, particularly avoiding shoes that compress the posterior heel 1, 3
• Ice application for 10-minute periods through a wet towel for pain relief 1
• NSAIDs for pain and inflammation control as first-line pharmacologic therapy 1, 3
• Heel lifts or shoe modifications to reduce friction between the calcaneus and Achilles tendon 3

When NSAIDs Are Insufficient or Contraindicated

• Analgesics such as paracetamol or opioids may be considered for pain control if NSAIDs are insufficient, contraindicated, or poorly tolerated 4, 1

Critical Caveat: Avoid Corticosteroid Injections

Corticosteroid injections should be avoided in retrocalcaneal bursitis, unlike other forms of bursitis where they may be beneficial 4, 1, 2. This is because:

• Steroid injection into the retrocalcaneal bursa may adversely affect the biomechanical properties of the Achilles tendon 2
• There is an anatomic connection between the retrocalcaneal bursa and anterior fibers of the Achilles tendon, allowing corticosteroid to infiltrate tendon tissue 5
• Case reports document combined ruptures of the Achilles tendon and gastrosoleus complex 6 months after corticosteroid injections for retrocalcaneal bursitis 5

While glucocorticoid injections are recommended for other entheseal areas (such as elbow or other bursae), the retrocalcaneal bursa is specifically excluded from this recommendation 4.

Advanced Conservative Measures

• Immobilization with a cast or fixed-ankle walker-type device may be necessary for persistent symptoms 1
• Avoid complete immobilization to prevent muscular atrophy and deconditioning 1

Surgical Intervention for Refractory Cases

Surgery should be considered when conservative treatment fails after 12 months 1, 6, 7. Surgical options include:

• Endoscopic calcaneoplasty (preferred): Less invasive approach with resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa 1, 7, 2
• Open surgical resection of the calcaneal prominence and bursa for recalcitrant cases 1, 6

The endoscopic approach demonstrates superior outcomes with AOFAS scores improving from 46/100 preoperatively to 89/100 at one year, with 90% satisfactory outcomes 6. Endoscopic technique also allows detection of minor anterior Achilles tendon tears (present in 54% of chronic cases) that may perpetuate symptoms 7.

Referral Indications

• Refer to podiatric foot and ankle surgeon or orthopedic specialist when symptoms persist beyond 12 months despite conservative management 1
• Consider earlier referral if there is concern for partial Achilles tendon tear or Haglund's deformity requiring surgical correction 7

Monitoring for Systemic Disease

• The presence of multiple symptomatic bursae should raise suspicion for systemic rheumatic disease requiring further evaluation 1