What is the best treatment for a patient with bursitis in the heel?

Treatment for Heel Bursitis

Begin with conservative therapy including open-backed shoes, NSAIDs, accommodative padding, activity modification, and physical therapy for 6-8 weeks; if symptoms persist, add corticosteroid injection into the bursa (carefully avoiding the Achilles tendon), and refer to a podiatric foot and ankle surgeon if no improvement occurs. 1

Initial Conservative Management (0-6 Weeks)

The American College of Foot and Ankle Surgeons recommends starting with non-invasive measures that address both inflammation and mechanical irritation 1:

Footwear Modifications

• Wear open-backed shoes to eliminate direct pressure on the posterior heel 1
• Avoid tight or closed-back footwear that aggravates the inflamed bursa 1
• Use accommodative padding around the affected area to redistribute pressure 1

Anti-Inflammatory Therapy

• Start NSAIDs such as naproxen 500 mg twice daily for pain relief and inflammation reduction 1, 2
• For acute bursitis, naproxen may be dosed as 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours 2
• Apply ice through a wet towel for 10-minute periods to reduce inflammation 3

Activity and Biomechanical Interventions

• Use heel lifts or orthoses to reduce tension on the posterior heel structures 1
• Modify activities that worsen symptoms, particularly those involving repetitive heel friction 4, 5
• Perform regular calf-muscle stretching exercises 3-5 times daily 3
• Consider weight loss if indicated to reduce mechanical stress 1

Physical Therapy

• Structured rehabilitation programs with active supervised exercises facilitate healing better than passive modalities 4
• Stretching exercises focused on the lower back and sacroiliac joints may provide additional benefit 6

If No Improvement After 6-8 Weeks

Refer to a podiatric foot and ankle surgeon while continuing initial treatments 1:

Corticosteroid Injection

• Inject corticosteroids directly into the inflamed bursa, using extreme caution to avoid the Achilles tendon 1, 5
• A typical regimen is 24 mg betamethasone with 1% lidocaine (or equivalent) 6
• Critical caveat: Never inject corticosteroids into or near the Achilles tendon insertion due to significant rupture risk 1, 7, 5
• Ultrasound guidance is strongly encouraged to confirm inflammation and ensure accurate needle placement away from the tendon 8

Advanced Conservative Measures

• Consider immobilization with a cast or fixed-ankle walker-type device for particularly acute or refractory cases 1
• Continue all initial conservative treatments alongside advanced interventions 1

Surgical Intervention for Refractory Cases

If symptoms persist despite 6-8 weeks of conservative therapy plus corticosteroid injection, surgical options should be considered 1:

• The indicated procedure is resection of the prominent posterior superior aspect of the calcaneus (Haglund's deformity) and removal of the inflamed bursa 1
• Some patients may require calcaneal osteotomy to correct underlying calcaneal alignment 1
• Surgical intervention shows satisfactory outcomes in 90% of chronic refrocalcaneal bursitis cases, with mean functional scores improving from 46/100 to 89/100 at one year 9
• Surgery is reserved for intractable symptoms not responsive to conservative management 5, 9

Key Clinical Distinctions

Pain relieved when walking barefoot but aggravated by shoe pressure is pathognomonic for heel bursitis associated with Haglund's deformity 1, 7. This distinguishes it from:

• Insertional Achilles tendonitis (central or global tenderness at tendon insertion) 1
• Plantar fasciitis (medial plantar heel pain, worse with first steps in morning) 7
• Neurologic heel pain (burning, tingling, or numbness) 1, 7

Critical Pitfalls to Avoid

• Never inject corticosteroids near the Achilles tendon insertion—this creates substantial risk of tendon rupture 1, 7, 8, 5
• Bursal aspiration of chronic microtraumatic bursitis is generally not recommended due to risk of iatrogenic septic bursitis 10
• If infection is suspected (acute onset, fever, erythema), perform bursal aspiration with Gram stain, culture, and crystal analysis before initiating antibiotics effective against Staphylococcus aureus 10
• Avoid complete immobilization initially, as this can lead to muscular atrophy and deconditioning 7