Bursitis of the heel

Introduction

Bursitis of the heel is an inflammation of the small fluid-filled sacs (bursae) located at the back or bottom of your heel. You might call it “heel bursitis” or “Achilles bursitis” in casual chat. It can seriously affect your daily life—walking, running, even standing in line at the coffee shop feels like a chore. It's pretty common in runners, hikers, or anyone who wears stiff shoes (hello, high heels). In this article we’ll talk about how it shows up, what causes it, available treatments and what to expect down the road.

Definition and Classification

Medically, bursitis of the heel refers to inflammation of one or more bursae around the heel bone (calcaneus). Bursae are tiny, fluid-filled sacs that cushion bones, tendons and muscles.

• Retrocalcaneal bursitis: Inflammation between the Achilles tendon and the heel bone, often called pump bump.
• Subcutaneous calcaneal bursitis: Affects the small bursa just under the skin at the back of the heel—think tender bump where your shoes rub.
• Classification: Usually acute if symptom onset is within days, or chronic when it persists beyond six weeks.

Depending on cause, you might see terms like mechanical (overuse), infectious (rare) or inflammatory (associated with arthritis). Bursitis of the heel mainly involves the musculoskeletal system, specifically the Achilles tendon region and posterior heel soft tissue.

Causes and Risk Factors

Bursitis of the heel develops when the bursa becomes irritated or inflamed. Here's a more detailed look:

• Overuse and mechanical stress: Repetitive activities—running, jumping, brisk walking—can overload the Achilles insertion. Runners who ups their mileage too fast often trigger inflammation.
• Footwear: Shoes with rigid backs (like work boots or high heels) press on the heel bursa, causing friction and microtrauma. Remember your friend Karen from yoga class who switched to sky-high wedges? Not a great idea.
• Biomechanical factors: Flat feet (pes planus) or high arches alter how forces transmit through your heel. Abnormal gait can increase pressure on the retrocalcaneal bursa.
• Tight Achilles tendon: Lack of calf stretching reduces ankle dorsiflexion, compressing the bursa when you move. A mailman I know skipped his daily calf stretches for months—ouch.
• Obesity: Extra body weight increases loading on heel structures, raising bursitis risk.
• Systemic inflammatory conditions: Rheumatoid arthritis or gout can trigger bursitis through crystal deposition or autoimmune inflammation, though less common in the heel compared to the elbow or knee.
• Infection: Penetrating injury or nearby cellulitis might cause septic bursitis. This is rare for the heel but needs urgent care.

Risk factors break down into:

• Modifiable: Footwear choices, training errors, tight muscles, poor biomechanics, overweight.
• Non-modifiable: Age-related tendon degeneration, certain systemic diseases, genetics of foot shape.

In many cases, it’s a mix—genetics give you high arches, then you pick the wrong sneakers and ramp up your mileage, and bam: bursitis of the heel.

Pathophysiology (Mechanisms of Disease)

Understanding how bursitis of the heel develops involves looking at the bursa’s normal role. These sacs reduce friction between the Achilles tendon and calcaneus bone or beneath skin. When overloaded, the bursa’s lining cells (synoviocytes) ramp up fluid production and release inflammatory mediators like prostaglandins and cytokines.

• Microtrauma: Tiny tears in adjacent tendons or repetitive shearing forces injure bursal tissue, drawing immune cells and causing swelling.
• Inflammatory cascade: Neutrophils and macrophages migrate in, releasing proteolytic enzymes that break down tissue—this perpetuates inflammation.
• Edema and fibrosis: Fluid accumulates in the bursa, making it distended and tender. Over time, chronic cases see bursal wall thickening and scar tissue formation, reducing the cushion’s elasticity.
• Biomechanical disruption: Inflamed bursa changes heel mechanics, leading to altered gait, compensatory loading on midfoot and forefoot, and increased risk of plantar fasciitis or tendon tears.

So, boll weevil style: small damage begets inflammation, begets more damage, until you end up with a swollen, painful heel sac.

Symptoms and Clinical Presentation

Symptoms can vary but typically include:

• Pain: Localized to the back of the heel or just below the Achilles tendon. Often worse first thing in the morning or after sitting for a while (post-static dyskinesia).
• Swelling and warmth: The heel looks puffy, sometimes red if superficial bursa is involved.
• Tender bump: You might feel a palpable lump—classic “pump bump” if you wear heels often.
• Stiffness: Reduced ankle flexibility, difficulty flexing foot upward without pain.
• Crepitus: A grating sensation when ankle moves, from roughened tendon sliding over an inflamed bursa.

Early stage: mild discomfort after activity; you might ignore it. Advanced: pain at rest, limping, possible compensatory hip or knee pain. Presentation differs person-to-person—some feel sharp stabbing when climbing stairs, others ache all day.

Warning signs requiring prompt care:

• Fever with heel pain (possible septic bursitis).
• Severe inability to bear weight.
• Red streaks or intense heat around the bursa (infection).
• Sudden worsening of pain without any clear cause (consider tendon rupture).

Diagnosis and Medical Evaluation

Diagnosing bursitis of the heel usually starts with:

• History: Onset, activities, footwear, and prior injuries.
• Physical exam: Inspection for swelling, palpation of tenderness, assessment of ankle range of motion. The doctor checks if pain localizes to the retrocalcaneal bursa (deep) or subcutaneous bursa (superficial).

Imaging helps confirm and rule out other causes:

• X-ray: Rules out bone spurs or calcifications. Usually normal in bursitis.
• Ultrasound: Visualizes fluid-filled bursae, bursal wall thickening, and may guide aspiration.
• MRI: Reserved for chronic or complicated cases; shows soft-tissue contrast—can distinguish tendon tear vs bursitis.

Laboratory tests if infection or systemic disease suspected:

• Blood counts, ESR/CRP (inflammatory markers).
• Joint/bursal fluid analysis if aspiration performed (to check for bacteria or crystals).

Differential diagnosis includes Achilles tendinopathy, plantar fasciitis, Haglund’s deformity, stress fractures of calcaneus, or cellulitis. Usually the exam plus targeted imaging clarifies the cause.

Which Doctor Should You See for Bursitis of the heel?

If you suspect heel bursitis, start with your primary care physician or a general practitioner—they can evaluate basic history and exam. They might recommend seeing:

• Orthopedic specialist—particularly a foot and ankle surgeon if structural issues or surgery considered.
• Podiatrist—expert in foot biomechanics, custom orthotics, and conservative care plans.
• Physical therapist—for guided rehab exercises, stretching, and manual therapy.

Urgent or emergent care: go to the ER if you have severe pain, fever, redness spreading beyond the heel, or inability to bear weight—possible septic bursitis or tendon rupture.

Online consultations (telemedicine) can be really helpful for initial guidance, second opinions, interpreting imaging, or clearing up questions you forgot to ask in person. However, remote visits don’t replace hands-on exam or urgent care if you need it.

Treatment Options and Management

Management of bursitis of the heel typically follows a stepwise approach:

• Rest and activity modification: Avoid aggravating activities; reduce mileage or intensity in running.
• Ice therapy: 15–20 minutes, 3–4 times daily to reduce swelling.
• NSAIDs: Ibuprofen or naproxen to manage pain and inflammation for short-term use.
• Shoe modifications: Cushioned heel pads, soft-backed shoes, or switching from heels to supportive sneakers.
• Physical therapy: Heel cord stretching, eccentric calf exercises, massage, and ultrasound therapy.
• Corticosteroid injection: For persistent cases—guided by ultrasound, may give relief but carries small risk of tendon weakening.
• Orthotics: Custom insoles to correct biomechanical issues.
• Surgery: Rarely needed—debridement of inflamed bursa or removal of Haglund’s bump if structural.

First-line = conservative care; second-line = injections; third-line = surgical intervention for refractory cases.

Prognosis and Possible Complications

Most people improve with conservative measures within 4–6 weeks. Chronic cases may linger for months, especially with ongoing irritants (like ill-fitting shoes).

• Good prognosis if early activity modification and proper footwear.
• Complications:
  • Chronic bursitis with fibrotic changes, limiting ankle mobility.
  • Development of Achilles tendinopathy or tendon rupture from untreated inflammation.
  • Infection leading to septic bursitis—rare but serious.
  • Altered gait causing knee, hip, or back pain due to compensation.

Factors worsening prognosis: delayed treatment, obesity, diabetes, systemic inflammatory diseases, or repeated heel trauma.

Prevention and Risk Reduction

While you can’t eliminate all risk, you can do a lot to reduce bursitis of the heel:

• Proper footwear: Choose shoes with soft heel counters and good arch support. Rotate pairs—don’t wear the same runners every day.
• Gradual training: Increase running or walking volume by max 10% per week. Avoid sudden spikes in activity.
• Stretching and strengthening: Daily calf stretches, Achilles eccentric exercises, foot intrinsic muscle drills.
• Weight management: Reducing body weight decreases load on heel structures.
• Orthotics: Insoles or heel lifts to correct flat feet or high arches—reduces shear on the bursa.
• Cross-training: Mix low-impact activities (swimming, cycling) with running to give your heels a break.
• Regular check-ups: If you have arthritis or diabetes, keep medical follow-up to manage systemic inflammation or neuropathy.
• Early recognition: Stop activity at first sign of heel pain, ice the area, and evaluate—nipping it early is key.

Prevention isn’t foolproof, but these measures cut risk significantly and improve recovery if bursitis does occur.

Myths and Realities

Misconceptions around bursitis of the heel are common—let's clear a few up:

• Myth: Heel bursitis only happens in runners.

  Reality: Not true—any repetitive heel pressure (standing jobs, dancers, hikers) can cause bursitis.

• Myth: You need surgery for bursitis of the heel.

  Reality: Over 90% respond to conservative care—rest, ice, NSAIDs, therapy.

• Myth: Heel pain equals plantar fasciitis.

  Reality: Heel bursitis localizes at the back of the heel, while plantar fasciitis hurts under the arch.

• Myth: Steroid injections permanently weaken the tendon.

  Reality: Properly guided injections are generally safe; risk is small if dosing and technique are correct.

• Myth: Losing weight cures bursitis.

  Reality: Weight loss reduces strain but must accompany biomechanical corrections and rehab.

• Myth: Bursitis can’t recur.

  Reality: Without addressing risk factors (like footwear or training errors), bursitis often returns.

Sorting fact from fiction helps you tackle heel bursitis with realistic expectations and effective strategies.

Conclusion

Bursitis of the heel is a common, often painful, but usually treatable condition when caught early. We’ve covered what heel bursitis is, why it happens—from mechanical stress to systemic disease—how it shows up, and the broad spectrum of diagnostic tools. Conservative management, including rest, ice, NSAIDs, footwear changes, and therapy, resolves most cases within weeks to months. Rarely, injections or surgery become necessary. Prevention focuses on smart training, proper shoes, and maintaining flexibility. If symptoms worsen or infection is suspected, timely medical evaluation is essential. Remember, this guide doesn’t replace professional advice—talk to your healthcare provider for personalized care. Here’s to pain-free steps ahead!

Frequently Asked Questions

• Q: What is bursitis of the heel?
  A: Inflammation of the fluid-filled bursa at the back or bottom of the heel, causing pain and swelling.
• Q: How do I know if my heel pain is bursitis and not plantar fasciitis?
  A: Heel bursitis hurts at the back or side of the heel, while plantar fasciitis is under the arch near the heel bone.
• Q: Can heel bursitis heal on its own?
  A: Mild cases may improve with rest and ice, but most need targeted treatment like stretching and NSAIDs.
• Q: When should I see a doctor for heel bursitis?
  A: If pain persists beyond two weeks, worsens, or is accompanied by fever, redness or inability to bear weight.
• Q: Are there specific shoes that prevent heel bursitis?
  A: Choose shoes with cushioned heel counters, good arch support, and enough room at the back to avoid rubbing.
• Q: Do heel lifts or orthotics help?
  A: Yes, they can correct biomechanical issues like flat feet or high arches, reducing pressure on the bursa.
• Q: Is corticosteroid injection safe for heel bursitis?
  A: Generally safe when ultrasound-guided; small risk of tendon weakening if overused.
• Q: How long does recovery usually take?
  A: With conservative care, most people improve in 4–6 weeks, though some need months if chronic.
• Q: Can heel bursitis recur?
  A: Yes, if underlying risk factors (training errors, poor footwear) aren’t addressed, recurrence is common.
• Q: Are exercises important for healing?
  A: Absolutely—calf stretches and eccentric calf raises help restore tendon flexibility and reduce bursal stress.
• Q: When is surgery necessary?
  A: Rarely. It’s reserved for refractory cases, large Haglund’s deformities, or persistent bursitis despite conservative therapy.
• Q: Can I use heat instead of ice?
  A: Ice is preferred in acute phase to reduce swelling; heat may be beneficial later for muscle relaxation.
• Q: Does weight loss help heel bursitis?
  A: Losing excess weight reduces stress on heel structures, but must be combined with proper rehab.
• Q: Is heel bursitis contagious?
  A: No, it’s an inflammatory condition, not an infection, unless septic bursitis occurs (rare).
• Q: How can telemedicine help with heel bursitis?
  A: Online visits can guide initial care, interpret imaging results, provide stretching routines, and offer second opinions, but can’t fully replace in-person exams for complex cases.