Retrocalcaneal Bursitis

Retrocalcaneal bursitis is classified by underlying cause:

• Mechanical / Primary: associated with Haglund deformity and biomechanical overload (most common)
• Inflammatory: associated with seronegative spondyloarthropathies (bilateral, morning stiffness, often HLA-B27 positive)
• Septic: rare bacterial infection of the bursa (acute, erythema, fever)

Classification by associated pathology guides treatment:

• Isolated bursitis: bursal inflammation alone, best prognosis
• Haglund syndrome: triad of posterosuperior prominence, retrocalcaneal bursitis and insertional Achilles tendinopathy
• Combined superficial and deep bursitis: both bursal spaces involved

Standing Examination:

• Observe hindfoot alignment (varus predisposes to lateral impingement)
• Assess for visible posterosuperior prominence (Haglund deformity)
• Look for erythema suggesting superficial bursitis
• Check for swelling anterior to Achilles tendon insertion

Gait Assessment:

• Antalgic gait with shortened stance phase
• Reduced push-off power
• May adopt toe-walking pattern to avoid dorsiflexion
• Assess for limb length discrepancy

The visual appearance can help differentiate superficial from deep bursitis. Superficial bursitis presents with obvious posterior swelling that is fluctuant and superficial to the Achilles. Retrocalcaneal bursitis shows subtle fullness on either side of the Achilles when viewed from posterior aspect.

Systematic Approach:

1. Achilles tendon substance - check for nodularity or thickening
2. Achilles insertion on calcaneus - tenderness suggests insertional tendinopathy
3. Retrocalcaneal space - palpate anterior to Achilles on either side
4. Posterosuperior calcaneus - assess for bony prominence
5. Superficial bursa - palpate between Achilles and skin

Two-Finger Squeeze Test:

• Compress area anterior to Achilles between thumb and index finger
• Positive test reproduces characteristic pain
• Sensitivity approximately 85% for retrocalcaneal bursitis
• More specific than simple palpation of posterior heel

Pain localization is crucial for diagnosis. Pain anterior to the Achilles insertion suggests retrocalcaneal bursitis, while pain at the insertion suggests insertional tendinopathy. Both conditions frequently coexist.

Ankle Dorsiflexion Assessment:

• Measure dorsiflexion with knee extended (gastrocnemius tight)
• Measure dorsiflexion with knee flexed (gastrocnemius relaxed)
• Normal dorsiflexion: 15-25 degrees with knee extended
• Pain at end-range dorsiflexion suggests bursal compression

Provocative Maneuvers:

1. Forced dorsiflexion test - passive ankle dorsiflexion reproduces posterior heel pain
2. Active plantarflexion against resistance - may reproduce pain if Achilles involvement
3. Single heel raise - assesses Achilles function and reproduces pain

Ankle equinus (dorsiflexion less than 10 degrees) is present in approximately 60% of patients and contributes to increased bursal pressure during gait. Assessment should include both gastrocnemius and soleus contribution to equinus.

Clinical Assessment Tools:

Painful Arc Sign:

• Pain during specific arc of ankle motion (typically mid to end-range dorsiflexion)
• Indicates bursal compression during movement
• Helps differentiate from Achilles tendinopathy

Differential Diagnosis Tests:

• Thompson test to rule out Achilles rupture (should be negative)
• Simmonds test for Achilles continuity
• Heel raise test for Achilles function
• Check for sinus tarsi tenderness (lateral hindfoot pathology)
• Palpate for tarsal tunnel structures (posterior tibial nerve)

A comprehensive examination includes assessment of the entire lower limb kinetic chain including hip rotation, knee alignment, and foot pronation as contributing factors to abnormal heel loading.

Classification Overview

Retrocalcaneal bursitis is classified based on etiology and associated pathology:

Etiological Classification:

• Mechanical/Primary: Associated with Haglund deformity and biomechanical factors
• Inflammatory: Associated with systemic inflammatory arthropathies
• Septic: Rare bacterial infection of the bursa

Severity Classification:

• Mild: Bursal inflammation only, minimal functional limitation
• Moderate: Bursal inflammation with Haglund deformity
• Severe: Combined pathology with insertional Achilles tendinopathy

Advanced Classification Considerations

By Associated Pathology:

• Isolated bursitis: Pure bursal inflammation without bony or tendon involvement
• Haglund syndrome: Classic triad of Haglund deformity, retrocalcaneal bursitis, and insertional Achilles tendinopathy
• Bilateral disease: Suggests systemic inflammatory condition

Fowler-Philip Angle Classification:

• Greater than 75 degrees: Prominent posterosuperior tuberosity
• 44-69 degrees: Normal range
• Less than 44 degrees: Associated with increased retrocalcaneal pressure

Bursal Anatomy

Retrocalcaneal Bursa:

• Lies between Achilles tendon and posterosuperior calcaneal tuberosity
• Normal dimensions: 6mm anterior-posterior, 3mm depth
• Contains less than 1mL synovial fluid normally
• Does NOT communicate with ankle joint

Superficial Calcaneal Bursa:

• Located between Achilles tendon and skin
• Often develops secondary to friction from footwear
• May coexist with retrocalcaneal bursitis

Calcaneal Anatomy:

• Posterosuperior tuberosity is site of Haglund prominence
• Achilles insertion on posterior calcaneus below bursa
• Fowler-Philip angle measures prominence of posterosuperior corner

Advanced Anatomic Considerations

Biomechanical Anatomy:

• Bursa reduces friction between Achilles and calcaneus during dorsiflexion
• Bursal compression greatest at end-range dorsiflexion
• Haglund prominence increases compressive load on bursa

Blood Supply:

• Bursa receives supply from adjacent soft tissues
• Achilles tendon has watershed area 2-6cm proximal to insertion

Nerve Supply:

• Sural nerve courses posterolateral to lateral malleolus
• At risk during surgical approach

Technique: Posterolateral Incision

Patient Positioning:

• Prone or lateral decubitus position
• Tourniquet application optional
• Bump under ipsilateral hip if prone
• Ensure adequate fluoroscopy access

Surgical Steps:

1. Incision: 6-8cm posterolateral incision centered over posterosuperior calcaneus, lateral to Achilles tendon midline to avoid scar contracture

2. Dissection: Identify and protect sural nerve branches, incise deep fascia, identify retrocalcaneal bursa lateral to Achilles

3. Bursal Excision: Complete excision of thickened bursal tissue, visualize insertion of Achilles on posterosuperior calcaneus

4. Haglund Resection: If prominent, use osteotome or sagittal saw to resect posterosuperior prominence parallel to posterior facet of calcaneus

5. Bone Recontouring: Smooth remaining bone with rongeur or burr, ensure no sharp edges, preserve Achilles insertion

6. Achilles Assessment: Inspect for insertional pathology, debride diseased tissue if present, repair insertion if detached

7. Closure: Deep dermal sutures, skin closure with interrupted or continuous suture, sterile dressing, posterior splint in neutral

Key Technical Points:

• Incision must be lateral to avoid wound healing complications
• Preserve minimum 1cm superior calcaneal attachment of Achilles
• Resect prominence but maintain calcaneal pitch greater than 30 degrees
• Aggressive debridement of Achilles risks rupture

The posterolateral approach provides excellent visualization of the retrocalcaneal space and allows complete bursectomy with or without Haglund resection while protecting the Achilles insertion.

Technique: Endoscopic Calcaneoplasty

Advantages:

• Smaller incisions with improved cosmesis
• Less soft tissue dissection
• Potentially faster recovery
• Direct visualization of retrocalcaneal space

Portal Placement:

• Lateral portal: 2cm proximal and 1cm lateral to superior calcaneus
• Medial portal: 2cm proximal and 1cm medial to superior calcaneus
• Accessory portal if needed for instrumentation

Surgical Steps:

1. Portal Creation: Make small incisions, blunt dissection to retrocalcaneal space, insert 4.0mm arthroscope

2. Bursal Resection: Use arthroscopic shaver to remove inflamed bursal tissue, achieve complete bursectomy

3. Haglund Visualization: Identify posterosuperior prominence, assess extent of resection needed

4. Bone Resection: Use arthroscopic burr to resect prominence, fluoroscopic guidance to confirm adequate resection

5. Final Assessment: Ensure smooth contour, no residual impingement, Achilles insertion intact

6. Closure: Simple portal closure, sterile dressing, posterior splint

Limitations:

• Steep learning curve
• Limited ability to address severe Achilles pathology
• Equipment and expertise dependent
• Possible neurovascular injury with portal placement

Endoscopic technique is increasingly popular but requires specific training and may not be suitable for complex cases with significant Achilles tendinopathy.

Technique: With Achilles Detachment and Repair

Indications:

• Significant insertional Achilles tendinopathy requiring debridement
• Extensive Haglund deformity requiring wide resection
• Calcification within Achilles insertion
• Failed previous surgery without detachment

Surgical Steps:

1. Achilles Detachment: Sharply detach Achilles from posterosuperior calcaneus, maintain soft tissue sleeve, preserve medial and lateral insertional fibers if possible

2. Tendon Debridement: Excise diseased tendon tissue, remove intratendinous calcifications, debride to healthy bleeding tendon

3. Bone Preparation: Complete bursectomy, aggressive Haglund resection, prepare bone surface for reattachment, create trough or drill holes

4. Achilles Repair: Reattach with suture anchors (typically 2-3 anchors), tension-free repair, augment with FHL transfer if greater than 50% debridement

5. Closure: Careful soft tissue closure, drain placement optional, splint in equinus position

Fixation Options:

• Suture anchors: 5.0mm or 5.5mm titanium or bioabsorbable
• Bone tunnels with suture passage
• Combination techniques
• Augmentation with FHL or FDL transfer if needed

Detachment and repair allows complete treatment of combined pathology but requires protected weight-bearing and longer rehabilitation period.

Clinical Assessment Summary

History Taking:

• Duration and onset of symptoms
• Activity relationship (running, sport participation)
• Footwear aggravation
• Prior treatments attempted
• Systemic symptoms (bilateral, morning stiffness suggests inflammatory cause)

Examination Protocol:

• Standing inspection for hindfoot alignment
• Palpation of retrocalcaneal space (two-finger squeeze test)
• Range of motion assessment
• Differential testing (Thompson test for Achilles rupture)

Key Clinical Signs:

• Two-finger squeeze test positive (85% sensitivity)
• Pain with forced dorsiflexion
• Visible posterosuperior prominence (Haglund)

Advanced Clinical Assessment

Differential Diagnosis by Examination:

• Tenderness AT insertion = insertional tendinopathy
• Tenderness ANTERIOR to insertion = retrocalcaneal bursitis
• Visible posterior swelling = superficial bursitis
• Pain with plantarflexion = posterior impingement

Provocative Maneuvers:

• Ankle dorsiflexion test compresses bursa
• Single heel raise assesses Achilles function
• Squeeze test with ankle plantarflexed relaxes Achilles, isolates bursa

Investigation Summary

First-Line:

• Weight-bearing lateral foot radiograph
• Assess for Haglund prominence using parallel pitch lines
• Calculate Fowler-Philip angle (normal 44-69 degrees)

Second-Line:

• MRI if diagnosis uncertain or surgical planning needed
• Ultrasound for bursal assessment and guided injection

When to Order Bloods:

• Bilateral involvement
• Young patient without mechanical cause
• Features of inflammatory arthropathy
• Tests: ESR, CRP, RF, anti-CCP, HLA-B27, uric acid

Advanced Investigation Considerations

Radiographic Measurements:

• Parallel pitch lines method identifies Haglund prominence
• Fowler-Philip angle less than 44 degrees increases bursal pressure
• Posterior calcaneal angle (Chauveaux-Liet angle)

MRI Findings:

• T2 high signal in bursa (fluid distension greater than 3mm)
• Achilles tendon signal changes (if tendinopathy)
• Bone marrow edema in calcaneus (reactive changes)

Ultrasound Features:

• Anechoic or hypoechoic fluid collection greater than 3mm
• Achilles thickening at insertion
• Dynamic assessment with dorsiflexion

Surgical Technique Summary

Open Posterolateral Approach:

1. Position: Prone or lateral decubitus
2. Incision: 6-8cm posterolateral, lateral to Achilles midline
3. Identify and protect sural nerve branches
4. Incise deep fascia, identify retrocalcaneal bursa
5. Complete bursectomy
6. Haglund resection if prominent (parallel to posterior facet)
7. Smooth remaining bone with rongeur or burr
8. Preserve Achilles insertion
9. Layered closure, posterior splint in neutral

Endoscopic Approach:

• 2-portal technique (medial and lateral)
• Arthroscopic bursectomy and calcaneoplasty
• Smaller incisions, potentially faster recovery

Advanced Surgical Considerations

Key Technical Points:

• Incision must be lateral to midline to avoid wound healing problems
• Preserve minimum 1cm superior calcaneal attachment of Achilles
• Resect prominence but maintain calcaneal pitch greater than 30 degrees
• If greater than 50% Achilles insertion debrided, consider FHL augmentation

Achilles Detachment Indications:

• Significant insertional tendinopathy requiring debridement
• Extensive Haglund requiring wide resection
• Intratendinous calcification
• Reattach with 2-3 suture anchors

Complication Overview

Early Complications:

• Wound healing problems (6%) - especially with midline incisions
• Infection (less than 2%)
• Hematoma

Late Complications:

• Sural nerve injury (3%) - numbness lateral foot, neuroma
• Achilles rupture (2%) - higher risk if aggressive debridement
• Recurrence (5-10%) - usually from inadequate resection

Prevention Strategies:

• Use lateral incision, not midline
• Protect sural nerve throughout dissection
• Preserve Achilles insertion where possible
• Adequate but not excessive Haglund resection

Advanced Complication Management

Sural Nerve Injury:

• Initial: Observation, desensitization therapy
• Persistent pain: Neuropathic medications (gabapentin)
• Symptomatic neuroma: Surgical excision and nerve burial

Achilles Rupture Prevention:

• Limit insertion debridement to less than 50%
• If greater than 50% required, augment with FHL transfer
• Protected weight-bearing post-operatively

Recurrence Management:

• Re-assess adequacy of initial resection
• Revision surgery with adequate calcaneal ostectomy
• Address any untreated contributing factors

Rehabilitation Protocol

Phase 1 (Weeks 0-2): Protection

• Non-weight bearing in posterior splint or CAM boot
• No active dorsiflexion
• Toe range of motion, quad sets, hip strengthening

Phase 2 (Weeks 2-6): Early Motion

• Partial weight bearing in CAM boot
• Gentle passive ROM, progress to active
• Begin pool therapy if available

Phase 3 (Weeks 6-12): Strengthening

• Progress weight bearing as tolerated
• Transition from boot to supportive shoe
• Eccentric Achilles strengthening program
• Proprioceptive training

Phase 4 (Months 3-6): Return to Activity

• Sport-specific training
• Plyometrics when appropriate
• Full return to activity 4-6 months

Advanced Rehabilitation Considerations

Modified Protocol if Achilles Detached:

• Extended period of plantarflexion positioning (4 weeks)
• Delayed active ROM to 4-6 weeks
• More gradual progression of strengthening
• Return to sport typically 6-9 months

Milestones for Progression:

• Week 2: Wound healed, suture removal
• Week 6: Full passive ROM
• Week 12: Single heel raise without pain
• Month 4-6: Return to running/sport

Treatment Outcomes

Conservative Treatment:

• Success rate: 80-90% with comprehensive management
• Time to resolution: 3-6 months
• Recurrence: 10-15% with return to previous activity

Surgical Treatment:

• Good to excellent results: 85% at 3-5 year follow-up
• Patient satisfaction: 88-91%
• Return to previous activity level: 75-80%
• Complication rate: 11% overall

Functional Outcomes:

• AOFAS hindfoot scores improve from 52 to 88 post-operatively
• Most patients return to sport by 4-6 months

Advanced Outcome Considerations

Factors Affecting Outcome:

• Favorable: Isolated bursitis, mechanical etiology, good compliance, non-smoker
• Unfavorable: Inflammatory arthropathy, extensive Achilles pathology, workers' compensation, smoking, diabetes

Long-Term Outcomes:

• Most patients maintain good results long-term if activity modifications continued
• Small percentage develop insertional Achilles tendinopathy later
• Importance of ongoing Achilles flexibility and strength maintenance

Key Evidence

Conservative vs Surgical Treatment:

• Conservative management successful in 80-90% of cases
• Surgery reserved for failure of 6+ months conservative treatment
• No significant difference in long-term satisfaction between approaches

Surgical Approach Comparison:

• Open vs endoscopic: Similar satisfaction rates (91% vs 88%)
• Endoscopic may have faster return to work
• Complication rates similar between approaches

Steroid Injection:

• Limited high-quality evidence
• Risk of Achilles rupture outweighs potential benefit
• Not routinely recommended

Advanced Evidence Summary

Key Studies:

• Vaishya 2019: Meta-analysis of 847 patients, 85% good-excellent results at 3.2 years
• Ahn 2021: Endoscopic vs open calcaneoplasty RCT, similar outcomes
• ACFAS Clinical Consensus: 6 months conservative trial before surgery

Evidence Gaps:

• No high-quality RCTs comparing conservative vs surgical
• Limited evidence for injection therapy
• Unclear optimal Haglund resection extent

Global Epidemiology and Practice

• Posterior heel pain (insertional Achilles tendinopathy, retrocalcaneal bursitis and Haglund deformity overlap clinically) accounts for roughly one third of Achilles disorders; the spectrum is most common in adults aged 40-60 and in running/jumping athletes.
• There is no procedure-specific national joint registry for calcaneoplasty or bursectomy (registries capture arthroplasty, not soft-tissue/foot-and-ankle minor procedures), so evidence rests on systematic reviews and cohort series rather than registry survivorship data.
• Universal first principle across all societies: a structured conservative programme for a minimum of 3-6 months before surgical referral.

Imaging access by setting:

• Weight-bearing lateral radiograph is the universally available, low-cost first-line study.
• Ultrasound is the preferred soft-tissue and dynamic tool in most systems (cheap, no radiation).
• MRI is reserved for diagnostic uncertainty or surgical planning and may be rationed in publicly funded or limited-resource settings.

Side-by-Side Guidance and Resource Variation

No single society publishes a dedicated retrocalcaneal bursitis guideline; recommendations are drawn from the overlapping Achilles tendinopathy and Haglund literature.

High- vs limited-resource practice variation:

• High-resource: MRI-guided planning, endoscopic calcaneoplasty, suture-anchor reattachment and FHL augmentation readily available.
• Limited-resource: radiograph and ultrasound-led diagnosis; open bursectomy and bone-tunnel reattachment predominate; emphasis on prolonged supervised conservative care because surgical capacity is scarce.