Posterior Calcaneal Bursitis
Lower LimbOverview
Posterior calcaneal bursitis is inflammation of the bursa located between the Achilles tendon insertion and the calcaneus, resulting in pain at the posterior heel. This condition commonly affects athletes and individuals with altered biomechanics, causing localized swelling and tenderness directly behind the heel bone.
Pathophysiology
The retrocalcaneal bursa functions to reduce friction between the Achilles tendon and the calcaneal tuberosity. Repetitive microtrauma from excessive dorsiflexion, tight Achilles tendon, or direct compression (such as from rigid shoe heel counters) causes the bursal lining to become inflamed and produces excessive synovial fluid. Associated Haglund's deformity (bony prominence) may exacerbate compression and inflammation. Chronic irritation can lead to bursal fibrosis and adhesions.
Patient Education
Posterior heel pain often improves with activity modification, heel lifts to reduce Achilles tension, and gradual stretching; avoiding high heels and rigid shoes while managing training intensity are essential for recovery.
Typical Presentation
Site
Posterior heel, directly behind the calcaneus between the Achilles tendon insertion and heel bone; may be bilateral
Quality
Dull, aching pain with sharp exacerbation on palpation; may describe pressure or tenderness
Intensity
Mild to moderate pain (3-6/10), worse with activity, variable morning stiffness
Aggravating
Running and jumping, walking uphill, dorsiflexion movements, tight shoes with rigid heel counters, prolonged standing, repetitive stepping
Relieving
Rest and immobilization, heel lifts (0.5-1 inch), anti-inflammatory modalities (ice, NSAIDs), shoes with soft heel padding, gentle stretching
Associated
Localized swelling and erythema over posterior heel, Haglund's deformity on palpation, restricted ankle dorsiflexion, pain on passive plantarflexion, tight Achilles tendon, possible gait alteration
Orthopaedic Tests
Dorsiflexion Compression Test
Procedure
Patient seated or supine with knee extended. Examiner passively dorsiflexes the ankle while applying gentle compression or palpation over the posterior calcaneal bursa (between the Achilles tendon and calcaneus).
Positive Finding
Reproduction of pain or tenderness over the posterior calcaneal bursa region with dorsiflexion and compression.
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Suggests inflammation of the posterior calcaneal bursa; helps differentiate bursal pain from insertional Achilles tendinopathy.
Plantarflexion Compression Test
Procedure
Patient seated or prone. Examiner plantarflexes the ankle to relax the Achilles tendon, then palpates and applies gentle compression over the posterior calcaneal bursa.
Positive Finding
Localized pain or discomfort specific to the bursal site with plantarflexion and compression.
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Positive finding suggests posterior calcaneal bursal involvement; plantarflexion should reduce stretch on Achilles, isolating bursal irritation.
Palpation of Posterior Calcaneal Bursa
Procedure
Patient prone or seated with ankle off edge of table. Examiner palpates directly between the Achilles tendon insertion and posterior calcaneal prominence, applying gentle pressure.
Positive Finding
Localized tenderness, swelling, or fluctuance over the bursa; pain elicited on palpation.
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Direct palpation is a primary clinical indicator of bursal inflammation; swelling may indicate acute bursal distension.
Silfverskiöld Test (Modified for Bursal Irritation)
Procedure
Patient supine with knee extended, then flexed to 90°. Examiner attempts dorsiflexion of the ankle in both positions to assess gastrocnemius and soleus tightness while observing for pain localization over the posterior bursa.
Positive Finding
Asymmetric restriction or reproduction of posterior heel pain (specifically over the bursa rather than diffuse calf pain) when knee is extended versus flexed.
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Helps differentiate posterior calcaneal bursitis from Achilles tendinopathy; bursal pain may be exacerbated by tension on the Achilles.
Functional Movement: Single-Leg Stance with Plantarflexion
Procedure
Patient stands on one leg and rises onto the ball of the foot (plantarflexion), holding for 10–15 seconds. Examiner observes for pain reproduction over the posterior calcaneal region.
Positive Finding
Pain localized to the posterior calcaneal bursa during plantarflexion weight-bearing.
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Reproduces functional loading that typically aggravates posterior calcaneal bursitis; helps confirm symptomatic bursal involvement in weight-bearing.
Achilles Tendon Palpation with Differentiation
Procedure
Patient prone. Examiner palpates the Achilles tendon from mid-calf to insertion, distinguishing tenderness at the tendon insertion from localized bursal tenderness just posterior and superior to the calcaneal insertion.
Positive Finding
Tenderness isolated to the bursal area (posterior to the tendon insertion) rather than the tendon substance itself.
Sensitivity / Specificity
Unknown / Unknown
Interpretation
Clinical differentiation between insertional Achilles tendinopathy and posterior calcaneal bursitis; bursal pain is typically posterior and may be more superficial.
⚠ Red Flags
- •Severe sudden onset pain suggesting Achilles tendon rupture (palpable defect, inability to plantarflex)
- •Signs of systemic infection (fever, chills, spreading erythema, lymphadenopathy)
- •Unilateral swelling with calf pain and warmth suggesting deep vein thrombosis
- •Neurological symptoms (numbness, tingling along foot) suggesting nerve involvement
- •Severe constitutional symptoms or night pain unrelieved by rest
⚡ Yellow Flags
- •High training volume without adequate recovery or load management
- •Excessive focus on heel pain leading to kinesiophobia and activity avoidance
- •Perfectionist or competitive athlete mindset resisting activity modification
- •Previous failed treatments contributing to catastrophization
- •Secondary gain related to sport participation or work avoidance
Osteopathic Techniques
Region
Achilles tendon and posterior calf
Technique
Soft Tissue
Rationale
Deep transverse friction and myofascial release to the Achilles tendon and gastrocnemius-soleus complex reduces muscle tension, improves blood flow to the bursa, and addresses associated trigger points that contribute to compensatory tightness and inflammation
Region
Ankle and subtalar joint
Technique
Articulation
Rationale
Gentle dorsiflexion and plantarflexion articulation restores ankle mobility, reduces abnormal loading through the bursa, and normalizes proprioceptive input to reduce compensatory patterns
Region
Posterior calcaneus and bursal area
Technique
Soft Tissue
Rationale
Gentle soft tissue mobilization directly over the bursa (if not acutely inflamed) and surrounding structures promotes local circulation, reduces adhesions, and addresses fascial restrictions that compress the bursa
Region
Lower leg and foot
Technique
MET
Rationale
Muscle energy techniques applied to the plantarflexors and dorsiflexors restore balanced ankle mobility, reduce Achilles tension, and improve neuromuscular control to prevent recurrent irritation
Region
Whole lower limb kinetic chain
Technique
Functional
Rationale
Functional assessment and treatment of hip abductors, external rotators, and core stability address proximal biomechanical deficits that create compensatory ankle and heel loading patterns
Region
Plantar fascia and foot intrinsics
Technique
Soft Tissue
Rationale
Release of plantar fascia and intrinsic foot muscles improves arch support and reduces compensatory stress through the posterior heel during weight-bearing activities
Add-On Approaches
Chinese Medicine
TCM approach targets Kidney Yang deficiency and local Qi-Blood stagnation using acupuncture points such as BL-60 (Kunlun), BL-57 (Chenshan), and KI-3 (Taixi) combined with moxibustion to warm the channels and promote circulation around the heel
Chiropractic
Chiropractic care may include foot and ankle manipulation to address subtalar joint restrictions, assessment and correction of lower limb alignment, and orthotics prescription to optimize biomechanics and reduce bursal compression
Physiotherapy
Physiotherapy emphasizes eccentric Achilles strengthening (heel-drop exercises), proprioceptive training, progressive loading tolerance, gait retraining, and calf stretching progressions to restore strength and reduce recurrence
Remedial Massage
Remedial massage employs sustained pressure release and myofascial techniques over the gastrocnemius-soleus complex and Achilles insertion, combined with cross-friction techniques to address adhesions and improve tissue extensibility
Rehabilitation Exercises
Doorway Calf Stretch (Gastrocnemius)
Wall-Supported Soleus Stretch (Bent Knee Calf Stretch)
Ankle Plantarflexion and Dorsiflexion (Active ROM)
Ankle Inversion and Eversion Mobility Exercises
Double-Leg Heel Raise (Standing)
Eccentric Heel Lowering (Bilateral to Unilateral Progression)
Single-Leg Heel Raise (Standing Balance)
Seated Toe-Raise with Resistance Band
Single-Leg Stance on Firm Surface
Single-Leg Stance on Foam Surface (Proprioceptive Training)
Plantar Intrinsic Muscle Activation (Towel Scrunches, Marble Pickups)
Resistance Band Plantarflexion and Dorsiflexion Strengthening
Referral Criteria
- •Failure to improve after 4-6 weeks of conservative management including activity modification and structured physiotherapy
- •Suspected Achilles tendon rupture (acute onset, palpable defect, loss of plantarflexion strength, positive Thompson test)
- •Signs of systemic infection or bursal cellulitis (fever, spreading erythema, lymphadenopathy)
- •Severe pain disproportionate to clinical findings or night pain unrelieved by rest suggesting alternative diagnosis
- •Suspicion of bony pathology (Haglund's deformity causing significant functional limitation) requiring imaging assessment
- •Neurological signs suggesting nerve compression or other neural involvement
- •Consideration of imaging (ultrasound or MRI) to confirm bursal inflammation or rule out concurrent pathology such as Achilles tendinopathy or plantar fasciitis