Posterior Calcaneal Bursitis

Lower Limb

Overview

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 posterior calcaneal (retro-Achilles) bursa lies superficially, between the skin and the Achilles tendon; it is distinct from the deeper retrocalcaneal bursa between the tendon and the calcaneus. Repeated friction and direct compression, most often from a rigid shoe heel counter, cause the bursal lining to become inflamed and produce excess fluid. A prominent posterosuperior calcaneus (Haglund’s deformity) increases pressure under the heel counter. 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

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

No accuracy study

Heel Counter Pressure Test

Procedure

Press gently over the back of the heel, where a shoe's heel counter rubs, and ask about pain. Look at the patient's shoes for the rubbing area.

Positive Finding

Tenderness and swelling on the back of the heel, behind the tendon, often with redness or thickened skin.

Interpretation

The posterior calcaneal (retro-Achilles) bursa lies between the skin and the Achilles tendon and is usually irritated by shoe pressure ('pump bump'). The retrocalcaneal bursa is a different bursa, deep to the tendon.

Further reading

No accuracy study

Plantarflexion Compression Test

Procedure

With the ankle relaxed in plantarflexion, palpate the swelling on the back of the heel and gently roll the skin over the tendon.

Positive Finding

A tender, soft swelling that moves with the skin over the tendon.

Interpretation

A superficial swelling that moves with the skin supports posterior calcaneal (superficial) bursitis rather than a problem in the tendon or the deeper bursa.

Further reading

No accuracy study

Palpation of Posterior Calcaneal Bursa

Procedure

Patient prone. Palpate the back of the heel superficially, just under the skin over the lower Achilles tendon, then more deeply at the tendon insertion and in front of the tendon.

Positive Finding

Tenderness in the superficial layer behind the tendon, rather than in the tendon or in front of it.

Interpretation

Helps separate superficial (posterior calcaneal) bursitis from retrocalcaneal bursitis and insertional tendinopathy, which often occur together with a prominent heel bone (Haglund's deformity). Redness, heat and fever suggest infection and need medical assessment.

Sources

Not a diagnostic test

Silfverskiöld Test

Procedure

Patient supine. Hold the heel in neutral and dorsiflex the ankle with the knee straight, then bent to 90°. Compare the range with the other side.

Positive Finding

Dorsiflexion limited with the knee straight and better with it bent (gastrocnemius tightness).

Interpretation

Calf tightness is a common associated finding and a treatment target. Not a diagnostic test for bursitis.

Sources

No accuracy study

Functional Movement: Single-Leg Stance with Plantarflexion

Procedure

Ask the patient to walk in their usual shoes and then barefoot, and to rise onto the toes, noting where pain is felt.

Positive Finding

Pain at the back of the heel in shoes that eases barefoot.

Interpretation

Pain that depends on footwear strongly supports shoe-related superficial bursitis and guides footwear changes (softer or lower heel counter, padding).

Further reading

No accuracy study

Achilles Tendon Palpation with Differentiation

Procedure

Patient prone. Palpate the tendon from the calf to the heel, then the superficial tissue behind it and the area in front of it, noting where pain is greatest.

Positive Finding

Tenderness in the superficial tissue behind the tendon, with the tendon itself less tender.

Interpretation

Separates superficial bursitis from Achilles tendinopathy and retrocalcaneal bursitis. These conditions often occur together.

Sources

⚠ 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

Most bursitis settles with rest, ice, compression and elevation, plus well-fitting footwear that takes pressure off the back of the heel. Steroid injection is not recommended for a superficial bursa like this one, because of the risk of septic bursitis, tendon injury and skin atrophy.

Region

Posterior calf and Achilles tendon (not over the bursa)

Technique

Soft tissue, calf and lower legNo trials found

Rationale

Calf and lower-leg soft tissue is usually given alongside a loading or stretching programme.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the calf (gastrocnemius and soleus), the Achilles tendon and the peroneal and tibial muscles of the lower leg. In trials it was given alongside exercise, such as eccentric calf loading.

Evidence in Posterior Calcaneal Bursitis

Searched 25 Oct 2026: no trials of calf soft tissue in posterior calcaneal bursitis.

Region

Ankle and subtalar joints

Technique

Articulation, ankle and footNo trials found

Rationale

Ankle, subtalar and midfoot glides, mainly to restore dorsiflexion and foot mobility.

How it's done, cautions & evidence

How it's done

Passive, rhythmic, low-velocity glides of the ankle (talocrural), subtalar, midfoot and toe joints, within or up to the end of the available range, often aimed at restoring ankle dorsiflexion.

Cautions

Before mobilising an acute ankle injury, check for fracture with the Ottawa ankle rules (tenderness over either malleolus), and palpate the base of the 5th metatarsal, the navicular and the midfoot for a Lisfranc injury.

Evidence in Posterior Calcaneal Bursitis

Searched 25 Oct 2026: no trials of ankle or subtalar mobilisation in posterior calcaneal bursitis.

Region

Gastrocnemius-soleus (calf)

Technique

Muscle energy, calf (gastrocnemius and soleus)No trials found

Rationale

Calf muscle energy technique to ease gastrocnemius-soleus tightness that limits ankle dorsiflexion.

How it's done, cautions & evidence

How it's done

The calf is taken to its barrier by dorsiflexing the ankle. The patient pushes the foot gently down, at about 10–20% effort, against resistance for 5–10 seconds, relaxes for 3–5 seconds, and the new barrier is taken up.

Cautions

Not used with an acute fracture, a joint infection or a bone malignancy; take care with severe osteoporosis or after surgery that limits muscle contraction. Use the least force needed: too much can tear a muscle or pull off a tendon, especially in older patients.

Evidence in Posterior Calcaneal Bursitis

Searched 25 Oct 2026: no trials of calf muscle energy technique in posterior calcaneal bursitis.

Region

Plantar fascia and foot intrinsics

Technique

Soft tissue, foot and ankleNo trials found

Rationale

Soft tissue to the plantar fascia, foot muscles and the tissues around the heel and ankle ligaments.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the plantar fascia, the small muscles of the foot and the tissues around the heel and the ankle ligaments.

Evidence in Posterior Calcaneal Bursitis

Searched 25 Oct 2026: no trials of plantar foot soft tissue in posterior calcaneal bursitis.

Sources

Rehabilitation Exercises

Doorway Calf Stretch (Gastrocnemius)

StretchingBeginner

Wall-Supported Soleus Stretch (Bent Knee Calf Stretch)

StretchingBeginner

Ankle Plantarflexion and Dorsiflexion (Active ROM)

Range of MotionBeginner

Ankle Inversion and Eversion Mobility Exercises

Range of MotionBeginner

Double-Leg Heel Raise (Standing)

StrengtheningBeginner

Eccentric Heel Lowering (Bilateral to Unilateral Progression)

StrengtheningIntermediate

Single-Leg Heel Raise (Standing Balance)

StrengtheningIntermediate

Seated Toe-Raise with Resistance Band

StrengtheningBeginner

Single-Leg Stance on Firm Surface

BalanceIntermediate

Single-Leg Stance on Foam Surface (Proprioceptive Training)

BalanceAdvanced

Plantar Intrinsic Muscle Activation (Towel Scrunches, Marble Pickups)

PosturalBeginner

Resistance Band Plantarflexion and Dorsiflexion Strengthening

StrengtheningIntermediate

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