Retrocalcaneal Bursitis
Lower LimbOverview
Retrocalcaneal bursitis is inflammation of the bursa situated between the Achilles tendon and the calcaneus, commonly caused by repetitive friction, tight footwear, or Haglund's deformity. This condition presents with posterior heel pain, swelling, and functional limitation during walking and running. Early recognition and management are essential to prevent chronic inflammation and secondary tendinopathy.
Pathophysiology
The retrocalcaneal bursa acts as a shock-absorbing structure to reduce friction between the Achilles tendon and the calcaneal prominence. Repetitive microtrauma, excessive pronation, tight calf muscles, or direct pressure from footwear causes bursal inflammation and fluid accumulation. This leads to swelling within the constrained space between the tendon and bone, causing pain with dorsiflexion and pressure. Chronic irritation can result in bursal fibrosis, calcification, and secondary Achilles tendinopathy.
Patient Education
Retrocalcaneal bursitis responds well to activity modification, calf stretching, and graduated return to activity; early intervention prevents progression to chronic tendon involvement and functional disability.
Typical Presentation
Site
Posterior heel, deep to the Achilles tendon insertion, proximal to the calcaneal prominence
Quality
Dull, aching pain with sharp exacerbations; may feel like a pinching sensation
Intensity
Mild to moderate (3-6/10), worse with activity, variable at rest
Aggravating
Dorsiflexion and plantarflexion against resistance, prolonged walking or running, tight posterior heel footwear, going upstairs, repetitive impact activities
Relieving
Rest, ice application, anti-inflammatory medication, heel lifts, soft footwear, stretching of calf muscles
Associated
Posterior heel swelling, localized warmth, stiffness after rest, difficulty with dorsiflexion, possible crepitus, Haglund's deformity, pes planus or cavus, calf muscle tightness
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.).
Thompson Test
Procedure
Patient prone with the feet over the end of the plinth. Squeeze the calf and watch the foot.
Positive Finding
No plantarflexion when the calf is squeezed (positive = rupture).
Interpretation
Used here to exclude an Achilles rupture. In bursitis the foot plantarflexes normally. The figure stored here belongs to Achilles tendon rupture (see that page), not to this condition, so no figure is shown.
Retrocalcaneal Bursa Palpation
Procedure
Patient prone. Squeeze gently from side to side with thumb and index finger just in front of the Achilles tendon, above its insertion on the heel (the two-finger squeeze).
Positive Finding
Pain with the side-to-side squeeze in front of the tendon, above the heel.
Interpretation
Supports retrocalcaneal bursitis, which lies between the tendon and the heel bone. It often coexists with insertional Achilles tendinopathy and a prominent heel bone (Haglund's deformity). Ultrasound can confirm fluid in the bursa.
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 and ask about heel pain.
Positive Finding
Dorsiflexion limited with the knee straight and better with it bent (gastrocnemius tightness), or pain at the back of the heel at end of range.
Interpretation
Calf tightness increases compression of the bursa in dorsiflexion and is a treatment target (heel raise, calf stretching). Not a diagnostic test.
Sources
- Educational sitePhysiopedia. Silfverskiöld Test.
Achilles Tendon Palpation (Midportion vs Insertion)
Procedure
Patient prone. Palpate the tendon in its midportion (2–6 cm above the heel), at its insertion on the heel, and just in front of it, comparing the location of pain.
Positive Finding
Pain in front of the tendon above the heel (bursa) rather than in the midportion.
Interpretation
Helps separate retrocalcaneal bursitis (in front of the tendon, above the heel), insertional tendinopathy (at the bone) and midportion tendinopathy (higher up the tendon).
Passive Dorsiflexion (Bursa Compression)
Procedure
Patient prone or seated. Passively dorsiflex the ankle to end of range.
Positive Finding
Reproduction of the familiar pain at the back of the heel at end-range dorsiflexion.
Interpretation
Dorsiflexion squeezes the bursa between the tendon and the heel bone. Pain here supports a bursal or insertional source. Not a validated test.
Single-Leg Heel Raise Test (Plantarflexion Load Test)
Procedure
Ask the patient to perform single-leg heel raises on the affected side, and note pain and how many they can do.
Positive Finding
Pain at the back of the heel during the raises, or fewer raises than on the other side.
Interpretation
A loading check that guides rehabilitation. Heel raises off a step (into dorsiflexion) often aggravate bursitis and insertional tendinopathy, so start on flat ground.
⚠ Red Flags
- •Signs of acute infection: fever, severe localized warmth, systemic illness, immunocompromised state
- •Sudden severe pain with audible pop suggesting Achilles tendon rupture
- •Severe neurological symptoms: nerve compression causing distal sensory or motor changes
- •Significant swelling with calf pain suggesting deep vein thrombosis
- •History of malignancy with localized swelling
- •Signs of systemic arthropathy (rheumatoid arthritis, seronegative spondyloarthropathy) with polyarticular involvement
⚡ Yellow Flags
- •Psychologically-based pain amplification or catastrophizing about heel pain
- •High fear-avoidance beliefs limiting activity and rehabilitation engagement
- •Perfectionist or elite athlete mentality avoiding activity modification
- •Poor compliance with conservative measures or unrealistic expectations for rapid recovery
- •Secondary gain or compensation/litigation involvement
- •Depressive symptoms or anxiety exacerbating pain perception
- •Occupational factors with no activity modification: standing all day, repeated climbing
Osteopathic Techniques
Most bursitis settles with rest, ice, compression and elevation. Near the Achilles, well-fitting footwear that takes pressure off the area helps; NSAIDs or paracetamol are first-line for pain, and a corticosteroid injection is an option for a deeper bursa such as this one.
- Reference bookWilliams et al. · StatPearls 2023
Region
Calf muscles (gastrocnemius and soleus)
Technique
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 Retrocalcaneal Bursitis
Searched 25 Oct 2026: no trials. Indirect: Ko 2023 (network meta-analysis, 9 trials, insertional Achilles tendinopathy): eccentric exercise plus soft tissue therapy ranked best for short-term pain.
Sources
- Journal articleFurlan et al. · Cochrane 2015
- Journal articleKo et al. · BMC Musculoskelet Disord 2023
Region
Gastrocnemius-soleus (calf)
Technique
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 Retrocalcaneal Bursitis
Searched 25 Oct 2026: no trials of calf muscle energy technique in retrocalcaneal bursitis.
Sources
- Reference bookWaxenbaum & Sina · StatPearls 2026
Region
Subtalar and ankle joints
Technique
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 Retrocalcaneal Bursitis
Searched 25 Oct 2026: no trials of ankle or subtalar mobilisation in retrocalcaneal bursitis.
Sources
- Journal articleCoulter et al. · Spine J 2018
- Reference bookBergman et al. · StatPearls 2025
Region
Plantar fascia and intrinsic foot muscles
Technique
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 Retrocalcaneal Bursitis
Searched 25 Oct 2026: no trials of plantar foot soft tissue in retrocalcaneal bursitis.
Sources
- Journal articleFurlan et al. · Cochrane 2015
Rehabilitation Exercises
Standing Calf Stretch (Soleus Focus)
Dorsiflexion Stretch with Strap
Eccentric Calf Raises (Double to Single Leg)
Seated Gastrocnemius Strengthening
Intrinsic Foot Muscles (Short Foot Exercise)
Ankle Dorsiflexion and Plantarflexion Active Range of Motion
Single Leg Standing Balance with Proprioceptive Challenge
Gait Retraining: Normal Walking Pattern with Cadence
Plantar Fascia Self-Release with Massage Ball
Ankle Inversion and Eversion Resistance Band Work
Heel Walking Drill for Dorsiflexion Control
Pool Walking or Swimming (Non-Weight Bearing Cardio)
Referral Criteria
- •Failure to improve with 4-6 weeks of conservative management
- •Severe pain limiting basic function despite appropriate treatment
- •Suspected Achilles tendon rupture or significant tendinopathy
- •Signs of systemic inflammation (polyarticular involvement, constitutional symptoms)
- •Concern for infection: fever, severe localized heat, systemic illness
- •Imaging findings requiring specialist assessment: large bursal effusion, significant calcification, or bony prominence causing mechanical impingement
- •Refractory cases considering corticosteroid injection or surgical evaluation
- •Complex presentations with neurological involvement or vascular compromise