Are you running out of shoe options because of your heel pain? Does it feel like all your shoes just put too much pressure on your heel? You could have calcaneal bursitis.
Also known as heel bursitis, calcaneal bursitis is a common cause of heel pain either at the back of or just underneath your heel bone (calcaneus). Under normal circumstances the bursa can handle pressure and stretching, but if it’s swollen and inflamed even a tiny tap on your heel can cause excruciating pain. We often see this problem in athletes like runners or dancers. However, something like switching to flat shoes when you usually wear heels or wearing shoes that are too tight can also be the cause of your sore heel.
If staying off your feet isn’t an option, rather make an appointment with us and we can help you deal with your heel pain.
Anatomy of the calcaneal bursa
A bursa (plural bursae) is a small pocket of fluid that helps with shock absorption and protects your tendons from friction. That’s why you will find bursae anywhere a tendon attaches to bone. The other side of the tendon is attached to the muscle that shortens and lengthens as you move, so tendons should be able to glide freely. The bursa’s function is to reduce friction during this gliding movement.
There are 3 of these fluid-filled pockets in different parts of your heel.
Retrocalcaneal bursa
This bursa is found just in front of your Achilles tendon at the back of your heel bone (calcaneus).
Subcutaneous calcaneal bursa
The subcutaneous calcaneal bursa can be found at the back of your heel between your skin and where your Achilles tendon attaches to your calcaneus. Inflammation of this bursa is often confused with Achilles tendinitis.
Plantar calcaneal bursa
The third bursa that can cause a sore heel is also known as the sub-calcaneal bursa, because it is found underneath your heel bone. Bursitis in this area can also be related to plantar fasciitis.
What is calcaneal bursitis?
Under normal circumstances the calcaneal bursa helps to keep the gliding motion of your Achilles tendon smooth and effortless. However, if there’s extra pressure in the area, the bursa gets “squashed” which increases the friction. This injury to the bursa can be due to a direct blow, like getting kicked on the back of your heel or tightness in your calf muscles increasing the tension in your Achilles tendon. Dorsiflexion of your ankle (like walking on your heels or up a hill) puts a lot of strain on the structures at the back of your heel and can increase friction over the bursa. This friction can then lead to calcaneal bursitis.
This friction can damage the bursa, almost like a grass burn damages your skin. Your body responds by making extra synovial fluid inside the bursa. The end result is swelling, inflammation and pain in the heel of your foot.
So what could have caused my heel pain?
Inflammation is our body’s response to an injury. In the case of bursitis, this injury can be caused by getting hit on the back of your heel by a hockey ball to wearing tight-fitting shoes or walking up a steep hill.
A direct blow, for instance getting kicked on your heel, will effectively kickstart this inflammatory process. This means that the number of synovial cells in the bursa will increase. Under normal circumstances these cells produce just enough synovial fluid inside the bursa to maintain enough pressure for the bursa’s function. However, an increase in synovial cells means that more fluid is formed. As a result the pressure inside the bursa will increase, like a balloon being filled with water, and this is where the characteristic swelling comes from. Inflammation is actually helpful because it is the beginning of the healing process. Unfortunately, the resulting swelling and pain also means that you will be walking around with a limp for a couple of days.
Heel bursitis can also have a gradual onset, such as wearing tight shoes on occasion that increase friction on your heel or straining your heel by hiking up hills.
The next day your heel will be painful due to inflammation, so you’ll rest from hiking or put away the offending shoes for a couple of days. As soon as the inflammation settles you forget about your sore heel and go back to your usual habits. The cycle is repeated over and over, so your heel bursa needs to adapt to the repeated injuries.
Normally, the outer part of the bursa should be pliable and change shape as you move. However, each cycle of inflammation will cause more damage to the bursa, resulting in thickening of this outer part of the bursa. As a result the bursa is much less pliable, almost like playdough that was left outside for too long. Now you will find that your heel pain flares up with much less activity and is more sensitive to pressure.
Other examples that could cause chronic irritation of your heel bursa are:
- Overuse like increasing your running distance without enough rest in between training sessions.
- Tightness of your calf muscles, leading to compression of your calcaneal bursa by your Achilles tendon.
- Stiffness of your ankle joint, increasing the tension in the muscles and tendons around your heel.
- Flat feet (overpronation) and high foot arches can cause a “twisting” force on your Achilles tendon, putting more pressure on one side of the heel bursa.
How bad is my heel bursitis?
Is this pain or discomfort?
At first you will notice that the back of your heel is sensitive to the touch. There might be some swelling that comes and goes, but the tenderness and swelling will go away with some rest. So you will carry on with your normal routine without really paying attention to things that make your heel sore. A stretch in your calf muscles when you climb up stairs will be uncomfortable, but you will forget about the pain as soon as you reach the top. Your sore heel usually won’t bother you enough to seek help.
Definite discomfort starting to interfere with activities
As your heel bursitis gets worse you will be aware of a dull ache in your heel, even when you’re just sitting. The ache will get worse when you’re wearing tight shoes or high heels. Walking up a ramp will cause pain in your heel, because your tight calf muscles will start to limit your ankle movements.
The more you move around, the worse the pain will get and you will start to avoid unnecessary walks. This happens because your calf muscles contract to lift your heel off the ground when you walk. The muscle contraction creates tension in your Achilles tendon to lift your heel. However, your swollen and painful heel bursa sits directly under your Achilles tendon. Muscle contraction leads to tension resulting in extra pressure on the sensitized calcaneal bursa. At this point resting will help the pain to settle down a bit, but you will still have that dull ache no matter how much you stay off your feet.
Help, my foot hurts all the time!
Without treatment, your heel pain will keep on getting worse until, ultimately, any weight on your foot causes severe pain. You will start walking with a limp and have a constant, throbbing pain in your heel that doesn’t improve with rest. Ice or anti-inflammatory medication might give you some relief, but as soon as it wears off you will be back at square one. Any closed shoes will feel too tight, making your pain worse and you will dread putting weight on your foot for things like getting out of your car or climbing steps.
This doesn’t have to be your story. Call us if you have a sore heel and we can help you find a solution.
Diagnosing a swollen bursa
Our physiotherapists are experts in human anatomy and movement with the necessary knowledge and experience to diagnose calcaneal bursitis. We understand the intricacy of the biomechanics of your foot and ankle and we look at all other aspects that could be contributing to your heel pain. Getting the necessary information from you, together with a clinical assessment is the starting point.
During your physiotherapy evaluation, we will stretch and stress different structures around your ankle like your Achilles tendon, soft tissue around the inflamed bursa, your calf muscles, ligaments and your ankle joint. We also test muscle strength and length, range of movement and can measure swelling in the area.
Diagnostic ultrasound
Diagnostic ultrasound is a good way to confirm or rule out heel bursitis. The bursae that can cause calcaneal bursitis are located relatively close to the skin. Therefore, diagnostic ultrasound will be able to show signs of increased fluid in the bursa (swelling). Comparing the cross section and size on each side, will show if a bursa on one side is swollen or irritated. Doing a follow-up ultrasound after your treatment will show if the swelling has gone down.
Your physiotherapist will refer you for an ultrasound, if necessary.
X-rays
An x-ray of your heel will only show the bones that form your ankle joint, so it will not be necessary to diagnose calcaneal bursitis. It will however show fractures or signs of possible ankle joint degeneration or arthritis. If your physiotherapist feels that it is necessary for x-rays, you will be referred to the right place.
MRI
Although an MRI will show soft tissue structures, it is seldom necessary to get one if you have calcaneal bursitis. An MRI is a very expensive type of scan and you can only get one with a referral from an orthopaedic surgeon. There aren’t many soft tissue structures at the back of your heel, so this test will only be necessary if diagnostic ultrasound rules out bursitis and we suspect a deeper cause for your calcaneal pain.
Why is my heel bursitis not going away?
You have had heel pain for a while and got diagnosed with calcaneal bursitis. Initially, you rested for a while and took some anti-inflammatory medication. This seemed to help, but once the medication was finished and you wanted to get back to exercising, your pain just started again.
Without a proper evaluation and treatment plan, your calcaneal pain might improve, but it won’t stay better. In the case of heel bursitis, inflammation causes the bursa to swell and this irritates the surrounding soft tissues. If you focus on resting, it will probably help the inflammation and irritation to go down. However, now your ankle joint has become stiff and your calf muscles have become weak. Trying to push through the pain to get back to exercising will simply cause you to strain these muscles that will get tired quite quickly. A sudden increase in movement and exercise will cause friction over the calcaneal bursa, starting the whole cycle of inflammation again. Now you have become stuck in this cycle of pain and you don’t know whether it is better to rest or move.
Which is better? Resting or moving?
With more rest and a change in your day to day routine, the inflammation in the bursa will start to settle. Luckily there won’t be any scar tissue formation in the bursa itself. However, in the time that it took for the inflammation to improve, the calf muscles and their tendons have become either fibrotic or thickened and stiff. These stiff calf muscles are now not able to handle work of continuously contracting and they will fatigue quickly. This adds more pressure on the calcaneal bursa and irritates the bursa again – taking you back to square one.
The tricky part with heel bursitis treatment is to find the balance between resting and moving. It is important not to treat only the bursa, but to address the bigger picture of everything that contributes to your calcaneal bursitis. A very important aspect of your treatment should be to get your calf muscles back to their normal state to contract under load (walking uphill) and through the whole range of ankle movement. This can only be done through a proper rehabilitation and treatment program. We need to improve the capacity of your heel bursa to handle the extra load.
A big problem we see with heel bursitis
Waiting too long and not getting a proper diagnosis
A common problem we see is that patients wait too long before they seek help. By the time patients come to see us, they have had foot pain and problems for months. If you don’t get a proper diagnosis from the start, it will also waste time.
Not looking at the big picture
If anyone treating your pain does not also look at the movements, muscles and joints of your hip and knee as well as your foot, they will keep on treating the incorrect thing. This is ineffective and may aggravate the problem. Now, the pain becomes unbearable and it holds you back. Because you have waited so long, recovery will take so much longer.
Trying out other forms of treatment
Often, patients try to get relief by taking anti-inflammatory medication or getting a cortisone injection in the hopes of decreasing their pain. This only slows the process of healing. Initially, you will have to take some of these medications to decrease your pain and swelling. However, taking medication does not address the root of the problem. The only way to get rid of your pain will be to look at the bigger picture and everything that contributes to your calcaneal pain.
Resting too much or too little
Resting too much leaves you weaker than before. Moving too much causes extra friction over the soft tissue gliding over the bursa. This leads to increased swelling and inflammation in the bursa. Finding the balance between resting and moving is key!
Physiotherapy treatment for calcaneal bursitis
We are confident that we can provide the best treatment for calcaneal bursitis. We understand that patients are often anxious to get back to their day to day activities, so that is why we are here to provide guidance and answers. Physiotherapists can implement an amazingly effective and structured plan of action that treat all the aspects of the problem and get you back to where you want to be. Our physiotherapy treatment plays a vital role to restore the normal slide of the tendon and muscles over the bursa and ensure the bursa does what it’s supposed to do, without flare-ups.
The basic structure of our treatments:
- Determine what has been injured.
- How badly is it injured?
- Protect it from further injury.
- Support the healing process.
- Strengthen surrounding muscles.
- Re-evaluate to monitor progress.
We will assess different aspects like testing and measuring your ability to climb up a step, jump or run. And we will also look at other aspects like muscle strength, range of motion, flexibility and stability.
Treatment will include:
- electrotherapy, including laser and ultrasound, to help with pain relief and to promote healing.
- myofascial release and dry needling to get rid of muscle spasm and tightness.
- joint mobilisation to improve or restore the movement of the joints around your ankle.
- taping/strapping to support and deload the painful area.
- gradual strengthening, control and conditioning of the muscles around your ankle to reduce the pressure on your calcaneal bursa.
- advice and education to help you to understand your condition and know what you can change to be in control of your symptoms.
It’s important that you commit to the treatment plan, as this improves your chances of successful long-term recovery.
Protect
We have found that patients tend to push through their pain. Calcaneal bursitis can cause heel pain with every step you take, causing you to walk with a limp. Any pressure or stretch over your heel increases the pressure on the inflamed bursa. If your pain is severe it may help to use a crutch or walking stick for a couple of days to decrease the load on your painful heel. You should also avoid wearing tight shoes or shoes that will chafe the back of your heel.
Avoid anti-inflammatory medication
Avoid using anti-inflammatory medication continuously. Inflammation is part of your body’s natural healing response, so by suppressing inflammation you can delay healing. If your pain is severe, rather use medication for pain without an anti-inflammatory component. That way, your pain will be under control, you’ll be able to get enough sleep and won’t have pain that constantly bothers you. Once the pain is under control, you can decrease the use of your medication and eventually stop taking it completely.
Support
By using strapping you can limit the movement around your ankle joint, decreasing the load on your calcaneal bursa. This can help to relieve inflammation and swelling leading to less pain. As the bursa starts to heal it will be able to tolerate more load, so you can gradually increase the movements of your ankle joint. The goal will be to increase the stress on the bursa without overdoing it and starting the cycle of pain and inflammation again.
Information
Its important to understand what you should and shouldn’t do. You can make better decisions if you are informed. Our physiotherapists are always ready with an explanation as we take you through the process of treatment and rehabilitation.
Load
Let pain guide you to gradually return to your normal activities. Initially, it is tricky to know if it is better to rest or to move, but finding a balance between the two is the best thing you can do. If you add too much load too quickly the cycle of inflammation will start again. However, if you rest for too long your muscles become weak and the bursa will never get used to extra load. As soon as you go back to your normal activities, your heel pain will just start up again. When you have completed the treatment process, your calcaneal bursa should have the capacity to handle walking, jumping and running without flare-ups.
First phase: Protection and initial pain management
The first phase of your treatment will involve lots of information about your condition. We will explain the treatment plan and give you advice on everyday things to help manage your pain. Like which shoes to avoid and how to position your foot when you are sleeping.
During this phase of treatment we will use electrotherapy like ultrasound and laser to help with pain relief during this stage. We also use strapping or taping to help support and protect the area while we start with gentle, pain free exercises.
Our goal is to get you moving again!
Second phase: Establish pain free range of movement
When you have heel bursitis any stretch of your calf muscles will increase pressure on the bursa. In other words, any ankle movements will cause sever pain.
After your initial assessment we will have a better idea of how much you can move without aggravating your calcaneal bursitis. This means that we can use strapping/taping to limit your ankle movements and keep you in this pain free zone. As your pain improves we will allow more movement of your ankle joint.
Third Phase: Promote tissue healing
We will keep on evaluating your pain and movements during the treatment process. This helps us to monitor the healing of your calcaneal bursa to give you the right exercises at the right time without interfering with your body’s healing process. Don’t worry if your pain flares-up at some time during your rehabilitation. We are experts in tissue healing and load management, so any flare-ups will give us more information about how much your heel bursitis can handle at that stage. Your exercises and treatment will be adapted accordingly and you can keep on moving forwards.
During this phase we may use dry needling, laser and ultrasound to promote and support the healing process.
Fourth Phase: Strengthening the rest of the chain
Often we find weakness of the lower back, hip or knee muscles during our initial assessment that contributes to your calcaneal bursitis. While your heel bursitis is still too painful to load, it’s the perfect time to start strengthening the other parts of your legs. Most of these exercises will be in positions that don’t put extra strain on your sore heel. By the time the pain free range of motion of your ankle has improved we can move on to correcting movements and patterns that contributed to your calcaneal bursitis.
Fifth Phase: Full range of movement
Regaining full pain free range of movement of your ankle is a crucial component of your rehabilitation. When your calf muscles are fully stretched your Achilles tendon puts pressure on the calcaneal bursa. During this part of your rehabilitation your calcaneal bursitis should have healed to the point where this increased pressure isn’t painful anymore.
At the end of this stage of rehabilitation you should be able to walk comfortably, walk uphill for short periods and climb up and down stairs without pain.
Sixth Phase: Muscle strength
During this phase of your rehabilitation, you will work on strengthening not only your calf muscles, but also continue strengthening your lower back-, hip- and thigh muscles. Stronger muscles have the capacity to work harder and can help to carry the load while keeping your hip, knee and heel bone stable. If there is too much movement and tilt of your heel bone when you walk, your Achilles tendon will cause chafing of the calcaneal bursa. Controlling the position of your whole leg when you walk or run is crucial, otherwise your heel bursitis will return as soon as you stop treatment.
As you get stronger, we will keep on adapting your exercises by adding resistance, doing more repetitions and building your overall strength.
Seventh Phase: Muscle control and stability
It is one thing to feel your muscles get stronger, but another thing to feel like you have control when you move. The type of muscle contraction we use during this phase of rehabilitation is called eccentric muscle contractions. Muscles are able to contract and shorten concentrically, but they are also able to slowly lengthen eccentrically. This slow lengthening allows you to control movements and keep your balance, for example when climbing stairs or standing on one leg. Without this control there will be constant tilting and movement of your foot to keep you from falling, causing extra pressure and friction over your calcaneal bursa.
At the end of this phase of treatment you should be able to stand on one leg and do small squats with minimal movement of your foot.
How long will my calcaneal bursitis take to heal?
There is no quick fix for heel pain. Taking into account that the healing process takes about 6 weeks, you will need to allow yourself space within that 6 weeks for recovery. In all but the extreme cases of calcaneal bursitis, you should recover quickly and be able to return to your sport after you have followed the prescribed treatment protocol from your physiotherapist. Depending on the severity of your symptoms and initial inflammation, you will need physiotherapy treatment twice a week for the first two weeks. After this, your treatment sessions can be spread out to once a week or once in two weeks. You only spend an hour at a time with your physiotherapist, so how fast you recover will mostly be up to you.
Other medical treatments for calcaneal pain
Injections
A cortisone injection into the bursa is one other option to treat calcaneal bursitis. However, cortisone weakens tendons and the bursa causing your pain is exactly where your Achilles tendon inserts into your heel bone. This means that an injection into the bursa will increase your risk of an Achilles tendon rupture.
Topical creams or muscle rubs
Your swollen heel bursa will be very sensitive to direct pressure, so rubbing creams on the back of your heel will be quite painful. The pain from bursitis is caused by increased pressure due to swelling inside the bursa. Massage or creams on the outside of your heel will have no effect on this pressure, so it will not help to get rid of your pain.
Orthotist or podiatrist
Orthotics or inner soles can help with treatment of calcaneal bursitis, especially if you have high foot arches or flat feet (overpronation). An orthotist or podiatrist can assess your foot and make these orthotics if necessary.
Heel cups
Silicone inserts or heel cups in your shoes can also help managing your heel pain. The silicone helps with shock absorption, taking some of the pressure off of the inflamed bursa.
Braces, bandages and splints
Using a brace or bandage to block ankle movements may give you temporary relief. Friction over your calcaneal bursa is what led to the swelling and increased pressure. In theory, this should mean that stopping movement i.e. friction should solve the problem? Unfortunately, if you don’t solve the underlying problems like muscle tightness and incorrect biomechanics, your heel pain will be back in full force as soon as you remove the brace or bandage.
Aspiration
This is when a needle is inserted into the bursa to remove fluid and reduce the pressure. With any invasive procedure there’s always a risk of infection, so this should not be your first treatment option.
Medication
Your GP can prescribe medication to help with inflammation and pain. Topical medication (like patches or ointment) can always help with pain relief and swelling.
Shockwave therapy
A controversial treatment for heel bursitis is shockwave therapy. In theory the high energy shockwaves can speed up the healing process. However, this technique feels like strong pulses directly over the painful bursa and can be extremely painful.
Biokineticist
For long-term management and strengthening we might refer you to a biokineticist after completing physiotherapy treatment for your heel pain.
Surgery for heel bursitis
Bursectomy
There is no quick fix for a bursitis, but you may be a candidate for a bursectomy if 3 to 6 months of non-surgical treatment isn’t successful. This is when the bursa is removed by a surgeon. It will never be the first treatment option as the wound will be over a bony part of your foot with relatively poor blood supply, therefore the wound can take a long time to heal.
Haglund’s resection
Haglund’s deformity is a bony spur that forms at the back of your heel bone. It can cause extra pressure and friction of the calcaneal bursa resulting in chronic heel bursitis. A resection is when the surgeon removes the bony spur. The calcaneal bursa will often also be removed, because Haglund’s deformity is usually associated with calcaneal bursitis.
What else could be causing my sore heel?
Heel fat pad pain
If the fat pad under your heel is causing your symptoms, it will feel as if you have a bruise in the middle of your heel. Walking on hard floors or barefoot will make your pain worse.
Achilles tendinitis
Heel bursitis is often misdiagnosed as Achilles tendinitis. If the pain at the back of your heel gets better after a warmup or after rest, it might not be calcaneal bursitis.
Plantar fasciitis
Your heel pain will be at its worst in the morning when you get up and start walking. Plantar fasciitis gets better with rest and it will feel as if there’s a sharp thorn at the front part of your heel (closer to your toes).
