Retrocalcaneal (heel) bursitis – Non-Surgical treatments

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

A common problem we see is the problem of heel bursitis or the more medically sounding term retrocalcaneal bursitis. Further and like many other problems we see here at Caring Medical, the patient has a medical history where he/she followed the basic guidelines of the anti-inflammatory attack on the problem without great success. These anti-inflammatory treatment guidelines while very successful for some, are not successful for others and the problem of heel bursitis continues and compounds.

For most people when they are told they have bursitis, the first thing that comes to their mind is that they now have a reason or a diagnosis for their heel and foot pain. The second item that that bursitis suffers “learns” is that this pain is being caused by a swelling of the small fluid-filled sacs or bursa, that surrounds our joints that act as a pad to decrease friction between tissue and bone.

Now most people, they did not need to learn this. The people we see have had heel, leg, and foot problems for some time. They have seen swelling in the back of their foot by their heel and where their Achilles tendons “should be.” Probably like yourself, many times the swelling became significant enough that you “lost your Achilles tendon in the swelling and could not see it.”

The treatment of heel bursitis – what if you have become anti-inflammatory resistant?

If you are reading this article it is very likely that you have become well versed in the use of various anti-inflammatories in managing bursitis you have in your heel or ankle. While you may have been able to get the swelling, redness, and pain down at times, one problem remains. You are having a hard time walking.

A trip to your doctor may mean a little stronger dose of anti-inflammatory or a much more aggressive dosage to “knock out that inflammation once and for all.” But what if you have become anti-inflammatory resistant? That means you still have ankle swelling, you have tenderness in the ankle and heel and you still have pain.

The next stop will be continued conservative care with a  referral to a specialist and likely a strong recommendation for a cortisone injection, and for many people that is where the journey ends. Not with the resolution, but with the idea that this condition will just have to be managed along because the inflammation will just come and go and you will just need more comfortable footwear. For women, heels will need to go during inflammatory times. See our article  Nonsteroidal anti-inflammatory drugs (NSAIDs)

Video: Treating Heel Bursitis and Achilles Tendinopathy with PRP Prolotherapy

Danielle Matias, PA-C discusses our approach to treating Heel Bursitis and Achilles Tendinopathy with PRP Prolotherapy when an acute problem has become chronic. For those who have been unable to return to pain-free sports and activities after months of trying cortisone, stretching, icing, ibuprofen, etc, it could be that you really have an undiagnosed chronic degenerative condition versus true bursitis.

Chronic heel bursitis is usually not a problem by itself.

For people who have had success with anti-inflammatory medications, possibly a single cortisone shot, a temporary walking boot, a heel lift, and looser shoes, this is usually an indication of a problem with heel bursitis in a foot that is “not too far gone.” But how about someone with years of chronic foot problems and heel pain? Here is an example. This person had heel problems and swelling. They also had:

• Posterior tibial tendon (tibialis posterior tendon) tear.
  • So this person also was having a problem with the arch of their foot and pain that runs just inside the bone of the ankle between the heel and the ankle. This was also noted by a tear in their spring ligament complex. The complex that makes up the arch of the foot.
• Peroneus brevis tendon tear
  • So this person also had pain and swelling on the outside of his/her foot, leg, and ankle caused.
• Achilles tendinosis
  • So let’s add to this list an injury to the Achilles tendon. In some people, the Achilles injury became the center point of their treatment as they may have described to their doctor an onset of pain that can be traced to a new and sudden burst in activity (a new exercise program). In many cases this acute injury has occurred from chronic wear and tear – the tendon has finally torn sufficiently enough to be considered an acute injury.
  • Noticeable here will be a heel and Achilles tendon area that feels sore and tender to the touch with the soreness coming and going to varying degrees and making clicking and popping sounds.
• Plantar fasciopathy
  • So finally let’s add a problem with plantar fasciitis.

Now by the time we see a patient like this they have a story to tell. They have been online and bought balls to roll with the soles of their feet, they have gone on youtube to watch demonstrations of foot and calf stretches. They have been fitted or bought various ankle and foot braces and possibly a walking boot. They have also:

• Stopped running
• Limited walking
• Taken lots of anti-inflammatory medications

The complex bursitis

Not everyone will have a history like that which we just described above. Again, if you have “simple” bursitis, it may clear up on its own or with a gentle nudge of medications and some rest and some ice. But the people we do see, their problems as described above are more complex. A simple cortisone shot into the heal will not repair all this degenerative damage. Chronic heel bursitis is usually a multi-factorial problem involving those structures previously described.

The treatment of retrocalcaneal (heel) bursitis will often involve the Achilles tendon because it is the Achilles that rides on the bursa. In this still image from the video, we see the relationship between the Achilles tendon and retrocalcaneal bursitis. 

The retrocalcaneal (heel) bursitis and the Achilles tendon

When the patient’s situation worsens, the last conservative care step before surgery to be considered is cortisone injections. Cortisone injections, as mentioned, can help many people. However, doctors and patients are now more leery of the beneficial aspects of the injection as compared to the risks and side effects cortisone may offer.

Does cortisone in the heel cause a complete rupture of the Achilles Tendon?

Here is a paper that was published in the Journal of Ultrasound. (1) Let’s let the medical researchers speak for themselves:

“Complete rupture of the Achilles tendon is relatively rare, but it is an injury of considerable clinical relevance. A common cause of non-traumatic tendon rupture is local corticosteroid infiltration. Corticosteroid injections may start a degenerative process resulting in partial rupture and subsequent complete rupture of the tendon due to a direct toxic effect because corticosteroids inhibit the production of extracellular matrix collagen and also because of poor local vascularization.”

This paper then went on to describe the patient case of a man who suffered a complete rupture of the Achilles tendon shortly after administration of local corticosteroid injections in the treatment of deep retrocalcaneal bursitis.

The paper then concludes: “This confirms that corticosteroid treatment which is not correctly and accurately administered may be a factor contributing to a major injury.”

“We hypothesize that this part of the Achilles tendon might be most vulnerable to rupture after corticosteroid injections.”

Here is a paper published in the journal Bone and Joint Research. (2)

We will let the research team speak for themselves:

“Inflammation of the retrocalcaneal bursa is a common clinical problem, particularly in professional athletes. Retrocalcaneal bursa inflammation is often treated with corticosteroid injections however a number of reports suggest an increased risk of Achilles tendon rupture.”

In this study, the researchers wanted to know if the cortisone injected into the bursa area made its way into the Achilles tendon and could be implicated in sudden ruptures of the Achilles. So the researchers examined medical cadavers and injected an ink to see where the ink traveled. It raveled into the Achilles tendon. Here is the conclusion of this experiment:

“This study confirmed the existence of connections between the retrocalcaneal bursa and the Achilles tendon, especially rich in the anteroinferior (in front and lower) portion of the tendon, which should be considered a weak zone for substances injected into the Retrocalcaneal bursa. We hypothesize that this part of the AT might be most vulnerable to rupture after corticosteroid injections.

Is cortisone then safe? The subsequent Achilles tendon rupture rate was 1.8% within 59 days post-injection.

A May 2021 study comes to us from researchers at the Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine. The goal of this paper was to “determine the safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection for retrocalcaneal bursitis.” The paper was published in the journal Skeletal Radiology. (3)

What did the researchers do to assess the safety of cortisone injections?

• The study followed the impact of two hundred eighteen cortisone injections given to 181 female patients average age of 54.5 years. The injections were given under ultrasonographic or fluoroscopic guidance and were then evaluated for complications and long-term outcomes.
• Injections with short-term follow-up (62 of the 181) yielded excellent or good responses in 62.9% of the patients.
• Thirty patients (14%) had subsequent elective Achilles surgery.
• Four Achilles ruptures (1.8%) occurred 15-59 days post-injection, each with immediately preceding acute injury.

Conclusion: Image-guided retrocalcaneal bursa corticosteroid injection yields a significant short-term decrease in pain score in the majority (63%) of patients. The subsequent Achilles tendon rupture rate was 1.8% within 59 days post-injection.

What is Haglund’s deformity?

A 2016 paper in the journal Cureus (8) describes Haglund’s deformity this way: “Haglund’s deformity was first described by Patrick Haglund in 1927. It is also known as retrocalcaneal exostosis (extra growth of bone), Mulholland deformity, and ‘pump bump.’ It is a very common clinical condition, but still poorly understood. Haglund’s deformity is an abnormality of the bone and soft tissues in the foot. An enlargement of the bony section of the heel (where the Achilles tendon is inserted) triggers this condition. The soft tissue near the back of the heel can become irritated when the large, bony lump rubs against rigid shoes.” It is seen in hockey players, and called the “Bauer bump.” Bauer is a brand of hockey skate with the bump occurring in the context of wearing ice hockey skates. This is discussed by Columbia University Medical Center researchers in their May 2022 paper published in The Physician and Sports Medicine. (7)

Haglund’s deformity has been implicated as we will see in the research below in Achilles tendon tears and ruptures. As stated above Haglund’s deformity develops when there is a frequent compression or pressure on the backs of your heels. This problem is often seen in patients who wear shoes that are too tight or stiff in the heel. Since it often develops in women who wear pump-style high heels, Haglund’s deformity is sometimes referred to as “pump bump.”

Surgery for Haglund’s deformity?

An April 2022 study in the journal Advances in Orthopedics (9) suggest good outcomes with surgery. They suggest “operative treatment is indicated after failure of conservative measures and includes resection of the bony hump along with retrocalcaneal bursectomy. . . Endoscopic calcaneoplasty is a safe, less invasive surgical procedure for the management of Haglund’s syndrome after failure of conservative treatment. It provided a satisfactory clinical result without serious complications at a minimum 4-year follow-up.”

An August 2021 paper in the journal Knee Surgery, Sports Traumatology, Arthroscopy (10) suggested: “Surgical correction of Haglund’s deformity provides overall good clinical results and high subjective satisfaction. Endoscopic procedures demonstrated better final American Orthopaedic Foot & Ankle Society (AOFAS) scores, a lower rate of complications and failures, and shorter recovery time when compared to open techniques.”

Chronic bursitis – the evaluation – looking for a secondary cause

In the example given above, we demonstrated how bursitis can be part of multiple factorial problems. When someone continues to have problems with their bursitis and it has become chronic bursitis that has not responded to rest and the other treatments mentioned above, in these cases we want to explore and evaluate the possibility of a secondary cause to the problem.

In the case of the heel or retrocalcaneal bursitis, it can be the Achilles tendon causing an issue. Often we will perform an ultrasound of the heel area and the Achilles tendon and find injuries to the tendon in the presence of this bursitis. These injuries would be Achilles tear, tendinopathy which is tendon degeneration, and chronic tissue damage.

The reason why someone will develop bursitis or swelling of this bursa is that the Achilles tendon itself is damaged and to protect itself, the Achilles will thicken, swell and expand. This expanded and swelled Achilles will put great pressure and cause more friction on this bursa. The bursa’s response to this new pressure? Swelling and the “itis,” of inflammation. Bursitis – “inflammation of the bursa.” This is why cortisone can be risky. The anti-inflammatory properties of the cortisone to try to calm down the bursa will further injure the Achilles tendon as demonstrated in the research above.

In these cases, we would treat the Achilles tendon with Prolotherapy or PRP which is platelet-rich plasma to work to repair the whole tendon and grow new healthy tissue so that this bursa no longer has to swell.

Prolotherapy and PRP: An introduction to non-surgical regenerative injection options

Some people will find effective solutions to their heel bursitis and Achilles problems with surgery. These are typically not the people we see at our center. We see the people who had the surgery and did not get the expected results or are trying to delay or put off surgery but their current regimen of medications is not helping them so they are looking for “alternatives.” Sometimes that alternative is the eventual surgery.

Prolotherapy is a regenerative injection technique that stimulates the repair of injured tissue. In this case, the Achilles tendon is impacting the Retrocalcaneal bursa.

In 2016, Caring Medical published our review of Prolotherapy in the journal: Clinical Medicine Insights Arthritis and Musculoskeletal Disorders. (4) Here we wrote:

• “Consensus is growing regarding the efficacy of dextrose prolotherapy as an alternative to surgery for patients with chronic tendinopathy who have persistent pain despite appropriate rehabilitative exercise.”

Sometimes we may have to differentiate the treatment based on the type of injury. We can inject dextrose into a degenerative tendon and regenerate tissue but if we’re trying to essentially glue back fibers from a more significant tear, we get healing factor cells from the patient. This would be platelet-rich plasma or PRP cells that come from the patient’s own blood. These cells are injected into the tendon using ultrasound guidance.

A brief discussion of ultrasound diagnosis and Prolotherapy treatments for Achilles tendon problems

A transcript summary and explanatory notes are below the video.

Danielle R. Steilen-Matias, MMS, PA-C.

• We do see a lot of patients with Achilles tendon pain. These are typically avid athletes, runners, hikers, etc.
• When these patients come to see us for these problems, we can use an ultrasound image to help show us tears and tendon degeneration. Later during treatment, we can use the ultrasound to help guide our injections into the specific problem areas of injury.
• At 0:55 of the video the ultrasound imaging begins
• Often times we find that patients with chronic Achilles pain have more of an issue with degeneration as compared to acute tearing or inflammation. This means that the tendon is becoming weaker because it is wearing out. This is when we can have a good expectation that we can help this patient with Prolotherapy injections to strengthen the tendon.

Noninsertional Achilles Tendinitis and Insertional Achilles Tendinitis

• Noninsertional Achilles Tendinitis is where the tendon has begun to fray and break down in the middle of the Achilles tendon. This is an injury more typical of active patients.
• Insertional Achilles Tendinitis occurs closer to the heel area where the Achilles attaches or inserts itself to the heel bone.

We do see many patients who have failed Platelet Rich Plasma treatments. One of the reasons for the failure is not adequate treatment. PRP is usually not a single miracle injection. We will explain this below.

Platelet Rich Plasma Therapy is an autologous derivative of whole blood that contains a supraphysiological (greater than the normal amount) concentration of platelets. You can learn more about this treatment here What is Platelet Rich Plasma Therapy?

Doctors writing in the Journal of Tissue Engineering and Regenerative Medicine have made the case that platelet-rich plasma injections awaken and stimulate native stem cells to repair Achilles tendon damage. Here are the bullet points:

• The study’s purpose was to investigate whether platelet-rich plasma would activate tendon-derived stem cells to promote regeneration of Achilles tendon post-rupture in rats.
• In the in vitro study, platelet-rich growth factors significantly enhanced cell DNA synthesis (cell replication) improved viability, and promoted proliferation, while facilitating cell migration and the recruitment of tendon-derived stem cells.
  • In other words, PRP promoted the creation and multiplication of stem cells. (5)

What does this mean to the patient?

• More evidence that PRP can non-surgically repair an Achilles tendon in various degrees of rupture and tear.

In addition to the research cited above, another Italian research team evaluated the long-term clinical outcome in patients affected by mid-portion Chronic Recalcitrant Achilles Tendinopathies (CRAT) treated with administration of single platelet-rich plasma (PRP).

A total of 73 patients age 43 years old predominantly males had 83 tendons treated with a single PRP injection. They were then evaluated using standard scoring systems.

Here are their results

• 91.6% were rated as satisfactory and patients would repeat the treatment.
• 8.4% were classified as unsatisfactory at the 6 months follow-up and underwent a second PRP injection.
• In addition to this, patients reported no Achilles tendon rupture.

Therefore the conclusion: The use of a single PRP injection can, therefore, be a safe and attractive alternative in the treatment of non-insertional CRATs. (6)

What are we seeing in this image?

Achilles tendon degeneration helped with PRP Prolotherapy. After trying a variety of other treatment methods, PRP Prolotherapy was able to help this patient to repair his Achilles Tendon and achieve fully-restored function. While we have helped many people achieve this level of function others had some or partially restored function depending on the severity of the injury. This image shows in the top panel the darkened area on imaging signifying a tendon tear and the same darkened area “lightened” to signify soft tissue repair has occurred to fill up the “black hole.”

For patients who have already received steroid injections or surgery for Achilles tendinopathy, but still have pain, Prolotherapy and Platelet Rich Plasma Injections may be a good regenerative treatment to consider to improve the entire heel, Achilles, and ankle complex, especially with tight Achilles tendon pain that may be causing Equinus a condition that limits the motion of the ankle.

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your heel bursitis problems.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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References

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This article was updated June 26, 2022

• Surgery
• NSAIDs
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