Whenever tissues rub against one another, a bursa forms to allow for smooth gliding. A bursa is a fluid-filled sac and occurs normally throughout the body. Only a few cell layers thick, a bursa is filled with a lubricating fluid. However, when irritated, a bursa can become markedly thickened and painful. This is often referred to as bursitis. The retrocalcaneal bursa is positioned to allow the Achilles tendon to glide over the back part (posterior aspect) of the heel bone. When this bone becomes enlarged, inflammation of the retrocalcaneal bursa occurs. This inflammation results in exquisite tenderness along the posterior aspect of the heel.
Inflammation of the bursa causes synovial cells to multiply and thereby increases collagen formation and fluid production. A more permeable capillary membrane allows entrance of high protein fluid. The bursal lining may be replaced by granulation tissue followed by fibrous tissue. The bursa becomes filled with fluid, which is often rich in fibrin, and the fluid can become hemorrhagic. One study suggests that this process may be mediated by cytokines, metalloproteases, and cyclooxygenases.
Common signs and symptoms associated with infracalcaneal bursitis include redness under the heel. Pain and swelling under the heel. Pain or ache in the middle part of the underside of the heel. Heel pain or discomfort that increases with prolonged weight-bearing activities.
When a patient has pain in a joint, a careful physical examination is needed to determine what type of movement is affected and if there is any swelling present. Bursitis will not show up on x-rays, although sometimes there are also calcium deposits in the joint that can be seen. Inserting a thin needle into the affected bursa and removing (aspirating) some of the synovial fluid for examination can confirm the diagnosis. In most cases, the fluid will not be clear. It can be tested for the presence of microorganisms, which would indicate an infection, and crystals, which could indicate gout. In instances where the diagnosis is difficult, a local anesthetic (a drug that numbs the area) is injected into the painful spot. If the discomfort stops temporarily, then bursitis is probably the correct diagnosis.
Non Surgical Treatment
Most bursitis cases can be treated by the patient without having to see a doctor. A trip to a pharmacy, a conversation with the pharmacist, and some self-care techniques are usually enough. The NHS (National Health Service, UK) recommends PRICEM, a self-care management approach. PRICEM stands for Protection. Rest. Ice. Compression. Elevation. Medication. Protect the affected area, Some people place padding to protect the affected bursae from any blow. Rest. Do not exercise or use the joints in the affected area unless you really have to. Let it rest. Bursitis is a condition that responds well to rest. Ice packs. Ice packs can help reduce pain and inflammation. Make sure you do not place the ice directly on the skin, use a pack or towel. A small pack of frozen vegetables are ideal. Raise the affected area. If you can, lift the affected area, raise it, less blood will gather there. This may help reduce the inflammation. Painkillers. Ibuprofen is an effective painkiller for treating pain, it also reduces inflammation. Steroids. For more severe symptoms the doctor may inject steroids into the affected area. Steroids block a body chemical called prostaglandin. Prostaglandin causes inflammation. Steroids may raise the patient’s blood pressure if used for too long, as well as increasing his/her risk of getting an infection. UK doctors are advised not to give more than three steroid injections in one year. Antibiotics. If the fluid test confirms that there is a bacterial infection, the doctor will probably prescribe antibiotics. These will be administered orally (via mouth).
Only if non-surgical attempts at treatment fail, will it make sense to consider surgery. Surgery for retrocalcanel bursitis can include many different procedures. Some of these include removal of the bursa, removing any excess bone at the back of the heel (calcaneal exostectomy), and occasionally detachment and re-attachment of the Achilles tendon. If the foot structure and shape of the heel bone is a primary cause of the bursitis, surgery to re-align the heel bone (calcaneal osteotomy) may be considered. Regardless of which exact surgery is planned, the goal is always to decrease pain and correct the deformity. The idea is to get you back to the activities that you really enjoy. Your foot and ankle surgeon will determine the exact surgical procedure that is most likely to correct the problem in your case. But if you have to have surgery, you can work together to develop a plan that will help assure success.