The full name for the bursitis you get in the back of your heel, underneath the Achilles tendon, is retrocalcaneal bursitis. That’s a bit of a tongue-twister, so to refer to it as heel bursitis is also fine. It usually manifests as a pain in the back of the heel, accompanied by a puffiness of the painful area.
I've also discussed this in more detail in this video:
The heel bursa is the little blue sac in the image below. It is filled with fluid and sits between your Achilles tendon and heel bone where the tendon goes over the bone. We have bursas all over the body wherever tendons are close to one another and where a tendon is close to bone. Their function is to protect your tendons; they prevent friction and absorb some of the compression forces.
Causes of heel bursitis
There are 3 main reasons why you may develop heel bursitis.
The first is if you have an inflammatory reaction or inflammatory condition that makes the bursa more sensitive than it should be. For example, gout can be a cause, as well as conditions like rheumatoid arthritis or any other inflammatory type of disease. So, if you have a painful bursa and you know you have an inflammatory condition running in the family, it is worth asking your doctor to look into that possibility.
The second cause of heel bursitis is trauma. If you get a direct knock on the bursa, it can swell dramatically and become super painful.
The third cause of heel bursitis is the one that we deal with most in our practice, and that is when there has been chronic overuse or an acute increase in compressive forces on the bursa. The bursa is supposed to handle compression between your Achilles tendon and your heel bone when you run or walk, but when there is excessive force or a lot of frequent compression, the bursa can get irritated because it is just not used to that. So, compression in itself is not the problem, it is the amount of compression.
There are several ways in which you can inadvertently subject your heel bursa to too much compression.
One that we often see in our practice is when people suddenly switch from wearing shoes with a bit of a heel to flat shoes or going barefoot. When this happens, your ankle moves into a bigger range of dorsiflexion when you walk or run, which means that the Achilles tendon stretches tighter over your heel bone, which increases the compression on your bursa. Walking barefoot around the house may be fine, but you might be asking too much too suddenly of your heel bursa when you go on holiday and then go sightseeing all day in flip-flops and/or go for long barefoot walks on the beach, where the soft sand causes yet more dorsiflexion.
A similar thing happens when you suddenly take up hill running or hill walking, and especially walking fast up a hill. Going up a hill will increase that dorsiflexion angle, increasing the pull of the Achilles tendon over the heel bone and increasing the compression on the bursa.
A third cause of too much compression on the heel bursa is stretching too much. The typical calf stretch, where you lean forward against something while keeping the heel flat on the floor, as well as deep stretches in yoga, such as really dipping into the downward dog and getting your heel down, all involve dorsiflexion that can put too much compression on the heel bursa. So, if you are going to do this kind of stretch, be careful to ease into it over time.
Treatment of heel bursitis
Take the pressure off
The most important thing to start doing immediately is to offload that painful bursa. Give it a little bit of breathing space so that it can calm down. By far the easiest way to do this is to wear shoes with a bit of a heel to decrease the dorsiflexion and therefore the amount of compression of the Achilles tendon on the bursa. Just make sure that the back of the shoe does not press directly on the bursa. I usually tell my patients to wear shoes with a slight heel all day long at home or to use an insole with extra heel lift. If it is a mild case, they do not have to wear these around the house, just when they go for longer walks. So, it depends on how sensitive yours is. If you can immediately offload that bursa and give it a little bit of breathing space to take the pressure off it and you stick to it for a few days and really protect it, you will see that it calms down much more quickly than if you try to tough it out and keep on going about in flat footwear.
This will also work in cases where there has been direct trauma to the bursa, but it might take a few weeks rather than a few days to calm down properly.
Can you still get in some training while waiting for your heel bursitis to calm down? If you’re a runner and you can run without pain on the flat, then avoid hilly runs for now and go slower than usual. If you usually run in flat or minimalist shoes, swop them for running shoes with a heel for the time being or use inserts with a heel (in both shoes). As mentioned above, check that the back of your running shoe does not press directly on the bursa. If you’re a walker, slow it down somewhat and stick to flat walks until the bursa has calmed down. Cycling can often irritate it due to the position of your foot on the pedal.
Do not stretch!
One thing you should absolutely not do for heel bursitis is calf stretches or any other dorsiflexion stretches. It is quite shocking when you do online searches about heel bursitis and you come across people prescribing calf stretches and dorsiflexion stretches for bursitis. Please do not stretch your calf or your Achilles tendon into dorsiflexion if you have bursitis, because it increases the compression on that bursa and excess compression is what has caused the irritation in the first place.
I realise why people would want to do it: the calf feels tight and they think, “If I can release the calf it will release the pressure and then the bursa will be happy”. That calf is tight because you have a painful heel, and that calf will stay tight until the pain in the heel settles down. The tightness will not settle down until the bursa is better and if you're going to continue to stretch, you're going to continue pushing on the bursa and it's not going to get better.
If you want to do something for your calf that feels tight, you can use a massage gun on it, obviously not on the heel that's painful but by all means on the muscle. You can also use a foam roller or get a massage, but do not let anybody dig into that bursa; they will just make it worse because rubbing and massaging on the bursa also causes compression.
Are there any strength exercises you can do to fix heel bursitis? Not really. You do not need any strength training because this condition is not about a strength deficit. It is more about avoiding the compression and slowly easing back into your usual foot positions over time. However, heel bursitis often occurs in combination with insertional Achilles tendinopathy. In that case, you will have to do exercises for the tendinopathy to get that tendon stronger and better. This is where some guidance from a physio would come in handy because you have to limit the range of movement of the exercises to avoid more compression on the bursa.
If you know or suspect that you are prone to inflammatory disease, it is worth getting tested for it, because anti-inflammatories can make a massive difference to get the inflammation down. Check with your GP before you start taking anti-inflammatories, though, because they are not suitable for everyone. And if you do take anti-inflammatories, do not do so for more than ten days. Even in cases where heel bursitis is not due to inflammatory disease, anti-inflammatories may be useful. However, it is worth trying the things mentioned above before resorting to anti-inflammatories.
Sometimes people follow the above advice, but their bursa does not want to get better. In these cases, an injection might be an option. It will usually be a steroid injection, and corticosteroids work really well to calm down a bursa, but they are bad for tendons as they can increase the risk of tendon rupture. Therefore, make sure they do it under ultrasound guidance so that they hit your bursa and not inject it into your Achilles tendon by mistake. In any event, some of the corticosteroid injected into the bursa will find its way to your Achilles tendon, and that is why an injection should be the last resort.
In short, there is no one-size-fits-all approach; it has to be something that works for you and for your specific case.
Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.