Heel bursitis – Causes, symptoms, and treatment
- Maryke Louw
- Jun 9
- 11 min read
If you have pain and swelling at the back of your heel, the cause could be heel bursitis. This condition develops when the small cushioning sac between the Achilles tendon and heel bone becomes irritated and inflamed.
In this article, we'll explain what causes heel bursitis, how to tell it apart from Achilles tendon injuries, and which treatments are most likely to help you recover.
Remember, if you need help with an Achilles injury, you're welcome to consult one of our physio team via video call.
The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in most of our articles.
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What is heel bursitis?
The heel bursa is the little fluid-filled sac shown in the image below. It sits between your Achilles tendon and heel bone, right where the tendon passes over the bone.
We have bursae (small protective sacs) all over our bodies – wherever tendons are close to one another or close to a bone. Their job is to protect your tendons by preventing friction and absorbing compression forces.
Heel bursitis is when the bursa becomes inflamed. This causes extra fluid to build up inside it, making it swell – this can be very painful.
The full medical name for the bursitis you get at the back of your heel, underneath the Achilles tendon, is retrocalcaneal bursitis. That's quite a mouthful, so "heel bursitis" works perfectly well.
What causes heel bursitis?
The most common cause is excessive compression or pressure on the bursa. This can happen in a number of ways:
Tight or stiff shoes that rub against the lower heel area – something we see regularly in our online clinic.
A direct knock to the area – for example, a shopping trolley bump or a hit from a hockey stick.
Excessive stretching – calf and Achilles stretches pull the tendon tight over the heel bone, which compresses the bursa. This is usually fine, but very strong or prolonged stretches can cause trouble.
Switching to flatter footwear too quickly – going from shoes with a slight heel (like regular work shoes) to flat shoes (flip-flops or sandals) increases the stretch on the Achilles tendon. If the change is too sudden (e.g. suddenly walking long distances in flip-flops while on holiday), the tendon and bursa don't have time to adapt.
A sudden increase in uphill running or walking – going uphill increases the angle at the ankle, which pulls the Achilles tendon harder over the heel bone and puts more pressure on the bursa. Building up these activities gradually helps the Achilles and bursa to get used to this increased force.
The shape of your foot arch – people with high arches are naturally more prone to heel bursitis, because the lower part of the Achilles tendon sits closer to the heel bone, making it more sensitive to overstretching or sudden footwear changes.
The shape of your heel bone – a Haglund's deformity (an extra bony bump at the back of the heel) can also increase your susceptibility to bursitis.
Less common causes include:
Quinolone antibiotics (a specific class of antibiotic)
Inflammatory conditions such as gout
Autoimmune conditions such as rheumatoid arthritis, psoriasis, or ankylosing spondylitis
Infection.
Symptoms of heel bursitis
Heel bursitis can be tricky to distinguish from insertional Achilles tendinopathy or tendonitis (an injury to the Achilles tendon at the point where it attaches to the heel bone), since both cause pain right at the base of the Achilles tendon.
đź’ˇ And it's quite common to have a combination of heel bursitis and insertional Achilles tendinopathy, because most activities that irritate the bursa also put stress on the lower part of the Achilles tendon.
With recent-onset bursitis, you'll typically notice a puffiness or swelling around the Achilles tendon near the heel. If the bursa is very inflamed, the area may also look red and feel warm compared to your other heel.
With chronic bursitis (present for more than three months), visible swelling and redness may be much less obvious.
Calf or Achilles stretches may be painful while you're doing them – but watch out for a delayed symptom response too: the stretch might feel fine in the moment, only for your pain to increase a few hours later.
How it is diagnosed
Most cases can be diagnosed from looking at the history of how your injury started, combined with the typical signs and symptoms above.
Scans and blood tests might be helpful if:
the diagnosis isn't clear from your assessment alone,
your clinician suspects a different type of injury,
an inflammatory condition might be contributing, or
your injury isn't responding to treatments that typically work for heel bursitis.
Both ultrasound and MRI scans can be used to diagnose heel bursitis and Achilles tendon injuries. X-rays might be useful if a heel bone injury is suspected, but they don't show soft tissues like tendons or bursae.
How long does heel bursitis take to recover?
Mild cases can settle in as little as four to six weeks, while more significant flare-ups can take three months or longer. If you also have an Achilles injury, the bursitis will usually settle well before the Achilles has fully recovered.
Recovery time varies depending on:
how significantly your bursa has flared up,
whether you also have an Achilles injury, and
how soon you start addressing the things that are irritating it (more on this in the treatment section below).
Treatments that work for most cases
There are three steps to an effective treatment plan for heel bursitis:
Temporarily reduce the stretch and compression on the bursa to calm the irritation down.
Use treatments that reduce inflammation and swelling.
Slowly reintroduce stretch and compression once things have settled, giving the bursa enough time to adapt.
What works best will depend on your specific situation, so let's look at the most common and effective ways to achieve each of these steps.
How to reduce stretch and compression
1. Wear the right shoes
Heeled shoes usually work best – and no, I don't mean stilettos! Any shoe where the heel sits slightly higher than the toes will already make a difference, as it reduces the amount of stretch on the calf and Achilles tendon.
Your shoes should also not push or rub against the painful area. We've discussed the best shoes for heel bursitis in detail in this article, including specific brands we find work well.
2. Try insoles or heel lifts
If your foot rolls inward excessively when you walk (known as overpronation), this can increase the stretch on the inner part of the Achilles tendon. Arch-supporting insoles can help if this applies to you.
Heel lift inserts are another affordable option worth trying if you feel you need a little extra heel height in your regular shoes.
👉 Remember to use insoles in both shoes to keep things balanced – even if only one heel is painful.
3. Avoid or adapt stretching exercises
Any movement that takes your foot and ankle into a strong dorsiflexion position (toes moving closer to your shin) has the potential to irritate the bursa while it's healing. This includes the obvious ones like the classic runner's calf stretch, but also:
deep squats or lunges
downward-facing dog
dropping your heels over the side of a step
pulling your foot towards you with a belt.
💡 It's also worth watching out for positions you might not think of as stretches – like sitting with your feet tucked back under your chair at work.
The good news is that you can often continue with exercises like squats during recovery with small adjustments. These articles share tips on adapting common exercises to reduce the stretch on your Achilles tendon:
4. Avoid direct pressure on the area
Shoes that rub the back of your heel are the obvious ones to avoid. But habits like resting your heels on a coffee table can also aggravate things.
If your bursa is very sensitive and even the pressure of your bedding is uncomfortable, try placing a pillow under your lower leg so that your calf and knee are supported but your heel hangs free.
Treatments that help reduce inflammation and swelling
Ice is a safe, easy option you can use at home. Apply for no more than 10 minutes at a time, with short breaks in between – for example, 10 minutes on, 10 minutes off, then 10 minutes on again.
Anti-inflammatory medication (NSAIDs)Â such as ibuprofen or naproxen can also help. Do speak to your doctor or pharmacist first to make sure it's safe for you to take.
Inflammatory and autoimmune conditions (such as gout or rheumatoid arthritis) usually require specific prescription medication from a doctor.
👉 If you haven't been diagnosed with an inflammatory condition but a close relative has, it's worth mentioning this to your doctor – they can arrange blood tests to check whether it might be contributing to your symptoms.
Getting the bursa used to stretch again
This third step is where a lot of people come unstuck. Once the pain has settled, it's very tempting to assume you can immediately return to business as usual – back into the flat shoes, straight into the yoga stretches. And it might feel fine for a week or so. But then the bursitis flares back up.
Bursae, like all the tissues in our bodies, respond and adapt to how we use them. If you use them regularly, they become a bit thicker and their tissues more robust. If you don't place much strain on them for a long period, they become less robust.
The time out from pressure helps the injured bursa to calm down, but once that's happened, it needs to be slowly reintroduced to normal levels of stretch and compression so it has time to adjust and adapt.
Here are some ways to do this progressively:
Gradually reduce the number or height of heel lifts in your shoes until you're comfortable without them.
Start wearing flatter shoes or walking barefoot for short periods (e.g. around the house) and slowly increase the time and distance.
If you've been using a rolled towel under your heels for squats, slowly reduce the height until you're comfortable without it.
Introduce gentle calf stretches that don't go to the end range, held for just a few seconds at a time.
If you're a runner, you might start by sticking to your running shoes (which have a slight heel lift) but gradually introduce hillier terrain.
đź’ˇ If you also have insertional Achilles tendonitis or tendinopathy, it's important to include the rehab exercises for that condition too. A well-structured plan will naturally progress into more stretched positions during the later stages.
Treatments to avoid with heel bursitis
Stretches and flat shoes are the obvious ones, but a couple of others are worth highlighting.
Night braces
You'll often see night braces recommended for heel bursitis, but this isn't something I would advise. These braces can press directly on the injured area or cause a mild sustained stretch, both of which can aggravate symptoms over time.
The reason they're commonly suggested is that they're thought to reduce the stiffness you feel when you first get out of bed in the mornings. But that morning stiffness is mainly due to reduced circulation from lying still all night – and it usually improves quickly once you start moving.
A better solution is to gently move your foot up and down a few times before you stand up from the bed, then slip straight into a heeled shoe (like a clog) that reduces the stretch required during those first steps of the day.
Massaging the painful area
Massaging your calf muscles can be genuinely helpful and make things feel more comfortable. But please avoid firm pressure directly over the irritated bursa – rubbing an inflamed bursa will only make it more inflamed.
⚠️ This applies to all forms of massage alike: massage guns, foam rollers, and hands-on massage from a therapist.
I demonstrate some safe ways to self-massage your calves in this video.
When heel bursitis is stubborn – treatments worth considering
Some cases of heel bursitis are persistent and refuse to settle despite the patient doing all the right things. If you've been struggling for several months without improvement, the following treatments might be worth discussing with your doctor or physio.
Corticosteroid injections
We usually advise people with Achilles tendon injuries to avoid corticosteroid (cortisone) injections, as they're not good for tendon healing. However, they may have a role in chronic bursitis – and the key difference is that the injection goes into the bursa, not the tendon.
The research consensus is that this should be done under ultrasound guidance to ensure accurate placement. Even so, there is a small risk of Achilles tendon tears. One study of 280 injections found that four patients (1.8%) experienced an Achilles tear between 15 and 59 days afterwards.
👉 This risk can be reduced by following a progressive strengthening programme after the injection to strengthen the Achilles tendon.
Surgery
Surgery can bring relief in long-standing cases. The type of procedure will depend on what's identified as the underlying cause:
A simple bursectomy (removal of the bursa) may be performed when no other contributing factors are found.
In other cases, the bursa may be left intact while the surgeon shaves down the heel bone to remove bony bumps or calcium deposits, and trims any damaged parts of the Achilles tendon.
Some studies report excellent results while others don't show the same success for the same procedures. The difference might lie in how a patient is treated after the surgery.
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One study that stands out for its great results followed a very conservative approach during the postoperative period, keeping the affected ankle in a degree of plantar flexion (a slightly pointed position) for more than six weeks (sometimes longer depending on the full procedure) – similar to the approach used after Achilles tendon surgery. This likely allowed the tissue time to calm down and recover before stretch and compression were introduced again.
How we can help
Need help with your Achilles or related 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.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. All of us have a wealth of experience working with athletes across a broad variety of sports and ranging from recreationally active people to professional athletes. You can meet the team here.
About the author
Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.
