Recognizing and Treating Heel Bursitis—Symptoms and Treatment for Bursitis of the Heel or Calcaneus

Bursae are small sacs of tissue filled with a clear fluid (synovial fluid). They are found at nearly all joints, and here in particular over

• bones
• joints, and
• tendons

that are subjected to increased pressure or tension. There, they rest directly on the bone and act as a cushion. This reduces the pressure and friction between the bone and the associated structures, such as

• muscles,
• tendons, or
• skin.

When the foot is pulled back toward the top of the foot (dorsiflexion) at the ankle joint, the pressure inside the bursa increases. The opposite movement (plantarflexion)—that is, when the foot is extended—reduces the pressure.

The bursa between the heel bone and the Achilles tendon contains about 1.5 ml of fluid. Its purpose is to cushion impacts. In addition, it distributes the stress to which the heel bone is subjected during walking and running evenly across the ankle joint.

Painful inflammation can develop in the bursa. In medical terminology, this condition is called bursitis. The heel bone is also referred to by medical professionals as the calcaneus; inflammation of the heel bone is therefore called calcaneal bursitis. Excessive strain on the heel can overtax the bursa and the surrounding structures.

In calcaneal bursitis, the bursa located behind and below the heel becomes inflamed. Along with inflammation of the Achilles tendon, calcaneal bursitis is one of the most common causes of heel pain.

Athletes are particularly prone to this type of bursitis. Sports that carry a higher risk in this regard include

• jogging
• Soccer
• Handball
• Tennis

Wearing the wrong shoes can also irritate the heel area and thus cause inflammation. (Sports) shoes with a heel counter that is too stiff or with seams that dig into the heel put pressure on the heel and strain the bursa.

Congenital or post-traumatic misalignments of the legs or feet (such as bowlegs, knock-knees, or flat feet with a pronated arch) also have an adverse effect. If the feet roll inward or outward while walking or running, the bursa is subjected to additional strain.

In addition, pre-existing conditions can also contribute to inflammation, such as

• autoimmune rheumatic diseases (rheumatism), such as ankylosing spondylitis.
• the metabolic disorder gout, which is associated with elevated uric acid levels in the blood.

Last but not least, certain bacterial infections—such as those caused by staphylococci or streptococci—can lead to bursitis. This is referred to as septic bursitis. The bacteria can enter the bursa via the bloodstream or directly through an open wound.

The main symptom of bursitis in the foot is a stabbing pain in the heel area, which occurs primarily during movement. Other symptoms include:

• swelling in the heel area
• Warmth and redness at the affected site
• significant tenderness over the bursa
• depending on the severity of the inflammation, a pulling or stabbing pain in the calf
• very rarely, the discharge of cloudy, purulent fluid if there is an open wound and the bursa is exposed 

In cases of heel pain, swelling, and warmth in the heel area, rest is recommended as a first step. If this does not lead to a significant improvement in symptoms within a few days, a medical examination is recommended. This allows for a more detailed investigation of the causes of the symptoms and the initiation of the necessary treatment procedures.

The necessary examinations include:

• Review of medical history (anamnesis)
• Physical examination
• Laboratory tests
• Ultrasound
• X-ray
• MRI

During the medical history interview, you will be asked about your complaints, the exact symptoms, and possible triggers. 

Next, as part of a physical examination, the foot and lower leg are palpated. You will often be asked to point out the spot where you feel the most pain so that the examination can be made as pain-free as possible.

If, after taking your medical history and performing the physical examination, an infection is suspected—especially in the presence of fever, redness, swelling, and pus discharge—a blood test is usually ordered. Indicators of an infection include elevated inflammatory markers, such as a high white blood cell count. To assess the bursa, the joint, and the Achilles tendon more precisely, an ultrasound examination (sonography) may be necessary if needed. This is particularly recommended in cases where the situation is unclear or in cases of recurrent inflammation.

If the ultrasound reveals abnormal findings, or if the cause remains unclear even after the ultrasound, an MRI scan can provide more detailed insights into the bursa and the affected tissue in the foot and ankle.

If a bone injury is suspected—for example, following an accident or after surgery—an X-ray can provide further important clues about possible causes. It can reveal pathological changes in the ankle joint or injuries to the calcaneus.

Bursitis of the calcaneus can usually be treated effectively and heals relatively quickly. It is important to act quickly and to rest the painful area. The RICE protocol has proven effective here; it is considered a rule of thumb for first aid:

• P - Rest. The inflamed area should be rested. Temporary immobilization prevents further irritation of the bursa.
• E – Ice. Cold compresses or cooling pads can relieve pain and counteract inflammation. A cooling ointment can also reduce swelling. In consultation with your doctor, you can take anti-inflammatory and pain-relieving medications containing active ingredients such as ibuprofen or diclofenac.
• C – Compression. Light pressure helps reduce swelling and is ideal when used in combination with an ice pack or ointment dressings. Taping is another option. Tapes applied to the heel and calf can stabilize the ankle and relieve pressure on the irritated area.
• H - Elevation. Elevating the affected leg helps the swelling subside and allows the bursa to heal more quickly.

What should you do if these “first aid” measures do not relieve the symptoms?

The bursa does not always subside on its own once the inflammation has subsided. In this case, a puncture may be advisable. In this minimally invasive procedure, the inflammatory fluid is drawn out of the bursa using a syringe.

Anti-inflammatory cortisone is then injected into the bursa capsule. The aspiration can be an effective treatment for persistent inflammation. However, the benefits and risks must always be carefully weighed, as bacterial pathogens can enter the already irritated bursa through the puncture site and worsen the overall condition.

If other rheumatic or metabolic disorders have triggered the inflammation, the underlying condition is treated. The bursitis should then subside on its own.

When is surgery necessary?

If calcaneal bursitis is caused by bacteria, surgical opening of the bursa with the insertion of a drain is necessary. This ensures that all the inflammatory fluid can drain from the bursa. In addition, antibiotics are usually required to counteract bacterial growth.

Surgical removal of the inflamed bursa (bursectomy) is necessary only in rare cases: when the inflammation

• lasts longer than three to six months or
• recurs repeatedly.

Removal requires only a minor surgical procedure. However, it requires subsequent immobilization and, in some cases, a course of antibiotics.

Bursitis of the heel can have a wide variety of causes. Some of these can actually be prevented:

• Stretching and strengthening exercises to build muscle strength help stabilize and protect the joints and bursae
• Shoes should also protect and stabilize the foot. Make sure to choose well-fitting shoes that are suitable for specific activities as well as everyday use. When purchasing running or hiking shoes, professional advice combined with a gait analysis can be helpful in identifying potential problem areas
• Avoid uneven strain and overexertion. Take regular breaks during sports and at work, and under no circumstances should you push through the pain
• If bursitis is caused by an underlying medical condition, a mindful diet tailored to your needs can help reduce inflammatory processes in the body. 

Although bursitis of the heel bone is extremely painful, it can usually be treated effectively. If you take care of your body, bursitis can also be easily prevented.