Pain in side of ankle above heel

Insertional heel pain; Retrocalcaneal bursitis

Bursitis of the heel is swelling of the fluid-filled sac (bursa) at the back of the heel bone.

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Retrocalcaneal bursitis is an inflammation of the bursa at the back of the heel bone. A bursa is a fluid-filled sac that acts as a cushion and a lubricant between tendons and muscles sliding over bone. Repetitive or over use of the ankle, by doing excessive walking, running, or jumping, can cause this bursa to become irritated and inflamed. Symptoms of bursitis include pain in the heel, especially with walking, running or when the area is touched.

Causes

A bursa acts as a cushion and lubricant between tendons or muscles sliding over bone. There are bursas around most large joints in the body, including the ankle.

The retrocalcaneal bursa is located in the back of the ankle by the heel. It is where the large Achilles tendon connects the calf muscles to the heel bone.

Repeated or too much use of the ankle can cause this bursa to become irritated and inflamed. It may be caused by too much walking, running, or jumping.

This condition is very often linked to Achilles tendinitis. Sometimes retrocalcaneal bursitis may be mistaken for Achilles tendinitis.

Risks for this condition include:

• Starting a very intense workout schedule
• Suddenly increasing activity level without the right conditioning
• Changes in activity level 
• History of arthritis that is caused by inflammation

Symptoms

Symptoms include:

• Pain at the back of the heel, especially with walking, running, or when the area is touched
• Pain may get worse when standing on tiptoes
• Red, warm skin over the back of the heel

Heel pain can be a common problem. Though the cause is rarely serious, the pain can be severe and sometimes disabling. Heel pain is often the result of overusing your foot. Causes may include, running, especially on hard surfaces like concrete, tightness in your calf, or from Achilles tendonitis (inflammation of that large tendon that connects your calf muscle to your heel), shoes with poor support, sudden inward or outward turning of your heel, or landing hard or awkwardly on your heel after a jump or fall. Problems related to heel pain include bursitis (inflammation of the bursa at the back of the heel), bone spurs in the heel, and plantar fasciitis (swelling of the thick band of tissue on the bottom of your foot). Heel pain is something you can usually treat at home. If you can, try resting as much as possible for at least a week. Apply ice to the painful area twice a day or so, for 10 to 15 minutes. Take acetaminophen or ibuprofen for pain and inflammation. If you need to, you can buy a heel cup, felts pads, or shoe inserts to comfort your heel. You should call your doctor if your heel pain does not get better after two or three weeks of home treatment. But also call your doctor if your pain is getting worse, or your pain is sudden and severe, your feet are red or swollen, or you can't put weight on your foot. If you visit the doctor, you may have a foot x-ray. Your treatment will depend on the cause of your heel pain. You may need to see a physical therapist to learn exercises to stretch and strengthen your foot. To prevent future heel pain, we recommend you exercise. Maintaining flexible, strong muscles in your calves, ankles, and feet can help ward off some types of heel pain. And do yourself a favor, trade those sleek high heels in for a comfortable, properly fitting pair of shoes.

Exams and Tests

Your health care provider will take a history to find out if you have symptoms of retrocalcaneal bursitis. An exam will be done to find the location of the pain. The provider will also look for tenderness and redness in the back of the heel.

The pain may be worse when your ankle is bent upward (dorsiflex). Or, the pain may be worse when you rise on your toes.

Most of the time, you will not need imaging studies such as x-ray and MRI at first. You may need these tests later if the first treatments do not lead to improvement. Inflammation may show on an MRI.

Treatment

Your provider may recommend that you do the following:

• Avoid activities that cause pain.
• Put ice on the heel several times a day.
• Take nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen.
• Try using over-the-counter or custom heel wedges in your shoe to help decrease stress on the heel.
• Try ultrasound treatment during physical therapy to reduce inflammation.

Have physical therapy to improve flexibility and strength around the ankle. The focus will be on stretching your Achilles tendon. This can help the bursitis improve and prevent it from coming back.

If these treatments do not work, your provider may inject a small amount of steroid medicine into the bursa. After the injection, you should avoid overstretching the tendon because it can break open (rupture).

If the condition is connected to Achilles tendinitis, you may need to wear a cast on the ankle for several weeks. Very rarely, surgery may be needed to remove the inflamed bursa.

Outlook (Prognosis)

This condition most often gets better in several weeks with the proper treatment.

When to Contact a Medical Professional

Call your provider if you have heel pain or symptoms of retrocalcaneal bursitis that do not improve with rest.

Prevention

Things you can do to prevent the problem include:

• Maintain as good flexibility and strength around the ankle to help prevent this condition.
• Stretch the Achilles tendon to help prevent injury.
• Wear shoes with enough arch support to decrease the amount of stress on the tendon and inflammation in the bursa.
• Use proper form when exercising.

References

Kadakia AR, Aiyer AA. Heel pain and plantar fasciitis: hindfoot conditions. In: Miller MD, Thompson SR, eds. DeLee Drez & Miller's Orthopaedic Sports Medicine. 5th ed. Philadelphia, PA: Elsevier; 2020:chap 120.

Seller RH, Symons AB. Pain in the foot. In: Seller RH, Symons AB, eds. Differential Diagnosis of Common Complaints. 7th ed. Philadelphia, PA: Elsevier; 2018:chap 23.

Wilkins AN. Foot and ankle bursitis. In: Frontera, WR, Silver JK, Rizzo TD Jr, eds. Essentials of Physical Medicine and Rehabilitation. 4th ed. Philadelphia, PA: Elsevier; 2019:chap 86.

Version Info

Last reviewed on: 7/25/2020

Reviewed by: C. Benjamin Ma, MD, Professor, Chief, Sports Medicine and Shoulder Service, UCSF Department of Orthopaedic Surgery, San Francisco, CA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.