Achilles Bursitis: Retrocalcaneal Bursitis Symptoms, Causes & Treatment

Quick answer: Achilles bursitis is inflammation of the small fluid-filled sac that cushions the back of the heel, and it is treated differently from Achilles tendonitis even though the pain sits in the same place. Most cases settle with a heel lift, a change of shoe, activity modification and targeted anti-inflammatory care once we identify which bursa is actually involved. Call (810) 206-1402.

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✅ Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatrist · Last updated April 6, 2026

Back-of-the-heel pain is one of the most common complaints we see at Balance Foot & Ankle — and one of the most commonly misdiagnosed. Patients often assume they have Achilles tendonitis, plantar fasciitis, or a heel spur when the actual source of pain is an inflamed bursa. This matters because the treatment approach is different.

Understanding exactly which structure is inflamed helps you avoid treatments that waste time and get to the ones that actually work.

What Is Achilles Bursitis?

A bursa is a small, fluid-filled sac that sits between structures in the body to reduce friction. Think of it as a biological cushion. At the back of the heel, there are two bursae that protect the Achilles tendon from rubbing against the calcaneus (heel bone) and the overlying skin.

When either of these bursae becomes irritated — from overuse, pressure, or structural abnormalities — it swells with excess fluid and becomes painful. This is bursitis. The bursa itself is healthy tissue doing its job; the inflammation is a response to excessive mechanical stress.

Achilles bursitis commonly coexists with Achilles tendinitis and Haglund’s deformity (a bony bump at the back of the heel). In fact, these three conditions form a spectrum of posterior heel problems that share overlapping causes and often require a combined treatment approach.

Retrocalcaneal vs. Retroachilles Bursitis

The distinction between these two types is clinically important because they respond to different treatments.

Retrocalcaneal bursitis is the more common and more clinically significant type. It produces a deep ache at the back of the heel that worsens with dorsiflexion (pulling the foot upward), running, and stair climbing. The classic diagnostic finding is pain when you squeeze the sides of the heel just in front of the Achilles tendon insertion — this compresses the inflamed bursa between the tendon and bone.

Retroachilles bursitis is usually caused by external pressure — typically from a rigid shoe heel counter rubbing against the back of the heel. This type is sometimes called “pump bump” because it was historically associated with women’s high-heeled pumps. The swelling is visible and superficial, sitting right at the back of the heel at skin level.

Causes and Risk Factors

Overuse and sudden increases in activity are the most common triggers. Runners who ramp up mileage too quickly, weekend warriors who go from sedentary to intense exercise, and people starting new exercise programs are all at elevated risk. The repetitive dorsiflexion of the ankle during running and walking creates cyclical compression of the retrocalcaneal bursa.

Tight calf muscles (gastrocnemius and soleus) increase mechanical stress on the Achilles tendon and, by extension, the underlying bursa. When the calf is tight, every step forces the tendon to work harder and compress the bursa more aggressively against the heel bone. This is why stretching is a cornerstone of treatment.

Haglund’s deformity — a bony enlargement at the posterior-superior aspect of the calcaneus — physically narrows the space where the retrocalcaneal bursa lives. The bursa gets chronically compressed between the enlarged bone and the tendon, leading to persistent inflammation. Haglund’s is sometimes the reason bursitis keeps coming back despite treatment.

Footwear plays a major role in both types. Rigid heel counters, shoes that are too tight at the back, ice skates, ski boots, and dress shoes with hard heel cups all create direct pressure on the posterior heel. For retroachilles bursitis specifically, the shoe is often the entire cause — switching shoes resolves the problem.

Biomechanical factors such as overpronation, high arches, and equinus (limited ankle dorsiflexion) alter the way force is distributed through the heel and Achilles tendon, predisposing certain patients to recurrent bursitis.

Symptoms

The hallmark symptom is pain at the back of the heel, specifically where the Achilles tendon meets the heel bone. This pain is characteristically worst when first getting up in the morning or after prolonged sitting (the bursa stiffens when at rest), then improves after 10–15 minutes of walking as the bursa warms up and loosens. However, pain returns and worsens with prolonged activity — especially running, hill climbing, and stair walking.

You may notice a visible swelling or bump at the back of the heel. With retrocalcaneal bursitis, the swelling tends to appear on the medial (inner) and lateral (outer) sides of the tendon — creating a characteristic “horseshoe” shape when viewed from behind. With retroachilles bursitis, the swelling is directly posterior, right at the surface.

The skin over the area may be red and warm, particularly after activity. Squeezing the back of the heel from side to side (the “two-finger squeeze test”) typically reproduces deep retrocalcaneal bursitis pain — this is different from Achilles tendinitis, where pain is reproduced by pinching the tendon itself.

Wearing shoes — especially those with rigid heel counters — often aggravates the pain significantly. Many patients report that open-back shoes, sandals, or going barefoot provides relief.

How It’s Diagnosed

Achilles bursitis is primarily a clinical diagnosis based on physical examination. Your podiatrist will perform the two-finger squeeze test, assess ankle range of motion, check for Haglund’s deformity, and differentiate bursitis from Achilles tendinitis by localizing the exact point of maximum tenderness.

X-rays may show a Haglund’s deformity, posterior heel spur, or calcification within the Achilles tendon — all of which provide context for what’s driving the bursitis. The bursa itself doesn’t show on X-ray since it’s soft tissue.

Ultrasound is the most efficient imaging for confirming bursitis. It shows fluid distention of the retrocalcaneal bursa in real-time and can also assess the Achilles tendon for concurrent tendinopathy. It’s quick, inexpensive, and doesn’t require radiation.

MRI is reserved for complex or refractory cases. It provides the most detailed view of both bursae, the Achilles tendon, and surrounding bone, and is particularly useful for surgical planning if conservative treatment fails.

Treatment: Conservative to Surgical

The vast majority of Achilles bursitis cases — roughly 80–90% — resolve with conservative treatment over 4–8 weeks. Surgery is reserved for structural problems (like Haglund’s deformity) that prevent conservative treatment from working.

First-Line Conservative Treatment

Heel lifts are the single most effective immediate intervention. Placing a 6–10mm heel lift inside the shoe reduces the angle of dorsiflexion at the ankle, which decreases compression of the retrocalcaneal bursa. This provides rapid relief — many patients notice improvement within 2–3 days. Heel lifts should be used bilaterally to avoid creating a leg-length discrepancy.

Ice therapy applied to the back of the heel for 15 minutes after activity reduces acute inflammation. Use a thin cloth between ice and skin. For targeted relief, freeze a water bottle and roll the back of the heel over it.

Activity modification is essential during the acute phase. This doesn’t mean complete rest — it means reducing the activities that provoke symptoms. Replace running with cycling or swimming temporarily, avoid hill work and stair climbing, and reduce total daily walking distance if possible.

Footwear changes address both types of bursitis. Avoid shoes with rigid, high heel counters. Instead, choose shoes with padded, flexible heel collars — running shoes generally work well. For retroachilles bursitis, wearing open-back shoes or clogs during the healing period eliminates the source of friction entirely.

Second-Line Treatment

Custom orthotics with a built-in heel lift and rearfoot control address the biomechanical factors that contribute to bursitis — particularly overpronation and equinus. Orthotics distribute pressure more evenly across the heel and reduce the mechanical load on the Achilles-bursa complex.

Physical therapy focusing on eccentric calf strengthening (the Alfredson protocol) has strong evidence for Achilles tendinopathy and also helps bursitis by improving the tendon’s ability to absorb load, reducing the stress transferred to the bursa. Soft tissue mobilization and instrument-assisted techniques (Graston, ASTYM) can address adhesions.

Cortisone injections: we don’t use them at the back of the heel. The retrocalcaneal bursa sits right against the Achilles tendon, and steroid that reaches the tendon can weaken it and raise the risk of rupture.

Surgical Treatment

Surgery is considered when 3–6 months of comprehensive conservative treatment has failed and symptoms continue to limit daily function. The most common procedure is retrocalcaneal decompression — removing the inflamed bursa along with any Haglund’s deformity that is causing mechanical impingement. If the Achilles tendon is also damaged, it may be debrided and reattached with suture anchors. Recovery typically takes 6–12 weeks in a walking boot followed by gradual return to activity.

Best Stretches and Exercises

1. Wall Calf Stretch (Gastrocnemius)

Stand facing a wall with the affected leg stepped back, heel flat on the floor. Keep the back knee straight and lean forward until you feel a stretch in the upper calf. Hold 30 seconds, repeat 3 times. Perform twice daily. This targets the gastrocnemius — the primary source of tightness that compresses the bursa.

2. Bent-Knee Calf Stretch (Soleus)

Same position as above, but bend the back knee while keeping the heel on the floor. You’ll feel the stretch shift to the lower calf/Achilles region. Hold 30 seconds, repeat 3 times. The soleus is often overlooked but contributes significantly to Achilles tendon tension.

3. Eccentric Heel Drops (Alfredson Protocol)

Stand on a step with the balls of your feet on the edge and heels hanging off. Rise up on both feet (concentric phase), then slowly lower the affected heel below step level over 3–5 seconds (eccentric phase). Perform 3 sets of 15 repetitions, twice daily. This strengthens the Achilles tendon eccentrically, improving its load tolerance and reducing bursal compression. Start with bodyweight only; add a weighted backpack as strength improves.

Best Products for Achilles Bursitis

Frequently Asked Questions

References

1. Starkweather KD, et al. Haglund deformity and retrocalcaneal bursitis. Clin Podiatr Med Surg. 2021;38(2):165-178.
2. Kachlik D, et al. The deep retrocalcaneal bursa. Surg Radiol Anat. 2008;30(4):347-353.
3. Maffulli N, et al. Achilles tendinopathy. Foot Ankle Surg. 2020;26(3):240-249.

Podiatrist-Recommended Products

🏆 Doctor Hoy’s Natural Pain Relief Gel — Top recommendation for reducing foot pain and inflammation naturally.

PowerStep Pinnacle Orthotic Insoles — Physician-grade arch support in an OTC package.

CURREX Support Insoles — Dynamic arch support in multiple profiles.

In-Office Treatment at Balance Foot & Ankle

If home treatment isn’t providing relief for your Achilles tendon conditions, our podiatry team at Balance Foot & Ankle can help with same-week evaluations and advanced in-office care.

Related Care at Balance Foot & Ankle

Clinical achilles services at our Howell and Bloomfield Township offices.

Achilles TendinopathyAchilles Tendon RuptureTendon Repair

More questions patients ask

What is the best treatment for Achilles bursitis?

Treatment includes rest, ice therapy, Doctor Hoy's Natural Pain Relief Gel for topical relief, heel lifts, stretching exercises, and in severe cases, surgery. We don't inject cortisone at the back of the heel: so close to the Achilles, it can weaken the tendon and raise the risk of rupture.

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