Retrocalcaneal Bursitis: Posterior Heel Pain Between the Achilles Tendon and Heel Bone

Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

What Is Retrocalcaneal Bursitis?

Retrocalcaneal bursitis is inflammation of the retrocalcaneal bursa — a small fluid-filled sac located between the Achilles tendon and the posterior calcaneus (heel bone). This bursa acts as a cushion to reduce friction between the tendon and the bony heel during ankle movement. When the bursa becomes inflamed, it fills with fluid, swells, and causes pain directly at the back of the heel — a location distinctly different from the inferior heel pain of plantar fasciitis.

At Balance Foot & Ankle, retrocalcaneal bursitis is a frequently encountered cause of posterior heel pain that is often confused with Achilles tendinopathy or dismissed as a non-specific heel problem. Accurate diagnosis determines appropriate treatment — and the two conditions require different management approaches.

Anatomy: The Two Bursae of the Posterior Heel

Two distinct bursae exist at the posterior heel, and distinguishing between them matters clinically. The retrocalcaneal bursa lies deep to the Achilles tendon — between the tendon and the heel bone — within the retrocalcaneal recess. Inflammation here creates pain that is felt deep inside the posterior heel, just in front of the Achilles tendon.

The subcutaneous calcaneal bursa (also called the superficial calcaneal bursa or retroachilles bursa) lies between the Achilles tendon and the overlying skin. Inflammation of this bursa creates a soft, fluctuant swelling visible directly behind the heel at the skin surface. This is the bursa more commonly inflamed by shoe counter pressure and is associated with Haglund deformity.

Both bursae can be simultaneously inflamed — a presentation called combined bursitis — which makes clinical distinction more challenging and typically requires ultrasound or MRI for definitive characterization.

Causes of Retrocalcaneal Bursitis

Overuse and repetitive loading are the most common causes. Athletes who rapidly increase running mileage, hillwork, or activities demanding repetitive ankle plantarflexion compress the retrocalcaneal bursa repeatedly against the heel bone. Runners, dancers, and gymnasts are particularly susceptible.

Haglund deformity — a bony prominence on the posterosuperior calcaneus — mechanically compresses the retrocalcaneal bursa between the deformity and the Achilles tendon with every step. Patients with Haglund deformity frequently develop concurrent retrocalcaneal bursitis and insertional Achilles tendinopathy from the triple pathology of bone spur, bursa, and tendon crowded into the retrocalcaneal space.

Inflammatory arthritis — particularly rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis — preferentially affects the entheseal sites (tendon-to-bone junctions) and adjacent bursae. Bilateral retrocalcaneal bursitis or bursitis occurring without obvious mechanical cause should prompt evaluation for underlying inflammatory arthritis.

Poorly fitted footwear with rigid or high heel counters that press directly on the posterior heel compresses the retrocalcaneal space and irritates the bursa. Pump bump (Haglund deformity in women who wear high-heeled pumps) is the classic example.

Symptoms of Retrocalcaneal Bursitis

The primary symptom is pain at the posterior heel — specifically at the insertion point of the Achilles tendon on the heel bone, rather than the bottom of the heel as in plantar fasciitis. Pain is typically worsened by activity (particularly uphill walking and stairs), by footwear with heel counters that press on the area, and by direct pressure from the back of a shoe. Morning stiffness is common.

On examination, the two-finger squeeze test — simultaneously compressing the medial and lateral aspects of the heel just anterior to the Achilles tendon insertion — reproduces deep posterior heel pain and is highly specific for retrocalcaneal bursitis. Visible swelling may be present at the posterolateral heel.

Diagnosis

Clinical examination establishes the provisional diagnosis. Ultrasound is the most accessible imaging modality for confirming bursal fluid accumulation — the inflamed bursa appears as an anechoic (dark) fluid collection anterior to the Achilles tendon on ultrasound. Real-time ultrasound also guides injections precisely into the bursal space. MRI provides the most comprehensive assessment, showing bursal distension, Achilles tendon pathology, and any Haglund deformity concurrently.

X-rays assess for Haglund deformity — measured by the parallel pitch lines method — and calcaneal bone spurs at the Achilles insertion. The degree of Haglund prominence helps determine whether conservative treatment alone is likely to succeed or whether the bony deformity will require surgical correction.

Conservative Treatment

Activity modification to reduce the repetitive compression loading is the cornerstone of initial treatment. Relative rest — maintaining fitness through low-impact cross-training (swimming, cycling) while eliminating the provocative activities — allows inflammation to subside without complete deconditioning.

Heel lifts (5 to 10mm) reduce Achilles tendon tension and decrease compression of the retrocalcaneal bursa by reducing the range of ankle motion through which the bursa is compressed. They are inexpensive, immediately helpful, and can be placed in most footwear. Avoid wearing heel counter-heavy footwear during the acute phase — backless shoes, sandals, or clogs with open heels eliminate the posterior heel pressure.

Ice applied to the posterior heel for 15 to 20 minutes after activity reduces inflammation. NSAIDs (if not contraindicated) provide systemic anti-inflammatory effect. Physical therapy addressing calf flexibility, eccentric Achilles loading, and any biomechanical contributors to the condition provides lasting benefit.

Ultrasound-guided corticosteroid injection into the retrocalcaneal bursa provides rapid pain relief and can facilitate rehabilitation progress. Care is taken to inject into the bursa rather than the Achilles tendon itself, as intratendinous corticosteroid increases tendon rupture risk. Ultrasound guidance ensures accurate needle placement and safety.

Surgical Treatment

Surgery is considered when conservative treatment has been comprehensively implemented for 3 to 6 months without adequate relief. The surgical approach addresses both the inflamed bursa and any contributing Haglund deformity. Through a posterior heel incision, the retrocalcaneal bursa is excised, the posterosuperior calcaneal prominence is resected, and any concurrent insertional Achilles tendon degeneration is debrided. In severe cases with significant Achilles tendon involvement at the insertion, the tendon is detached, the degenerated tissue excised, and the tendon reattached with suture anchors.

Recovery after posterior heel surgery requires 6 to 10 weeks of protected weight bearing and 3 to 6 months of physical rehabilitation for full return to activity. Outcomes are generally excellent for patients with adequate conservative treatment trials who are appropriately selected for surgery.

Contact Balance Foot & Ankle for evaluation of posterior heel pain. We serve patients throughout Southeast Michigan with comprehensive diagnostic and treatment capabilities, including ultrasound-guided injections and surgical options when conservative care is insufficient.

Posterior Heel Pain Treatment at Balance Foot & Ankle

Retrocalcaneal bursitis causes pain at the back of the heel where the Achilles tendon inserts. Dr. Tom Biernacki at Balance Foot & Ankle provides targeted treatment including physical therapy, injection therapy, and surgical debridement when needed at our Howell and Bloomfield Hills offices.

Learn About Our Heel Pain Treatment Options | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Kvist M. “Achilles tendon injuries in athletes.” Sports Medicine. 1994;18(3):173-201.
2. McGarvey WC, et al. “Endoscopic calcaneoplasty for insertional Achilles tendinosis and retrocalcaneal bursitis.” Foot and Ankle International. 2012;33(1):8-13.
3. Sofka CM, et al. “Posterior heel disorders.” HSS Journal. 2010;6(1):68-73.

Differential Diagnosis: What Else Could It Be?

Not every case of haglund’s deformity is straightforward. In our clinic we routinely rule out three look-alike conditions before confirming the diagnosis. If your symptoms don’t match the classic presentation, one of these may explain the pain — which is why physical exam matters more than self-diagnosis.

Condition	How It Differs
Retrocalcaneal bursitis alone	Anterior to the Achilles insertion, no posterior bone prominence.
Insertional Achilles tendinopathy	Pain at the tendon-bone junction; calcification may be present on X-ray.
Sever’s disease (pediatric)	Child or adolescent with growth-plate pain; Haglund presents in adults.

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