Heel pain: Superficial Calcaneal Bursitis

A superficial calcaneal bursa is an adventitious bursa, which means it forms due to mechanical stress on soft tissues, and is not a true anatomical bursa. This particular bursa forms between the skin and the posterior aspect of the calcaneus (the back of the heel bone) or the posterior aspect of the Achilles tendon and the skin, in a central-lateral position (in the middle and towards the outside).

These sheer forces arise due to excessive rearfoot movement whilst wearing shoes, causing sheer forces to act upon the skin and underlying soft tissues (sheer forces – pressure and friction combined). It these sheer forces continue unabated for a long time, then the calcaneus itself can become affected, forming a bony lump, called a “Haglund’s Deformity”. The bigger the deformity becomes, the more sheer forces are produced, leading to further irritation of the bursa and bone tissue and a gradual worsening of the condition in many cases. This condition is considered ” fluctuant”, which means it is changeable and characterised by flares and remissions. In some cases, blistering and ulceration can occur, possibly leading to infection.

Superficial calcaneal bursitis (SCB) presents with an inflamed and painful area at the central-lateral aspect of the posterior surface of the heel. Localised swelling and a Haglunds’ Deformity may also be evident in chronic cases, although it must be said that someone can have a Hagland’s Deformity without SCB. The patient will often have an antalgic gait, which means they will have a shortened stance phase and a prolonged swing phase on the affected limb in comparison to the unaffected limb.

Differential diagnoses for this condition include chilblains, blisters, and insertional Achilles tendinopathy (more on that in a future post).

SCB is usually treated with conservative methods. The principle means of reducing the inflammation is to remove the original stressor, i.e. the sheer forces. Podiatry treatment would could involve three components:

1. Encouraging the patient to wear more accommodating footwear or modify the patient’s existing shoes with padding (or applying the padding to the foot directly).

2. Controlling excessive rearfoot movement by prescribing functional, in-shoe orthoses (insoles).

3. Acupuncture, topical, and/or oral analgesics to manage pain during the initial stages of recovery.

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