Ross Hauser, MD, Danielle Matias, PA-C, Demi Foster, APRN

Pain and swelling at the back of your heel can make an ordinary walk difficult. You may have tried different shoes, ice, anti-inflammatory medication, a heel lift, or a walking boot. These measures may have helped temporarily, but the discomfort returned when you resumed your usual activities.

If you have been diagnosed with retrocalcaneal bursitis, the next question is why the bursa remains irritated. Is footwear pressing on the area? Is the Achilles tendon also painful or thickened? Is a bony prominence contributing to compression? Does the pain come from more than one structure?

We discuss these questions because a diagnosis of heel bursitis does not necessarily explain every part of a person’s heel or ankle pain. This article focuses on the bursa, the nearby structures that can contribute to heel pain, and the evidence for treatment. Our companion article on Achilles tendinopathy, partial tears, and complete ruptures provides the detailed tendon-treatment and injection research.

What is retrocalcaneal bursitis?

The retrocalcaneal bursa is a small fluid-containing sac between the Achilles tendon and the heel bone, called the calcaneus. It helps these neighboring structures move against one another. Bursitis means that the bursa is irritated or inflamed. A different, more superficial bursa can become irritated between the skin and the tendon, especially where a shoe rubs.

Achilles tendinopathy describes a tendon disorder associated with pain and reduced ability to tolerate load. It can involve the tendon’s attachment to the heel, called insertional tendinopathy, or the tendon farther above that attachment, called midportion or non-insertional tendinopathy. Bursitis and tendon disease can coexist, but they are not interchangeable diagnoses. Ultrasound and MRI can help distinguish tendon changes, tears, and neighboring abnormalities when imaging is appropriate. Bursitis can also accompany inflammatory arthritis. (1)

For a patient, the distinction matters. Pain directly behind the heel, pain higher along the tendon, and pain underneath the heel can lead to different treatment decisions. We want the explanation of your pain to match its location, its triggers, and the findings on examination.

Why can heel bursitis keep returning?

Reducing a painful activity can settle symptoms without changing the conditions that provoked them. A return to running, prolonged standing, or footwear that presses on the heel may bring the discomfort back. Persistent symptoms therefore deserve reassessment rather than an assumption that the bursa simply needs another round of inflammation treatment.

The relationship between the bursa and tendon may work in both directions. A 2026 cadaveric study examined how simulated bursal fluid affected the Achilles insertion during ankle movement. Mild fluid accumulation did not increase insertional loading, whereas more severe distension altered tendon deformation and compression. This offers a possible mechanical explanation for interactions between the two structures. It does not show which structure causes a living patient’s pain or establish the effectiveness of an injection. (2)

A practical discussion should address the activity or pressure that brings on symptoms, whether the tendon insertion is involved, and whether another condition explains continuing pain. Failure of an anti-inflammatory medication does not, by itself, diagnose tendon degeneration or ligament instability.

Video: Treating Heel Bursitis and Achilles Tendinopathy with PRP Prolotherapy

In this video, Danielle Matias discusses the difference between an acute irritation and a longer-standing tendon problem. Chronic posterior heel pain can involve the Achilles tendon as well as the bursa. PRP and dextrose prolotherapy are different treatments, and the studies discussed below explain what is known about their potential benefits.

Other foot and ankle problems can overlap with heel bursitis

Someone with heel bursitis may also have pain elsewhere in the foot or ankle. We should not assume that every symptom comes from the bursa, or that every additional abnormality is responsible for the heel pain.

Relevant overlapping problems include:

• Posterior tibial tendon and arch problems. Pain along the inside of the ankle, changes in the arch, and problems involving the spring ligament deserve their own assessment. Our article on fallen arches and flat feet discusses this region.
• Peroneal tendon problems. A peroneus brevis tear or other peroneal disorder usually directs attention to the outside of the ankle. See our discussion of peroneal tendon injuries.
• Achilles tendinopathy or a tendon tear. These require differentiation from isolated bursal irritation. We discuss them further in our Achilles tendon article.
• Plantar heel pain. Pain beneath the heel may involve plantar fasciopathy rather than the retrocalcaneal bursa. Our plantar fasciitis article addresses that separate diagnosis.

These distinctions help organize the evaluation. They do not mean that a posterior tibial tendon problem, peroneal tear, or plantar fascia disorder automatically causes retrocalcaneal bursitis. A painful structure, an imaging finding, and the reason symptoms persist are not always the same thing.

Nonsurgical care: match rehabilitation to the painful structure

Footwear changes, activity modification, heel lifts, and an individualized rehabilitation program are commonly discussed for posterior heel pain. The appropriate combination depends on the diagnosis and the patient’s ability to tolerate activity. A boot may temporarily reduce loading, but the discussion should also include how walking and other activities will be resumed.

Insertional Achilles pain needs particular attention to compression. A 2025 randomized trial found better outcomes with rehabilitation that reduced compression in insertional Achilles tendinopathy. This was a tendon trial, not a trial of isolated bursitis. Our companion Achilles article explains the program and findings. (3)

The implication is that an exercise helpful for one Achilles condition may aggravate another. Lowering the heel deeply below a step can increase compression at an irritable tendon insertion. Rehabilitation should be adjusted to the location of symptoms rather than prescribed solely because the word “Achilles” appears in the diagnosis.

Equinus and limited ankle movement

Equinus describes limited upward movement of the ankle, or dorsiflexion. Calf tightness and restricted movement can be relevant to a foot and ankle assessment. However, this does not mean that every person with posterior heel pain should stretch aggressively.

The question is whether restricted movement, insertional compression, or another finding is most relevant to the individual. The insertional rehabilitation trial illustrates why increasing stretch and reducing compression can sometimes pull in different directions. (3)

Corticosteroid injections: symptom relief and Achilles tendon concerns

A corticosteroid injection may be proposed to reduce bursal inflammation. Because the bursa lies close to the Achilles tendon, the discussion should include both potential relief and tendon-related risks.

A 2014 case report described a complete Achilles rupture after corticosteroid infiltration for deep retrocalcaneal bursitis. A case report cannot establish how frequently this occurs or prove that the injection was the only cause. It does illustrate why injection location and the condition of the nearby tendon matter. (4)

An anatomical and radiological study subsequently demonstrated pathways through which material injected into the retrocalcaneal bursa could reach Achilles tendon tissue. This is a mechanism of concern, rather than a calculation of clinical rupture risk. (5)

A 2021 retrospective study provides a more balanced picture. Researchers reviewed 218 image-guided retrocalcaneal bursa steroid injections. Among the 62 injections with short-term pain follow-up, 62.9% produced good or excellent relief. Four Achilles ruptures, corresponding to 1.8% of injections, were identified 15–59 days afterward; each followed an acute injury. The study also reported that 14% of patients later underwent elective Achilles surgery. These observations do not establish that steroids caused every rupture, but they show that short-term relief and meaningful complications can coexist. (6)

For someone considering an injection, useful questions include whether the problem is primarily bursal or tendinous, what benefit is expected, what alternatives are available, and how activity should be managed afterward. Temporary relief should not be interpreted as proof that the tendon has recovered its capacity to withstand load.

Haglund’s deformity, the “pump bump,” and the “Bauer bump”

Haglund’s deformity refers to a bony prominence at the back of the heel. Haglund’s syndrome describes the associated painful combination of bony prominence and neighboring soft-tissue problems, which may include bursitis and Achilles insertional disease. Rigid footwear can aggravate the area, but shoe pressure is not the only proposed contributing factor. Conservative treatment can help some patients; surgery is generally considered when symptoms remain resistant to appropriate nonsurgical care. (7)

The term “Bauer bump” has been used in ice hockey. A study of hockey players described Haglund-related heel problems associated with the demands and fit of skating equipment. Footwear history can matter beyond ordinary walking shoes. This does not mean that every hockey-related heel bump requires an operation. (8)

We should also distinguish a bony prominence from tendon thickening or calcification. An X-ray finding needs to be interpreted alongside symptoms. It is not evidence that the tendon intentionally built a protective barrier, and an injection cannot be assumed to remove a mechanically important bone prominence.

What does the surgical research show?

Endoscopic calcaneoplasty is an operation intended to address a painful posterior heel prominence. A 2022 study followed 17 patients with 21 treated feet for at least four years. Function improved and satisfaction was favorable, although this was a small series without a comparison group. (9)

A 2021 systematic review reported better outcomes, fewer complications, and shorter recovery with endoscopic than open procedures. The underlying studies and patient selection limit how confidently those comparisons can be applied to an individual. (10)

Surgery remains a relevant option when an identifiable mechanical problem and continuing symptoms justify it. A nonsurgical discussion should explain where conservative care may help and where its limitations lie. Prolotherapy research does not establish that injections replace calcaneoplasty for every patient with Haglund’s syndrome.

Prolotherapy and PRP: when the Achilles tendon is also involved

Our discussion of regenerative injections begins with the distinction between the bursa and the tendon. Dextrose prolotherapy uses a dextrose-containing solution with the aim of stimulating a tissue response. PRP is prepared from a patient’s blood to concentrate platelets and associated signaling proteins. These are different treatments, and neither should be described as a glue that reconnects a ruptured tendon.

Much of the research relevant to this region concerns Achilles tendinopathy rather than retrocalcaneal bursitis. A newer retrospective Achilles prolotherapy study reported favorable symptom outcomes, but lacked a comparison group. It does not establish effectiveness for isolated bursitis. (11)

We retain the discussion of prolotherapy and PRP because tendon disease may coexist with heel bursitis. However, injections directed at a tendon disorder and treatments intended to reduce bursal inflammation answer different questions. There is also no established evidence that an injection removes a symptomatic Haglund’s prominence.

For the detailed randomized trials, observational studies, newer prolotherapy reviews, PRP limitations, and ultrasound illustrations, see our updated Achilles tendon article. That discussion explains why symptom improvement, changes on imaging, and proof of restored tendon strength should be considered separately.

Persistent swelling

Recurring bursitis can be frustrating when short periods of relief are followed by another flare. The location of the pain and the activities that provoke it remain useful information. Symptoms may be related to pressure on the heel, bursal irritation, an Achilles insertion problem, or a combination.

Persistent symptoms do not automatically prove that an ankle ligament is loose or that a tendon needs an injection. Conversely, an imaging report that mentions bursitis does not exclude a separate tendon problem. We emphasize these distinctions because they help readers understand why two people with “heel bursitis” may have different underlying findings.

Inflammatory arthritis and infection also belong in the differential diagnosis when the history and examination suggest them. A hot, red, rapidly worsening swollen heel with fever or feeling unwell requires prompt medical assessment. A sudden pop with new weakness or difficulty walking raises a different concern: a significant tendon injury.

What should you understand before choosing treatment?

The treatment discussion should identify the painful structure, explain the expected benefit, and acknowledge the limits of the evidence. Relevant questions include whether the bursa is the main problem, whether the Achilles tendon is also involved, whether footwear or bone shape contributes, and whether previous treatment helped only briefly or improved activity tolerance.

For corticosteroid injections, relief needs to be weighed against nearby tendon concerns. For prolotherapy or PRP, the research must match the tissue and diagnosis being treated. For surgery, the discussion should explain the mechanical problem the operation is intended to address.

Our goal is to help you understand persistent posterior heel pain without losing sight of the differences between bursal inflammation, tendon disease, and a tendon rupture. The presence of overlapping conditions makes an accurate diagnosis more valuable, not less.

This article is for patient education and does not replace an individual medical evaluation, diagnosis, or treatment plan.

References

1 Pass B, Robinson P, Ha A, Levine B, Yablon CM, Rowbotham E. The Achilles Tendon: Imaging Diagnoses and Image-Guided Interventions—AJR Expert Panel Narrative Review. American Journal of Roentgenology. 2022;219(3):355–368. doi:10.2214/AJR.22.27632. [Google Scholar]
2 Sakamoto K, Edama M, Sato R, Kato Y, Nawir DA, Ishigaki T, Komiya M, Takabayashi T, Sato N. Influence of retrocalcaneal bursal effusion on the mechanical behavior of the Achilles tendon insertion during ankle dorsiflexion: a cadaveric study. Surgical and Radiologic Anatomy. 2026;48(1):170. doi:10.1007/s00276-026-03939-2. [Google Scholar]
3 Pringels L, Capelleman R, Van den Abeele A, Burssens A, Planckaert G, Wezenbeek E, Vanden Bossche L. Effectiveness of reducing tendon compression in the rehabilitation of insertional Achilles tendinopathy: a randomised clinical trial. British Journal of Sports Medicine. 2025;59(9):640–650. doi:10.1136/bjsports-2024-109138. [Google Scholar]
4 Vallone G, Vittorio T. Complete Achilles tendon rupture after local infiltration of corticosteroids in the treatment of deep retrocalcaneal bursitis. Journal of Ultrasound. 2014;17(2):165–167. doi:10.1007/s40477-014-0066-9. [Google Scholar]
5 Pękala PA, Henry BM, Pękala JR, Piska K, Tomaszewski KA. The Achilles tendon and the retrocalcaneal bursa: An anatomical and radiological study. Bone & Joint Research. 2017;6(7):446–451. [Google Scholar]
6 Boone SL, Uzor R, Walter E, Elsinger E, Catanese D, Ye K, Goldberg-Stein S. Safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection for the treatment of retrocalcaneal bursitis. Skeletal Radiology. 2021;50(12):2471–2482. doi:10.1007/s00256-021-03783-y. [Google Scholar]
7 Vaishya R, Agarwal AK, Azizi AT, Vijay V. Haglund’s Syndrome: A Commonly Seen Mysterious Condition. Cureus. 2016;8(10):e820. doi:10.7759/cureus.820. [Google Scholar]
8 Desai SS, Wong TT, Crockatt WK, Tedesco LJ, Trofa DP, Popkin CA. The ‘Bauer bump:’ ice hockey skates as a common cause of Haglund syndrome. The Physician and Sportsmedicine. 2023;51(5):414–419. [Google Scholar]
9 Fathi Mahmoud H, Feisal W, Samir Fahmy F. Satisfactory Functional Outcome and Significant Correlation with the Length of Haglund’s Deformity after Endoscopic Calcaneoplasty: A Minimum 4-Year Follow-Up Study. Advances in Orthopedics. 2022;2022:7889684. doi:10.1155/2022/7889684. [Google Scholar]
10 Alessio-Mazzola M, Russo A, Capello AG, Lovisolo S, Repetto I, Formica M, Felli L. Endoscopic calcaneoplasty for the treatment of Haglund’s deformity provides better clinical functional outcomes, lower complication rate, and shorter recovery time compared to open procedures: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2021;29(8):2462–2484. doi:10.1007/s00167-020-06362-1. [Google Scholar]
11 Pham H, Tseng W, Mendeszoon ER, Wong A, Hutchins R, Amin A, Reubens DB. Prolotherapy for Achilles Tendinopathy. Journal of the American Podiatric Medical Association. 2025;115(6):23-186. doi:10.7547/23-186. [Google Scholar]