Heel bursitis responds well to a combination of rest, footwear changes, and anti-inflammatory treatment, with most people recovering without surgery. The condition involves inflammation of a small fluid-filled sac near the back of the heel, and the pain it causes can range from a mild ache to a sharp enough sting that walking feels like a negotiation. What works best depends on how long the problem has been brewing and whether anything structural is driving it.
What Is Actually Inflamed
The retrocalcaneal bursa sits in a tight space between the Achilles tendon and the back of the heel bone. It is a small, fluid-filled cushion whose job is to reduce friction as the tendon slides over bone during movement.1PubMed Central. The Achilles tendon and the retrocalcaneal bursa: An anatomical and radiological study When the bursa becomes irritated, it swells, and because the space it lives in is already cramped, even moderate swelling creates pressure that translates directly into pain at the back of your heel.
There is also a superficial bursa that can form between the skin and the Achilles tendon, sometimes called the subcutaneous calcaneal bursa. This one tends to develop as a response to external pressure, like a stiff shoe counter rubbing against the back of the heel. Both can be inflamed at the same time, and distinguishing between the two matters because the deeper retrocalcaneal bursa is harder to treat with simple padding alone.
Why It Starts
Repetitive mechanical stress is the most common trigger. Running, jumping, and any activity that loads the Achilles tendon heavily can irritate the bursa over time. But sports with unusual ankle mechanics carry particular risk. A study of figure skaters, for example, found the heel to be a major area of concern for calcaneal bursitis, with the condition associated with higher in-skate ankle flexibility, suggesting that repeated bending of the ankle within a rigid boot drives bursal irritation.2PubMed Central. Lower Extremity Overuse Conditions Affecting Figure Skaters During Daily Training
Footwear is a major and underappreciated contributor. Rigid, prominent heel counters, especially on high-heeled shoes, impinge on the soft tissues at the back of the heel and can provoke both bursitis and swelling over the bony prominence.3Orthopedic Clinics of North America. Haglund’s Deformity and Retrocalcaneal Bursitis If you have ever felt a shoe digging into the back of your heel, that is exactly the kind of pressure that sets this off.
Biomechanical issues further upstream can also play a role. Weakness in the hip abductors relative to the adductors has been linked to increased foot pronation, which changes how forces distribute through the lower leg and heel.4Journal of Sport Rehabilitation. Correlations between Hip Strength and Static Foot and Knee Posture Excessive pronation shifts the angle at which the Achilles tendon pulls on the calcaneus, potentially increasing friction and compression in the retrocalcaneal space.
Making Sure It Is Actually Bursitis
Posterior heel pain has several possible sources, and getting the diagnosis right matters because the treatments diverge. Achilles tendinopathy causes pain along the tendon itself and typically worsens with activity and improves with rest. Retrocalcaneal bursitis produces tenderness that is more localized to the soft tissue just in front of the tendon, right where it meets the heel bone. Squeezing the sides of the heel at that spot often reproduces the pain.
Plantar fasciitis, the most common cause of heel pain overall, is easy to confuse if you are not paying attention to exactly where the pain lives. Plantar fasciitis hurts under the heel, especially with the first steps after waking or after sitting for a long time, and tenderness centers on the calcaneal tuberosity on the bottom surface of the bone.5American Academy of Family Physicians. Diagnosing heel pain in adults Bursitis pain is behind the heel, not beneath it. That distinction sounds small, but it is the fastest way to narrow things down.
Then there is Haglund’s deformity, a bony bump on the back of the calcaneus that often coexists with retrocalcaneal bursitis. An enlarged bursal projection at the posterosuperior aspect of the heel bone creates mechanical irritation that directly provokes bursitis.3Orthopedic Clinics of North America. Haglund’s Deformity and Retrocalcaneal Bursitis If you can feel or see a hard bump on the back of the heel in addition to the soft swelling, Haglund’s is likely involved, and treatment needs to address the bone as well as the bursa.
Systemic inflammatory conditions can also produce heel bursitis that looks identical to the mechanical kind. Seronegative arthritis, including psoriatic arthritis, can cause enthesopathies at the heel and should be considered when bursitis develops without an obvious mechanical trigger, especially if other joints are involved or the problem is bilateral.6PubMed Central. Heel pain due to psoriatic arthritis in a 50 year old recreational male athlete: case report If your heel bursitis is not responding to the standard treatments described below, this is worth bringing up with your doctor.
First-Line Treatment at Home
The initial approach is straightforward: reduce the load, calm the inflammation, and remove the external irritants. Rest does not mean complete immobilization, but it does mean backing off the activities that provoke the pain. Switching temporarily from running to swimming or cycling takes the repetitive compression off the bursa while keeping you active.
Ice applied to the back of the heel for 15 to 20 minutes several times a day helps control swelling in the acute phase. Over-the-counter anti-inflammatory medications like ibuprofen or naproxen address both pain and inflammation. If you are concerned about stomach side effects, topical NSAIDs are a good alternative. A comprehensive review found that topical and oral NSAIDs showed similar effectiveness for both acute and chronic musculoskeletal injuries, with oral versions causing more gastrointestinal side effects and topical versions causing more local skin reactions.7PubMed. Effectiveness and safety of topical versus oral nonsteroidal anti-inflammatory drugs: a comprehensive review A study specifically evaluating naproxen gel in patients with bursitis found that pain on movement dropped significantly over 15 days, with adverse events occurring in under 2% of patients, mostly dryness at the application site.8JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. Efficacy and Safety of Naproxen Gel in Musculoskeletal Pain Management: A Prospective Cohort Study
Footwear Changes and Orthotics
Changing what goes on your feet is often the single most effective intervention. The pain from retrocalcaneal bursitis can be controlled by lifting the heel and loosening the shoe counter.9PubMed. Rearfoot disorders and conservative treatment: a narrative review A heel lift works by slightly shifting the angle of the ankle, which increases the distance between the Achilles tendon and the calcaneus. Pilot data from a study on insertional Achilles tendinopathy found that this increased separation between tendon and bone corresponded with an immediate and short-term decrease in pain.10PubMed Central. Immediate and Short-Term Effects of In-Shoe Heel-Lift Orthoses on Clinical and Biomechanical Outcomes in Patients With Insertional Achilles Tendinopathy
Beyond heel lifts, protective padding around the tender area can make a real difference. One orthotic approach uses a neoprene sleeve holding a horseshoe-shaped foam pad placed directly over the injury to relieve pressure, or the horseshoe can be inverted to function as a counterforce brace that reduces tensile stress on the Achilles tendon.11PubMed. Use of an orthotic device in the treatment of posterior heel pain These are inexpensive and available without a prescription.
If your shoes have a rigid heel counter, switching to shoes with a softer, more flexible back or cutting a notch in the counter to relieve pressure on the bump can provide immediate relief. Open-back shoes, clogs, or sandals are reasonable temporary options while the bursa calms down. For runners and athletes, selecting shoes with a slightly higher heel-to-toe drop effectively functions as a built-in heel lift.
Corticosteroid Injections
When conservative measures stall, a corticosteroid injection into the retrocalcaneal bursa is the next step many clinicians consider. The evidence shows it works for the majority: image-guided injections yielded excellent or good responses in about 63% of patients in the short term, with a significant decrease in pain scores.12PubMed. Safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection for the treatment of retrocalcaneal bursitis Image guidance, whether ultrasound or fluoroscopy, helps ensure the medication reaches the right spot rather than ending up in the tendon itself.
The catch is the risk to the Achilles tendon. In that same dataset, the subsequent Achilles tendon rupture rate was 1.8%, with ruptures occurring 15 to 59 days after injection and each preceded by an acute injury event.12PubMed. Safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection for the treatment of retrocalcaneal bursitis That risk has to be weighed against the benefit, particularly for athletes and active individuals. Corticosteroid injection of the retrocalcaneal bursa may relieve symptoms, but the risk of Achilles tendon rupture needs to be part of the conversation, especially for professional and high-level athletes.13PubMed. Can local corticosteroid injection in the retrocalcaneal bursa lead to rupture of the Achilles tendon and the medial head of the gastrocnemius muscle? Most clinicians limit the number of injections and space them out to reduce cumulative tendon weakening.
Platelet-Rich Plasma as an Alternative
Platelet-rich plasma (PRP) injections have emerged as an option that may avoid the tendon-weakening risk of corticosteroids. PRP is drawn from your own blood, concentrated, and injected into the inflamed area, where growth factors theoretically promote tissue healing rather than just suppressing inflammation.
The early evidence is encouraging. A comparative study found that PRP-treated patients had better pain relief and functional outcomes than steroid-treated patients at the end of follow-up, with the beneficial effects lasting longer.14ISAKOS. Is Platelet-Rich Plasma Injection More Effective Than Steroid Injection In The Treatment Of Chronic Retrocalcaneal Bursitis In Achieving Long-Term Relief? In a larger cohort of 128 patients, roughly 59% reported pain relief after a single PRP injection at one month, and after a second injection given three weeks later for those who needed it, a total of about 89% had good clinical and functional outcomes at one year.15Journal of Orthopaedics and Sports Medicine. Autologous Platelet Rich Plasma-A Biological Therapeutic Option for Retrocalcaneal Bursitis and its Associations
PRP is not covered by most insurance plans, and the cost per injection can be significant. It also typically requires more than one treatment. But for someone whose bursitis keeps returning and who wants to avoid both repeated steroids and surgery, it fills a useful gap.
When Surgery Becomes the Answer
Surgery is reserved for cases that have resisted several months of conservative treatment. The most common procedures remove the inflamed bursa and, when Haglund’s deformity is present, shave down the bony prominence that has been causing the irritation in the first place.
Endoscopic approaches have gained ground over traditional open surgery. A study evaluating endoscopic calcaneoplasty and bursectomy found it to be effective and minimally invasive, with fewer complications and similar patient satisfaction compared to open procedures, along with less scarring and a shorter rehabilitation period.16PubMed Central. Short-term results of endoscopic calcaneoplasty and retrocalcaneal bursectomy for insertional Achilles tendinopathy
A systematic review and meta-analysis comparing endoscopic and open surgery put firmer numbers on the difference. Functional scores improved in both groups and were not significantly different. However, the complication rate was roughly 5% for endoscopic surgery versus about 12% for open, and surgical failure was also significantly lower in the endoscopic group. The recovery timelines were strikingly different: patients in the endoscopic group returned to daily activities in an average of about 7 weeks, compared to over 22 weeks for the open group. Return to sports averaged about 13 weeks for endoscopic versus over 22 weeks for open surgery.17PubMed Central. Endoscopic versus open surgery for insertional achilles tendinopathy: A systematic review and meta‐analysis of comparative outcomes Those are substantial differences in how quickly you get back to normal life.
For young athletes, a minimally invasive Zadek osteotomy, which removes a wedge of bone to decompress the area, has shown promising return-to-sport timelines. In one case series, all patients returned to their preinjury level of athletic participation, with a mean return time of about 4.2 months and no secondary procedures required.18PubMed Central. Return to Sport and Functional Outcomes After Minimally Invasive Zadek Osteotomy for Insertional Achilles Tendinopathy in Young Athletes: A Retrospective Case Series
Preventing Recurrence
Heel bursitis has a frustrating tendency to come back, especially if the underlying mechanical cause has not been addressed. Prevention is less about any one intervention and more about a few habits maintained over time.
Footwear vigilance is the foundation. Avoid shoes with rigid heel counters that dig into the back of the heel. If you run, rotating between shoes with different heel-to-toe drops prevents the same pressure point from being loaded identically day after day. Consider a heel lift in your everyday shoes if you have had a recurrence, since even a small lift reduces tendon-bone compression.
Eccentric calf exercises, where you slowly lower your heel below the level of a step, are a mainstay of Achilles tendon rehabilitation and reduce the mechanical load on the retrocalcaneal space over time by building tendon capacity. The strength of your hip abductors also matters more than you might think, given the link between hip weakness and foot pronation.4Journal of Sport Rehabilitation. Correlations between Hip Strength and Static Foot and Knee Posture Side-lying hip raises, banded walks, and single-leg balance exercises are simple additions that address this upstream contributor.
Gradual training progression matters as well. Sharp increases in running volume or intensity are a reliable way to flare up any overuse condition in the heel. A common guideline is to increase weekly mileage or training load by no more than about 10% per week. And if you are returning from a bout of bursitis, it is worth starting at a level well below your previous baseline and building back slowly rather than picking up where you left off.
When the Problem Is Systemic
Most heel bursitis is mechanical, but when it does not behave the way mechanical bursitis should, the problem may be coming from inside rather than outside. Inflammatory arthritis conditions, particularly the seronegative spondyloarthropathies like ankylosing spondylitis, reactive arthritis, and psoriatic arthritis, have a well-known affinity for the entheses, the points where tendons and ligaments anchor to bone. The heel is one of those anchor points.
Red flags that suggest a systemic cause include bursitis that develops in both heels simultaneously, pain that is worse in the morning and improves with movement rather than rest, swelling in other joints, low back stiffness, or skin changes like psoriatic plaques. A case report highlighted how a 50-year-old recreational athlete’s heel pain, initially assumed to be standard Achilles tendinopathy or retrocalcaneal bursitis, turned out to be driven by psoriatic arthritis, even though the patient had no prior history of skin conditions.6PubMed Central. Heel pain due to psoriatic arthritis in a 50 year old recreational male athlete: case report In cases like this, the bursitis is a symptom of a broader inflammatory process, and treating only the heel without addressing the underlying condition guarantees recurrence. If any of those warning signs apply to you, a referral to a rheumatologist is more useful than another round of ice and heel lifts.