Inferior calcaneal bursitis is inflammation of the inferior calcaneal bursa near the insertion of the plantar fascia. Diagnosis is mainly clinical but is confirmed with MRI. Treatment may include local injection of a glucocorticoid combined with an anesthetic.
Bursitis can develop at the inferior calcaneus, near the insertion of the plantar fascia. (See also Overview of Foot and Ankle Disorders.)
Inferior calcaneal bursitis typically presents as acute throbbing pain, particularly when walking barefoot on hard surfaces. The pain is most pronounced when the heel first contacts the ground during walking or running. Mild warmth and swelling may be present.
In contrast, chronic dull aching pain is associated with plantar fasciitis. The pain of inferior calcaneal bursitis also differs from fat pad syndrome, which is more common in older patients.
MRI can confirm the presence of the bursa as well as exclude a calcaneal stress fracture.
Fat pad syndrome
Fat pad syndrome can be confused with inferior calcaneal bursitis because both conditions present with heel pain. As patients advance in age, the subcutaneous tissue that comprises the inferior calcaneal fat pad thins and migrates peripherally. Long-standing rheumatoid arthritis, overuse of glucocorticoid injections to the heel, and even dehydration can lead to thinning of the skin at the heel and loss of the fat pad cushion. Patients present with dull aching pain similar to a bone bruise from repetitive stress. The diagnosis is typically clinical but may be confirmed by with ultrasound and MRI that can identify fat pad thinning and help differentiate it from other causes of heel pain. The treatment of fat pad syndrome also differs; accommodative inserts are used to cushion the area.
Treatment of Inferior Calcaneal Bursitis
Injection of a glucocorticoid combined with an anesthetic solution
Modification of footwear
Treatment of inferior calcaneal bursitis is injection of a local anesthetic/glucocorticoid mixture and soft-soled shoes with added protective heel cushion padding (see Considerations for Using Glucocorticoid Injections).
Orthotic inserts with a deep heel cup and supportive arch can provide patients with a functional treatment option to remain ambulatory. Stretching exercises focused on increasing flexibility of the Achilles tendon with ankle dorsiflexion can reduce repetitive stress to the plantar fascia insertion at the calcaneus.
For patients who do not respond adequately to conservative care, open excision of the bursa and release of the medial aspect of the plantar fascia can lead to symptomatic relief. However, this procedure is not without inherent risk, particularly due to the loss of the windlass mechanism of the medial longitudinal arch and the potential loss of arch height.
