Retrocalcaneal Region: Anatomy, Common Conditions, and Treatment

What is a Retrocalcaneal?

The term "retrocalcaneal" refers to the anatomical space and structures located behind the heel bone (calcaneus), primarily involving the retrocalcaneal bursa, the Achilles tendon, and the posterior aspect of the calcaneus itself. This region is critical for ankle movement and is a common site for inflammatory conditions.

Understanding the Retrocalcaneal Region

The human foot and ankle are marvels of biomechanical engineering, designed to bear weight, absorb shock, and facilitate complex movements. The "retrocalcaneal" area is a specific anatomical zone situated at the very back of the heel. To fully grasp its significance, it's essential to understand the key structures that define it:

• Calcaneus: This is the largest bone in the foot, commonly known as the heel bone. Its posterior aspect provides the primary attachment point for the Achilles tendon.
• Achilles Tendon: The strongest and thickest tendon in the human body, the Achilles tendon connects the calf muscles (gastrocnemius and soleus) to the calcaneus. It is crucial for plantarflexion (pointing the foot downwards) and propulsive movements like walking, running, and jumping.
• Retrocalcaneal Bursa: A small, fluid-filled sac located between the anterior (front) surface of the Achilles tendon and the posterior (back) surface of the calcaneus.

The Retrocalcaneal Bursa: A Key Player

The retrocalcaneal bursa is a synovial bursa, a small, slippery sac lined with a synovial membrane that produces synovial fluid. Its primary function is to reduce friction between moving structures. In this specific location, it acts as a cushion, allowing the powerful Achilles tendon to glide smoothly over the calcaneus during ankle movements, particularly dorsiflexion (flexing the foot upwards) and plantarflexion.

Without the bursa, the repetitive rubbing of the Achilles tendon against the bone would lead to significant wear and tear, pain, and inflammation. While typically small and inconspicuous, the retrocalcaneal bursa can become inflamed, leading to a painful condition known as retrocalcaneal bursitis.

Common Conditions Associated with the Retrocalcaneal Region

Given the high mechanical stresses placed on the heel and Achilles tendon, several conditions commonly affect the retrocalcaneal area:

• Retrocalcaneal Bursitis:
  • Definition: Inflammation of the retrocalcaneal bursa.
  • Causes: Often results from overuse, repetitive ankle movements, tight Achilles tendons, poorly fitting or rigid-backed footwear that rubs against the heel, or underlying conditions like Haglund's deformity.
  • Symptoms: Pain at the back of the heel, especially during activity or when starting to move after rest; tenderness to touch on either side of the Achilles tendon just above its insertion; swelling; warmth; and pain when wearing shoes that press on the area.
• Achilles Tendinopathy (Insertional):
  • Definition: Degeneration or inflammation of the Achilles tendon where it inserts onto the calcaneus.
  • Relationship to Retrocalcaneal Region: While distinct from bursitis, insertional Achilles tendinopathy often co-exists with or mimics retrocalcaneal bursitis due to their close proximity and shared biomechanical stressors. Differentiating between the two is crucial for targeted treatment.
• Haglund's Deformity ("Pump Bump"):
  • Definition: A bony enlargement or prominent bump on the posterior aspect of the calcaneus, specifically at the superior portion of the calcaneal tuberosity.
  • Impact: This bony prominence can impinge upon the retrocalcaneal bursa and the Achilles tendon, leading to chronic irritation, inflammation, and pain, often exacerbating retrocalcaneal bursitis. It's often associated with wearing rigid-backed shoes.

Diagnosis of Retrocalcaneal Issues

Accurate diagnosis is key to effective treatment. A healthcare professional will typically employ:

• Clinical Examination: A physical assessment involving palpation of the heel, evaluation of range of motion, and specific maneuvers to elicit pain. The "squeeze test" (squeezing the bursa between the thumb and forefinger) can help identify bursitis.
• Imaging Studies:
  • X-rays: Useful for identifying bony abnormalities such as Haglund's deformity or calcifications within the Achilles tendon.
  • Magnetic Resonance Imaging (MRI): Provides detailed images of soft tissues, clearly showing inflammation of the bursa, tendon thickening, tears, or fluid accumulation.
  • Ultrasound: A dynamic imaging tool that can visualize the bursa and tendon, assess inflammation, and identify fluid collections in real-time.

Treatment Approaches

Treatment for retrocalcaneal conditions typically begins with conservative measures, with surgical intervention reserved for persistent or severe cases.

• Conservative Management:
  • Rest and Activity Modification: Reducing activities that aggravate the pain.
  • Ice Application: To reduce inflammation and pain.
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Oral medications like ibuprofen or naproxen to manage pain and inflammation.
  • Footwear Modification: Avoiding shoes with rigid or tight heel counters; opting for open-backed shoes or those with softer, wider heels.
  • Heel Lifts or Pads: Elevating the heel slightly can reduce pressure on the bursa and Achilles tendon.
  • Physical Therapy: Stretching exercises for the calf muscles and Achilles tendon to improve flexibility, and strengthening exercises to support the ankle and foot.
• Injections:
  • Corticosteroid Injections: Can provide temporary relief by reducing inflammation directly in the bursa. However, they are used cautiously due to the potential risk of Achilles tendon weakening or rupture, especially if injected into the tendon itself.
• Surgical Intervention:
  • Considered when conservative treatments fail after several months.
  • Bursectomy: Surgical removal of the inflamed bursa.
  • Calcaneal Osteotomy: In cases of Haglund's deformity, a portion of the prominent bone may be removed to decompress the bursa and tendon.

Prevention Strategies

Preventing retrocalcaneal issues involves addressing common risk factors:

• Appropriate Footwear: Wear shoes that fit well, provide adequate cushioning, and do not have rigid or excessively tight heel counters. Avoid shoes that rub or irritate the back of the heel.
• Gradual Training Progression: Increase the intensity, duration, and frequency of exercise gradually to allow tissues to adapt. Avoid sudden increases in activity, especially running or jumping.
• Regular Stretching: Maintain good flexibility in the calf muscles and Achilles tendon through regular stretching routines.
• Strength Training: Incorporate exercises that strengthen the calf muscles and foot stabilizers to improve biomechanics and reduce stress on the Achilles tendon and bursa.
• Listen to Your Body: Pay attention to early signs of pain or discomfort and address them promptly before they escalate into chronic conditions.

When to Seek Medical Attention

If you experience persistent pain, swelling, tenderness, or difficulty walking due to discomfort in the retrocalcaneal region, it is advisable to consult a healthcare professional. Early diagnosis and intervention can prevent the condition from becoming chronic and help you return to your activities safely and effectively.