A bursa is a small fluid-filled sac that sits between tendons, bones, and soft tissues to reduce friction and absorb compressive load. Around the calcaneus (heel bone), there are two clinically significant bursae that can become inflamed: one at the back of the heel beneath the Achilles tendon, and one on the underside of the heel at the plantar fascia origin.
When either bursa is subjected to repetitive mechanical stress, direct pressure, or systemic inflammation, it responds with swelling, heat, and pain — this is bursitis. It is frequently misdiagnosed as plantar fasciitis or Achilles tendinopathy because of anatomical proximity, and in some cases more than one condition coexists. Accurate clinical assessment is essential before treatment begins.
Location — Posterior Heel
Calcaneal (Retrocalcaneal) Bursitis
Back of Heel
Inflammation of the retrocalcaneal bursa, which sits between the posterior-superior calcaneus and the Achilles tendon. Often associated with Haglund's deformity — a bony prominence on the back of the heel that reduces the available space for the bursa. Pain is felt at the back of the heel and is typically aggravated by footwear with a firm heel counter, hill running, and repeated Achilles loading. The medial/lateral squeeze test anterior to the Achilles insertion is the key clinical sign.
Location — Underside of Heel
Plantar Heel Bursitis
Underside of Heel
Inflammation of the adventitious bursa on the plantar surface of the calcaneus, near the plantar fascia insertion on the calcaneal tubercle. Commonly mistaken for plantar fasciitis. Pain is described as walking on a bruise or stone underfoot, is worst with the first steps of the day and after prolonged sitting, and is reproduced by direct plantar pressure on the calcaneal tubercle. Fat pad atrophy must be excluded as a concurrent or alternative diagnosis.
Pain location
Back of heel, at Achilles insertion
Underside of heel, central/medial
Worst time
Footwear pressure, Achilles loading
First steps in morning, after rest
Swelling pattern
Visible posterior heel swelling, soft and fluctuant
Diffuse plantar heel swelling, less visible
Tenderness test
Medial/lateral squeeze anterior to Achilles
Direct plantar pressure on calcaneal tubercle
Aggravating factors
Hill running, heel-counter shoes, stairs
Prolonged standing, barefoot, hard surfaces
Often confused with
Achilles tendinopathy, Haglund's deformity
Plantar fasciitis, fat pad atrophy
What You May Notice
Pain at the back or underside of the heel
Swelling or puffiness around the heel bone
Warmth and localised tenderness to touch
Worse first thing in the morning or after rest
Aggravated by shoes with a firm heel counter
Sensation of walking on a bruise or stone
Worsens during or after running, especially hills
Eases briefly with movement then returns
When to Seek Prompt Assessment
Most heel bursitis responds well to conservative management. The following features warrant earlier assessment to exclude more serious pathology:
Sudden severe heel pain without a clear cause
Significant swelling spreading beyond the heel
Skin redness, heat, or fever — possible septic bursitis
Constant pain at rest not improving over days
Known inflammatory arthritis with new heel symptoms
History of gout with acute heel flare
Suspected Achilles thickening or partial tear
Extrinsic — Training
Training Load Spike
A rapid increase in running mileage or intensity overloads the bursa before it can adapt. The retrocalcaneal bursa is particularly vulnerable during increased hill work or speed training — common when building towards a race.
Extrinsic — Footwear
Footwear Factors
Rigid heel-counter shoes create direct compression of the retrocalcaneal bursa. A sudden reduction in heel drop — switching to a zero-drop shoe — alters plantar heel loading and can provoke plantar bursitis. Worn or unsupportive footwear is a frequent background factor.
Structural
Haglund's Deformity
A bony prominence on the posterior-superior calcaneus reduces the space between the heel bone and the Achilles tendon, placing the retrocalcaneal bursa under chronic compressive and shear stress. Often called a "pump bump" due to its association with rigid heel-counter footwear.
Intrinsic — Muscle
Calf & Achilles Tightness
Reduced ankle dorsiflexion range increases compressive and shear forces through the heel complex during gait — loading both the retrocalcaneal bursa and the plantar heel, particularly during midstance and propulsion phases of the running cycle.
Intrinsic — Biomechanics
Biomechanical Loading
Excessive pronation, supination, or abnormal heel strike patterns create asymmetric shear stress on the heel bursae during loading. Leg length discrepancy and altered pelvic mechanics can direct disproportionate load to one heel.
Systemic
Inflammatory Conditions
Rheumatoid arthritis, gout, psoriatic arthritis, and other seronegative arthropathies can trigger heel bursitis as a systemic manifestation — important to consider in recurrent, bilateral, or otherwise unexplained presentations, especially if constitutional symptoms are present.
Heel bursitis shares its presentation with several other conditions — plantar fasciitis, fat pad syndrome, Achilles insertional tendinopathy, and calcaneal stress fracture — and distinguishing between them requires methodical clinical examination. We use palpation mapping to identify the precise pain source, load-response testing to assess how the heel behaves under stress, and ankle and Achilles range-of-motion assessment to identify the mechanical driver.
Where clinical findings are ambiguous or the presentation is not responding as expected, we refer for musculoskeletal ultrasound — the gold standard for visualising bursal swelling, confirming the diagnosis, ruling out concurrent Achilles pathology, and guiding injection therapy. Plain X-ray is arranged where Haglund's deformity or a calcaneal spur requires assessment.
These conditions can mimic or coexist with heel bursitis. A thorough clinical assessment — and ultrasound where indicated — clarifies the diagnosis before treatment is started.
Plantar Fasciitis
The most common differential for plantar heel pain. Plantar fasciitis produces traction pain along the plantar fascial band and at its calcaneal origin — typically sharp with the first steps of the day and after rest. Palpation along the fascia and at its medial insertion distinguishes it from the direct calcaneal tubercle tenderness of plantar bursitis. Both conditions can coexist.
Achilles Insertional Tendinopathy
Pain and thickening at the Achilles insertion closely mimics retrocalcaneal bursitis. Insertional tendinopathy tends to produce more diffuse posterior heel pain; bursitis is more focal with the medial/lateral squeeze test more specifically positive. Ultrasound distinguishes tendon degeneration from bursal swelling — both can be present simultaneously.
Haglund's Deformity
The bony prominence itself is not painful — but it creates the mechanical environment for retrocalcaneal bursitis and Achilles tendinopathy to develop. Confirmed on lateral X-ray. Its presence does not change the initial conservative management approach but is relevant if surgical decompression becomes necessary.
Fat Pad Atrophy
The plantar heel fat pad attenuates with age, high-impact activity, and corticosteroid exposure. Atrophy produces diffuse, aching plantar heel pain — similar in location to plantar bursitis but without a discrete focal tender point. Management differs: cushioning and offloading rather than anti-inflammatory intervention.
Calcaneal Stress Fracture
Should be considered in any runner with a sudden change in heel pain character, particularly with increased training load. Pain is diffuse, worsens with activity, and the calcaneal squeeze test is strongly positive. MRI is the gold standard. Requires immediate load modification and structured return-to-run rehabilitation.
Gout / Inflammatory Arthritis
Acute gout can affect the heel with rapid-onset severe pain, warmth, and swelling. Rheumatoid and psoriatic arthritis can cause a similar picture. Bilateral involvement, constitutional symptoms, or known inflammatory history should prompt blood tests and rheumatology liaison alongside podiatric management.
Effective treatment requires addressing both the inflammation and its mechanical cause. Reducing symptoms without modifying the loading pattern invariably leads to recurrence. Our approach combines targeted symptom management with a structured return-to-activity programme, tailored to each patient's presentation and goals — whether that is returning to recreational running, managing a chronic condition, or preparing for a race.
01
Comprehensive Heel Pain Assessment
Detailed palpation mapping to identify the exact pain source, load-response testing, ankle and Achilles range-of-motion assessment, and footwear review. Video gait analysis using Onform joint tracking provides an objective baseline of heel mechanics during walking and running, allowing progress to be measured at every follow-up. Where imaging is needed, we refer directly for MSK ultrasound or plain X-ray.
02
Load Management & Footwear Modification
Immediate reduction of provocative activities, combined with evidence-based footwear modification: heel lifts to decompress the retrocalcaneal bursa; cushioned, wide-fitting footwear with a softer heel counter for posterior bursitis; plantar cushioning and heel cups for plantar bursitis. A structured activity modification plan allows training to continue within pain limits where possible — we aim to keep you moving throughout rehabilitation.
03
Soft Tissue Therapy
Targeted calf, Achilles, and plantar fascial release using Graston instrument-assisted technique, sports massage, ART, and joint mobilisation to restore ankle dorsiflexion and reduce compressive load through the heel complex. Soft tissue therapy is a primary — not adjunct — intervention in our management of heel bursitis, and is incorporated from the first appointment where appropriate.
04
Injection Therapy
Ultrasound-guided corticosteroid injection directly into the bursa is an effective and well-established treatment for persistent or acutely inflamed bursitis. Accuracy of placement is essential — ultrasound guidance significantly improves this and reduces the risk of adjacent soft tissue complications. We do not routinely inject close to the Achilles tendon insertion. Ostenil (hyaluronic acid) injections may be considered as an alternative or adjunct. The full risk-benefit profile is discussed before any procedure is carried out. From £125 (corticosteroid) / £85 (Ostenil).
05
Custom Orthotic Therapy
Custom foot orthoses to correct the biomechanical load distribution driving bursal inflammation — offloading the calcaneal insertion or plantar heel as required, and modifying heel strike mechanics during gait. Prescribed only where a clear biomechanical rationale is identified in the assessment. Fabricated via 3D scan using Phits Dynaprint technology with a 5-day turnaround.
06
Rehabilitation Programme
A progressive, goal-based loading programme for the Achilles-heel complex. Eccentric and isometric calf exercises are introduced in a structured sequence, gated by pain and functional milestones rather than time alone. Hip and gluteal strengthening is incorporated where altered proximal mechanics are contributing to heel overload. Home programmes are provided with clear written instructions at every appointment.
07
Return to Activity Programme
A structured return-to-run or sport protocol with objective milestones — pain-free walking, pain-free jogging, progressive speed and distance increments. Footwear guidance and training load management principles to prevent recurrence. Where a race or competition is the target, the programme is built around your calendar.
✓
Precise differential diagnosisWe distinguish calcaneal bursitis, plantar bursitis, plantar fasciitis, Achilles tendinopathy, and fat pad syndrome — conditions that look similar but require different treatment.
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Treat the cause, not just the bursaReducing inflammation alone leads to recurrence. We identify and address the mechanical loading pattern driving the bursitis as a core part of every management plan.
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Injection therapy in-clinicCorticosteroid and Ostenil injections available, with ultrasound guidance referral where needed — no separate appointment elsewhere.
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Gait analysis with OnformObjective measurement of heel mechanics at baseline and every follow-up — so progress is demonstrated, not assumed.
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Goal-based return to activityStructured, milestone-driven protocols for runners and athletes — built around your race calendar where relevant.
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HCPC-registered podiatristsRichmond (TW9) and Kensington (W8). Recognised by BUPA, Aviva, WPA, AXA PPP, Vitality, Cigna, and Simply Health.
How do I know if I have bursitis or plantar fasciitis?
Both conditions cause heel pain and can present similarly. Plantar fasciitis typically produces pain along the plantar fascial band and at its calcaneal insertion — often sharp with the first steps of the day. Plantar bursitis tends to produce a more focal, deeper pain directly underfoot, sometimes described as a bruise or stone sensation, with tenderness concentrated at the calcaneal tubercle on direct pressure. A clinical assessment with careful palpation mapping is the most reliable way to distinguish them. Both can coexist, and getting the diagnosis right matters for treatment.
Can I continue running with heel bursitis?
In mild presentations, modified running — reduced volume, appropriate footwear, and offloading — can often be maintained. In acute or moderately inflamed cases, a short period of relative rest is usually necessary before loading is reintroduced. We aim to keep you active throughout rehabilitation wherever possible. Complete rest is rarely the right answer; continuing without modification often prolongs the condition. We will help you find the appropriate activity level for your presentation.
Is a corticosteroid injection safe for heel bursitis?
Corticosteroid injection into a bursa is a well-established and generally safe procedure with a good evidence base for reducing bursal inflammation. The main considerations are accurate needle placement — ultrasound guidance significantly improves this — and avoiding repeated injections into the same site. We do not routinely inject close to the Achilles tendon insertion due to the risk of tendon weakening. Where appropriate, we may discuss Ostenil (hyaluronic acid) as an alternative or adjunct. The full risk-benefit profile is discussed with you before any procedure.
How long does heel bursitis take to resolve?
With appropriate management, mild presentations often improve within 4–6 weeks. More established or chronic cases — particularly where Haglund's deformity is present, or where the mechanical loading pattern has not been addressed — can take 3–4 months to fully resolve. Our approach focuses on objective testing of your progress rather than estimating timelines, as individual responses to treatment vary considerably.
Do I need a scan before coming to see you?
No. We can assess and begin treatment on the basis of clinical examination alone. If imaging is indicated — to confirm bursal swelling, exclude a stress fracture, assess for concurrent Achilles pathology, or plan injection therapy — we refer directly for MSK ultrasound. Plain X-ray can be arranged if Haglund's deformity or a calcaneal spur is suspected. Any existing scans are always reviewed if you have them.
Will I need custom orthotics?
Not necessarily. Many patients improve with footwear modification, off-the-shelf heel lifts or cushioned insoles, soft tissue therapy, and rehabilitation alone. Custom orthotics are indicated when a clear biomechanical driver is identified that is not adequately addressed by other means. We only recommend orthotics if the assessment findings support them.
Is treatment covered by health insurance?
Yes — podiatry consultations are typically covered by most major insurers. We are recognised by BUPA, Aviva, WPA, AXA PPP, Vitality, Cigna, and Simply Health. See our
insurance page for full details.
Book a heel pain assessment today
Richmond and Kensington clinics available. No referral needed. Same-week appointments.
