Inferior Calcaneal Bursitis

Quick answer

A deep bursa sits beneath the calcaneus, between the heel bone and the heel pad. When this bursa becomes inflamed, the result is a deep, central heel pain — often confused with plantar fasciitis but with distinct features: more centrally located, deep rather than at the surface, often worse with prolonged standing on hard floors than with first morning steps.

How to tell it apart from plantar fasciitis

These two conditions are easily confused because both cause heel pain. Some distinguishing features:

The two can coexist, and the distinction sometimes only becomes clear with imaging or response to treatment.

What’s actually happening

The heel sits on a specialized fat pad — a honeycomb-like cushion of fat compartments designed to absorb impact. Beneath it, between the fat pad and the heel bone, sits a small bursa. With chronic pressure or impact, this bursa becomes inflamed, swollen, and painful.

Contributors:

• Hard-soled shoes or worn-out shoes
• Prolonged standing on hard floors — concrete, tile, hardwood
• Repetitive impact — running, jumping
• Weight gain — increases load on the heel pad
• Heel pad atrophy — natural thinning of the fat pad with age
• Direct trauma — stepping on a hard object, jumping from height
• Inflammatory arthritis — rarely

How to recognize it

• Deep, central heel pain — a “stone bruise” sensation
• Worse with prolonged standing on hard surfaces
• Worse barefoot on hard floors
• Better in cushioned shoes or on soft surfaces
• Tenderness when pressing on the center of the heel pad
• Often bilateral if related to weight or standing
• Usually no morning stiffness (in contrast to plantar fasciitis)

Diagnosis

This is typically a clinical diagnosis:

• Physical exam — central heel tenderness, intact plantar fascia tenderness
• X-rays — rule out calcaneal stress fracture, bone tumor, or significant arthritis
• Ultrasound — can directly visualize the inflamed bursa and assess the heel pad thickness
• MRI — for refractory cases or when the diagnosis is unclear

Treatment

Conservative care (almost always sufficient)

The strategy is to cushion and offload the heel:

• Cushioned heel cups — silicone or gel inserts that distribute pressure
• Cushioned shoes with thick midsoles
• Avoid hard-soled shoes, especially for prolonged standing
• Anti-fatigue mats for kitchen, workshop, or workplace standing
• Weight management — even modest weight loss reduces heel loading
• Activity modification — temporary reduction in high-impact activity
• NSAIDs short-term for inflammation
• Ice after activity
• Calf stretching — reduces overall heel loading

These measures resolve the great majority of cases over 4–8 weeks.

When more is needed

• Custom orthotics with deep heel cup and shock-absorbing material
• Cortisone injection — used cautiously; can thin the heel pad with repeated use, so generally limited
• Walking boot for 2–4 weeks for severe flares

Surgery

Surgery is rarely needed for isolated inferior calcaneal bursitis. When it is, the procedure is bursa excision — generally a last resort.

Bottom line

Heel pad bursitis is a common but underdiagnosed cause of heel pain — particularly in people who stand on hard floors all day. Cushioned heel cups, supportive shoes, and load reduction resolve most cases. If you have heel pain that’s deep, central, and worse with prolonged standing rather than first morning steps, this diagnosis is worth considering — and it’s much more responsive to cushioning than plantar fasciitis is.