Achilles Bursitis

Achilles bursitis is a condition where there is swelling, pain and discomfort in the fluid-filled sac (the retrocalcaneal bursa), which lies between the Achilles tendon and the heel bone. This sac lubricates the Achilles tendon’s movement over the heel bone.¹ Retrocalcaneal bursitis is another name for Achilles bursitis.

What is the Achilles Tendon?

The Achilles tendon connects the muscles in the back of the leg (the calf muscles) to the heel bone (calcaneus). It is also known as the tendon of Achilles.

What is Achilles Tendon Bursitis?

Posterior

Achilles tendon bursitis (Achilles bursitis) is also known as retrocalcaneal bursitis. The retrocalcaneal bursa is the deeper posterior of the two heel bursae, lying just over the upper back of the heel bone and under the lower part of the Achilles tendon. When it becomes inflamed, painful and swollen, this condition is known as Achilles tendon bursitis. 

Anterior

The subcutaneous calcaneal bursa lies superficially and is anterior to the two heel bursae, lying over the lower part of the Achilles tendon and the overlying skin. When it becomes inflamed, painful and swollen, this condition is known as subcutaneous calcaneal bursitis.

The symptoms and signs of retrocalcaneal bursitis and subcutaneous calcaneal bursitis are similar but can be differentiated on ultrasound scans and MRIs.

Signs and Symptoms

Redness, swelling, pain and warmth in the affected ankle and discomfort during ankle movements (such as when moving uphill or slowly) are the classic signs and symptoms of any inflammation in the body. In the worst cases, it may cause an inability to move the affected ankle or walk on the affected leg. You may also find it uncomfortable to wear shoes which press on the Achilles tendon.

This inflammatory process may also result in fever, in which case you should see your family physician at once.

Causes

• The most common cause is constant pressure on the Achilles tendon over a prolonged period in situations when you move the ankle persistently, such as during running long distances.
• Not warming up before training or overtraining are also common underlying causes. This can tighten the muscles in the back of the legs.
• Not using appropriate shoes for running or similar sports.
• Abnormal positioning of the foot when standing or running, either through learned habits during walking or exercising or due to having high-arched or flat feet.
• It can also occur due to injury to the heel and ankle.²

Risk Factors

Increasing age, rheumatoid arthritis, gout, psoriatic arthritis, ankylosing spondylitis and diabetes increase the risk of developing bursitis. Sports professionals and athletes such as long-distance runners are also more prone to having Achilles bursitis.³

Diagnosis

In most cases, your family physician can diagnose Achilles bursitis based on the history you give and an examination of the affected heel and ankle. Occasionally, they may also need to request X-rays, an ultrasound scan and an MRI of the affected heel and ankle for a more exact diagnosis and to guide specialist management and care if you are an athlete or sports professional.^3,4 Blood tests may also be necessary where other underlying medical conditions are suspected.

Treatment

Rest is the first treatment. Avoid movements and exercises which make the symptoms worse. Also, avoid bearing weight on the affected ankle. This may be needed for a few days to a couple of weeks. Avoid footwear that makes the symptoms worse.

Applying ice on the affected area using ice packs or a bag of frozen peas wrapped in a towel can also help to treat Achilles bursitis. This reduces the redness, swelling and pain. Apply for about 10 minutes every few hours during the day until the symptoms subside. Using the towel helps prevent burns from direct ice to the skin.

Elevation of the affected leg will help reduce swelling, pain and discomfort. You can try using a low stool when sitting out during the day or use extra pillows to lift the affected ankle in bed.

Over-the-counter pain medications like paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) like Ibuprofen can be used to treat the condition.⁶ NSAIDs can only be used after meals, and avoid them if you are allergic to them or when contraindicated, for example, in patients who have asthma. These drugs are also available as creams and ointments (avoid if there is a break in the overlying skin).

If you have tried the above and are still no better after a couple of weeks, or if your symptoms are becoming worse, then you should see your family physician. They can offer other management options such as other prescribable NSAIDs and other painkillers.

Steroid injections can be injected into the affected ankle, which can help to reduce swelling and pain. 

If abnormal foot movements are identified as a possible cause, your family physician would refer you to the orthotics team. They would usually prescribe suitable footwear or insoles or customize your footwear, such as using wedges to try and correct any abnormal foot positions and movements. It may also be necessary to refer you to a physiotherapist for more specialist physical therapy and stretching exercises.

If you are an athlete, your family doctor may refer you to a sports specialist.

Surgery is often the last resort if all interventions fail. Orthopaedic surgeons are specialist surgeons who do the surgery.

Outlook

Achilles bursitis is often resolved within a few weeks of adequate rest and simple painkillers. However, if you find that this is not the case, or at any time it appears that your symptoms are worse, you should see your doctor immediately.

Other causes of pain in the heel

Sever’s disease is a condition in which children and adolescents (usually between the age of 8 and 15 years) have pain and swelling in the back of the heel, which becomes more painful during exercise.⁵ This is more common in children who are athletes.

Insertional Achilles tendonitis is a condition in which adults have pain and swelling where the Achilles tendon attaches to the back of the heel. The heel becomes more painful when exercising. 

Achilles tendonitis is a condition where there is swelling and pain in the upper part of the Achilles tendon, called the belly.

Achilles tenosynovitis is a condition involving a swelling sheath covering the Achilles tendon, causing symptoms like Achilles bursitis.

Posterior impingement syndrome is a condition where soft and bony parts in the back of the heel get trapped between the parts of the lower leg and heel bone. There is a pain in the heel which becomes worse when standing on tiptoe.

Achilles tendon rupture is the separation of the Achilles tendon, resulting in detachment from the heel bone. This can be partial or complete. It occurs more commonly in middle-aged men who actively take part in sports, particularly recreational sports. A complete Achilles tendon rupture is often accompanied by sharp pain and a loud pop sound from the heel area, all of which occur suddenly. If suspected, urgent medical intervention is needed, as surgery may be required.

Haglund’s syndrome is a condition which causes pain and inflammation in the Achilles tendon and bursa simultaneously. There is a swollen area in the heel bone which irritates the Achilles tendon and the retrocalcaneal bursa. This bony abnormality is called Haglund’s deformity.

Conclusion

Achilles bursitis is a painful heel which occurs most commonly due to persistent movements in the Achilles tendon over time, causing swelling, pain, redness and discomfort on moving the heel and ankle. It is more common in long-distance runners.