The Achilles tendon is the strongest tendon in the body. With the huge amount of demand placed on it during functional activities like walking, running, squatting, and jumping, it makes sense that the Achilles tendon has to be extremely robust in order to keep up with the demands placed on it.

An injured Achilles tendon can have a huge impact on day-to-day function, and an injury is even more detrimental to athletes involved in sprinting or jumping sports. Some of the more common Achilles injuries include Achilles tendinopathy, a ruptured Achilles tendon, and more indirectly, calf strains.

Achilles tendon bursitis is less often talked about, and this is likely because it is often combined with other injuries, or may be misdiagnosed, as it can produce similar symptoms to Achilles tendonitis and Achilles tendinopathy, especially on the back of the heel. Achilles tendon bursitis can be quite painful, often limiting function, and it can become increasingly painful and limiting if not addressed properly.

This article will discuss some of the basics when it comes to Achilles tendon bursitis, including pathophysiology, signs and symptoms, and common treatment methods.

What is a bursa?

A bursa is a fluid-filled sac that helps reduce friction between anatomical structures that have to slide over each other. These are commonly located between bones and tendons. If you picture the tendon as being a rope and the bone as a cement block, if the tendon (rope) is constantly sliding back and forth on the bone (cement block) it may become damaged over time until it ultimately fails.

The bursa helps reduce this friction, thus allowing a smoother and more forgiving surface for the tendon to slide over. These bursae are located all over the body, with larger bursae found in the shoulders, elbows, hips, knees, and ankles.

What is bursitis?

Bursitis is a painful condition that involves inflammation of the bursa, which is typically the result of direct trauma, such as a direct impact to the bursa. Bursitis can also occur in combination with muscle and tendon dysfunction.

For example, those with Achilles tendinopathy may also have associated Achilles tendon bursitis, especially if they are involved in highly repetitive activities that really stress the Achilles tendon and subsequently more physical stress on the bursa. The most common symptom of Achilles bursitis is heel pain.

Achilles Tendon Bursitis

The most common form of Achilles tendon bursitis is retrocalcaneal bursitis. This bursa sits in front of the Achilles tendon and behind the calcaneus (heel bone) at its upper margins, which is why people sometimes refer to it more generally as heel bursitis.

This bursa helps prevent excessive irritation of the Achilles tendon as it slides up and down on the top portion of the calcaneus with movement. “Retrocalcaneal” means behind the calcaneus.

Another common form of Achilles bursitis is subcutaneous calcaneal bursitis. It’s a bit of a mouthful, but let’s break it down. “Subcutaneous” means just under the skin, “calcaneal” means relating to the calcaneus or heel bone, and “bursitis” is inflammation of the bursa. Putting these together, we can reason that this bursa is located at the back of the heel bone more superficially, meaning closer to the skin.

The subcutaneous calcaneal bursa sits a little lower directly behind the calcaneus, and as such, one of its primary symptoms is visible swelling and inflammation local to the very back of the heel bone.

In contrast, the retrocalcaneal bursa that we described previously is a little higher up, and since it’s covered by the thicker portion of the Achilles tendon, visible swelling and inflammation may not appear at the initial onset of symptoms, especially when those symptoms are mild.

Achilles Bursitis Treatment

For this section, we will be referring to both retrocalcaneal bursitis and subcutaneous calcaneal bursitis, but with a heavier emphasis on retrocalcaneal bursitis since it’s more common. Given there are lots of similarities between these conditions, we will continue to refer to them together as Achilles bursitis or Achilles tendon bursitis.

Physiotherapy for Achilles Bursitis

Physical therapy treatment for Achilles tendon bursitis will initially focus on reducing heel pain, protecting the area from further damage, and addressing any inflammation that is present (Aaron et al, 2011).

This can be done with the application of ice to the back of the heel, adjusting footwear to using less tight fitting shoes that offer good medial arch support and reduce contact on the back of the heal, advice to wear shoes with custom heel wedges, and/or incorporating pain reduction modalities such as TENS or IFC.

From there, we want to continue a conservative approach to treatment and ensure that there is no reduction in function while the patient is addressing the acute stages of their bursitis (Hunt and Anderson, 2009). This will involve maintaining joint range of motion with specific active and passive range of motion exercises. The physiotherapist can help guide you on what movements to perform.

Essentially, keeping the ankle moving while avoiding lots of pressure on the bursa (e.g. end range dorsiflexion or dorsiflexion overpressure) should help with the continuation of symptoms reduction while also maintaining function.

An example of this type of motion exercise would be tracing the alphabet with your foot by only moving your ankle within its tolerable range. While this may seem a little silly, it can help with both motion and joint position awareness (proprioception) and incorporates all directions of the ankle.

As Achilles tendon bursitis symptoms continue to resolve, loading the tendon by strengthening the calf muscles and surrounding ankle musculature, such as tibialis posterior, will be important, as there’s a good chance there is some form of ankle muscle dysfunction, especially if the Achilles bursitis has been lingering for a while.

The most basic form of strengthening will involve calf raises and static balance exercises, but will advance to more functional exercises that demand a high level of ankle control while loading the Achilles tendon as tolerated. A single leg squat, or a step down, are examples of functional exercises that can achieve this goal.

In addition to exercise-based therapy and electrotherapeutic modalities, another form of treatment that may be offered includes manual therapy. For example, if the calf muscles are very tight in a patient with Achille tendon bursitis, the physiotherapist may suggest massage or perform some soft tissue release themselves.

If soft tissue release is performed, it’s highly recommended to stay clear of the locally inflamed bursa, as rubbing the bursa will only promote further inflammation and irritation.

That said, given the Achilles tendon connects the calf muscles to the heel bone, releasing the calf muscles can indirectly reduce the tensile stress on the tendon, meaning it won’t be pulling in on the bursa and compressing it quite as much, thus helping to relieve pressure on the affected bursa.

Soft tissue release and massage can be effective, but the effectiveness is usually temporary unless the patient is regularly having this form of manual therapy applied. Nevertheless, if it helps reduce symptoms, buys a window for further exercise-based therapy, and the patient finds it’s really beneficial for them overall, then it can be a good adjunct to treatment assuming no contraindications.

Medication

If the Achilles tendon bursitis isn’t settling down and appears to maintain a high level of inflammation, it is recommended to consult with a doctor or pharmacist regarding appropriate medications. These will likely involve some form of anti-inflammatories, just like in the case of Achilles tendonitis, or if the patient is unable to take an anti-inflammatory due to other medical conditions, a more general pain reliever like Tylenol may be recommended.

Anti-inflammatories can come in a few different forms. The type that most people are familiar with are nonsteroidal anti inflammatory drugs, or NSAIDs for short. These include common over-the-counter anti-inflammatories such as Advil or Aleve.

Anti-inflammatories can also be applied topically, meaning a cream that is applied directly on the skin local tot he inflamed area. A common topical anti-inflammatory is Voltaren. If these application method is preferred, but the patient requires something a little stronger, a physician may write a prescription for a higher concentration form.

Corticosteroid Injections

If very conservative management and activity-based rehab don’t resolve symptoms for the patient, somewhat more invasive approaches may be considered. Steroid injections are somewhat common interventions, and while more invasive than physiotherapy, they are less invasive than surgery.

Given that there is a needle inserting into the bursa, there is always a risk of infection, but this risk is usually quite low. Additionally, corticosteroids can weaken tendon tissue, and given the extremely close proximity of the Achilles tendon to the retrocalcaneal bursa, subsequent tendon damage or rupture is a risk that needs to be considered.

These factors are a part of the reason that we typically wait to see if more conservative rehab works first. If a corticosteroid injection is warranted, administering it under the guidance of ultrasound or fluoroscopic imaging can be quite effective.

Recent evidence shows that image-guided corticosteroid injections for retrocalcaneal bursitis was successful in significantly alleviating pain for 63% of the participants included in the study, at least in the short-term, with approximately 1.8% of the participants experiencing an Achilles tendon rupture within 15-60 days post-injections. All cases of rupture were occurred with an identifiable acute mechanism of injury, so it’s difficult to tell the exact contribution of the injection itself in facilitating rupture (Boone et al, 2021).

Surgery

If all conservative heel bursitis treatment fails, then surgery may become a last resort option. There are many risks associated with surgery, including infection, a reaction to anesthetic, possible failure of the surgery, and possible post-surgical complications depending on other health conditions that may be present for the patient.

Nevertheless, if indicated, one of the most effective types of surgery for Achilles tendon bursitis is endoscopic calcaneoplasty. This technique involves accessing the retrocalcaneal space where the retrocalcaneal bursa is located.

Very small incisions are made and cameras inserted to view the bursa and surrounding structures. From there, the surgeon can remove the inflamed retrocalcaneal bursa, as well as a small portion of the calcaneus (heel bone) that was impinging on the bursa (Niek van Dijk et al, 2001).

More recent evidence shows this technique is highly promising, as it’s less invasive than open surgery, the latter of which is a much more comprehensive surgery involving large open incisions.

The endoscopic technique has shown a very high level of patient satisfaction in the short-term, as well as 5 years post-surgery, with the only adverse effects being temporary numbness or hyposensitivity in the surgical region (Opdam et al, 2021)

Summary

Achilles bursitis, also known as Achilles tendon bursitis, can be broken down into two sub-types: retrocalcaneal bursitis and subcutaneous calcaneal bursitis. These will be very similar in presentation, and the methods of treating the two are quite similar.

Treatment for Achilles tendon bursitis will focus on a combination of reducing inflammation with ice or medications, maintaining and subsequently improving ankle range of motion. Finally, ensuring that the ankle has sufficient functional strength, particularly the calf muscles and Achilles tendon, will go a long way in ensuring the symptoms don’t return and you can go about your daily routine or fitness routine without pain.

If conservative treatment fails, some form of injection therapy may be warranted, and in worst case scenarios, surgery may also be an option. While it’s best to avoid these interventions if possible, recent techniques show a high level of success with minimal adverse effects, and hopefully these techniques will only improve from here.

References

Aaron, D. L., Patel, A., Kayiaros, S., & Calfee, R. (2011). Four common types of bursitis: diagnosis and management. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 19(6), 359-367.

Boone, S. L., Uzor, R., Walter, E., Elsinger, E., Catanese, D., Ye, K., & Goldberg-Stein, S. (2021). Safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection for the treatment of retrocalcaneal bursitis. Skeletal Radiology, 50(12), 2471-2482.

Hunt, K. J., & Anderson, R. B. (2009). Heel pain in the athlete. Sports Health, 1(5), 427-434.

Niek van Dijk, C., van Dyk, G. E., Scholten, P. E., & Kort, N. P. (2001). Endoscopic calcaneoplasty. The American journal of sports medicine, 29(2), 185-189.

Opdam, K. T., Zwiers, R., Vroemen, J., Sierevelt, I. N., Wiegerinck, J. I., & van Dijk, C. N. (2021). High patient satisfaction and good long-term functional outcome after endoscopic calcaneoplasty in patients with retrocalcaneal bursitis. Knee Surgery, Sports Traumatology, Arthroscopy, 29, 1494-1501.

Disclaimer:

The content here is designed for information & education purposes only and is not intended for medical advice.