The small fluid-filled sacs located between two adjacent structures, namely muscles, tendons and bones are known as bursae. Their action is to reduce friction and assist in the movement of tendons over bony surfaces. This lubrication assists the joints to move freely. Inflammation of these bursae is known as Bursitis. Heel pain caused by bursitis around the ankle and the heel can often be misdiagnosed as Plantar fasciitis and Achilles tendinitis.
The image below demonstrates the most common areas of the foot and ankle affected by Bursitis.
The most common cause of bursitis is repetitive movements which cause irritation of the bursa. Another common cause is due to injury, which can irritate the tissue inside the bursa, causing inflammation. Other causes can be attributed to prolonged pressure or pre-existing secondary conditions such as rheumatoid arthritis or gout – in which crystals can form in the bursa, causing irritation and swelling.
Most of the time an accurate diagnosis can be made by careful examination of the affected area. Other physical assessments are also conducted to rule out other possible causes of heel pain, such as Plantar Fasciitis and Achilles Tendinitis.
A thorough medical history is also obtained to assess for any medical conditions that can cause inflammation.
In some instances, the following may also be done:
Treatment will depend on the cause of the bursitis. However, the aim of treatment is to alleviate pain through the healing process.
These may include:
If bursitis was caused by a particular form of overuse, activity modification will be advised and discussed. Recommendations are also given to prevent bursitis in the future.
A 36 year-old male presents to the clinic complaining of heel pain. He describes a sharp shooting pain at the back of his left heel. He has experienced this heel pain for 6 weeks, but reports that it has been getting progressively worse over the past 2 weeks. He runs 4 times a week, and reports the pain to be worse after running, especially on uneven ground. After some research on the internet he has concluded that he has Achilles Tendinitis – which is inflammation of the Achilles tendon. He has iced the area and performed calf stretches in an attempt to reduce pain. Anti-inflammatory medications have also been taken, which he reports have helped reduce his heel pain temporarily.
On visual examination, the area near the Achilles tendon is red and swollen.
There is pain on palpation of a bursa which is located behind the Achilles tendon, and the area is warm to touch. His ankle range of motion is also assessed, and stiffness at the joint is noted.
His Achilles tendon is also palpated to rule out Achilles Tendinitis. There is no pain on palpation of the tendon or its insertion on to the calcaneus heel bone.
This patient is informed that his heel pain is due to Bursitis and not Achilles Tendinitis.
Biomechanical examinations are conducted whereby the patient is asked to walk and run on a treadmill, as his walking and running form is analysed and video recorded. Feedback on his biomechanics and overall foot function is given, as well as his running style. Amongst other things, it’s also noted that he pronates mildly through his subtalar joints, and has tightness of the calf muscles – which pull on to the Achilles tendon and subsequently the bursa, causing irritation and further contributing to the heel pain.
A footwear assessment is also conducted, and its noted that the sneakers he wears for running are not supportive for his foot form and function.
It is explained to the patient that he has Retrocalcaneal bursitis – inflammation of the bursa which is located between the Achilles tendon and the heel bone.
Although it is not uncommon to have both bursitis and Achilles Tendinitis at the same time, this patient does not have inflammation of the Achilles tendon, and the heel pain he experiences is caused by inflammation of the bursa alone.
In the short term, the patient is given felt padding to offload and reduce the friction between the back of his heel and his shoes to reduce further irritation of the bursa, giving immediate relief to the heel pain. He is also advised to ice and rest the area.
Footwear changes are also made, and the patient is advised to wear shoes that are most appropriate for his foot function, and accommodating for the inflamed bursa. A small heel lift is inserted into both shoe to elevate the heel and reduce strain on the tendon and bursa. This also reduces his heel pain immediately.
In the long term, gentle mobilising exercises of the ankle joint are performed, which aid in improved range.
Specific calf stretches are also demonstrated to target the tightness of the calf muscles and reduce the pull through the Achilles tendon.
He is also advised to reduce and modify high-risk overuse activities to prevent the onset of bursitis in the future.
Injection therapy is also discussed if the heel pain does not subside within the estimated 8 week period.