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Achilles Tendon Bursitis

By Kendrick Alan Whitney, DPM

Achilles tendon bursitis is inflammation of the fluid-filled sac (bursa) located either between the skin of the back of the heel and the Achilles tendon (called posterior Achilles tendon bursitis) or in front of the attachment of the Achilles tendon to the heel bone (called anterior Achilles tendon bursitis or retromalleolar bursitis).

  • Typical symptoms include swelling and warmth and a tender spot at the back of the heel.

  • The diagnosis is based on symptoms, an examination, and sometimes x-rays.

  • Treatment is aimed at relieving the inflammation and, depending on the location of the Achilles tendon bursitis, eliminating the pressure on the back of the heel.

The Achilles tendon is the tendon that attaches the calf muscles to the heel bone. Bursitis is painful inflammation of a bursa (a flat, fluid-filled sac that provides cushioning and reduces friction in areas where skin, muscles, tendons, and ligaments rub over bones).

Posterior Achilles tendon bursitis occurs mainly in young women but can develop in men. Walking in a way that repeatedly presses the soft tissue behind the heel against the stiff back support of a shoe can cause or aggravate the bursitis. Shoes that taper sharply inward toward the posterior heel (such as high-heeled shoes or pumps) can cause or worsen an enlargement of the bone of the back of the heel (called pump bump or Haglund deformity), which contributes to posterior Achilles tendon bursitis.

Anterior Achilles tendon bursitis (also called Albert disease or retromalleolar bursitis) can be caused by any condition that puts extra strain on the Achilles tendon. Injuries to the heel (such as those caused by stiff or poorly fitting shoes) and diseases (such as rheumatoid arthritis and gout) can also cause it.

Bursitis in the Heel

Normally, only one bursa is in the heel, between the Achilles tendon and the heel bone (calcaneus). This bursa may become inflamed, swollen, and painful, resulting in anterior Achilles tendon bursitis.

Abnormal pressure and foot dysfunction can cause a protective bursa to form between the Achilles tendon and the skin. This bursa may also become inflamed, swollen, and painful, resulting in posterior Achilles tendon bursitis.

Symptoms

Symptoms depend on the cause and location of the bursitis.

Posterior Achilles tendon bursitis

Early symptoms of posterior Achilles tendon bursitis may include redness, pain, and warmth at the back of the heel. Later, the top layer of skin may wear away. After several months, a bursa, which looks like a raised, red or flesh-colored area (nodule) that is tender and soft, forms and becomes inflamed. If posterior Achilles tendon bursitis becomes chronic, the bursa may become hard and scarlike.

Anterior Achilles tendon bursitis

When the bursa becomes inflamed after an injury or gout, symptoms usually develop suddenly. When the bursitis develops because of other disorders, symptoms develop gradually. Pain, swelling, and warmth develop at the back of the heel. People have difficulty walking and wearing shoes. A minimally red, swollen, tender spot develops on the back of the heel. When the inflamed bursa enlarges, the swelling spreads sideways to both sides of the heel.

Diagnosis

  • A doctor's examination

  • Sometimes x-rays

The diagnosis of both disorders begins with an examination.

For posterior Achilles tendon bursitis, doctors look for a red or flesh-colored nodule.

For anterior Achilles tendon bursitis, doctors squeeze the space between the tendon and the heel bone to see whether it causes pain. X-rays do not diagnose tendon bursitis, but doctors may do x-rays to rule out other causes of heel pain such as a fracture of the heel bone or damage to the heel bone caused by rheumatoid arthritis or other inflammatory arthritis.

Treatment

  • For both disorders, warm or cold compresses, nonsteroidal anti-inflammatory drugs (NSAIDs), and injections of a corticosteroid/anesthetic mixture

  • For posterior Achilles tendon bursitis, footwear changes and sometimes surgery

For both disorders, warm or cold compresses, NSAIDs, and injections of a corticosteroid/anesthetic mixture into the inflamed bursa can temporarily relieve the pain and inflammation. The doctor is careful not to inject the mixture into the tendon. After this treatment, the person should rest.

For posterior Achilles tendon bursitis, treatment is aimed at reducing the inflammation and adjusting the foot’s position in the shoe to relieve pressure and motion on the back of the heel. Foam rubber or felt heel pads can be placed in the shoe to eliminate pressure by elevating the heel. Placing protective gel padding over the painful bursa or stretching the back part of the shoe and placing padding around the inflamed bursa may help. A backless shoe may be worn until inflammation lessens. Sometimes a special shoe, such as a running shoe designed to stabilize the midsole heel, devices placed in the shoe (orthoses), or both can help to control abnormal foot and heel motion contributing to the posterior heel irritation. Other shoes have padding that reduces irritation to the posterior heel and Achilles tendon.

If these treatments are not effective, part of the heel bone may need to be surgically removed.

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