Posterior Achilles tendon bursitis is inflammation of a bursa that forms in response to shoe pressure and is located at the top edge of the posterior shoe counter between the skin and Achilles tendon. Diagnosis is clinical. Treatment is footwear modification.

This disorder occurs mainly in young women. Wearing high-heeled shoes is a predisposing factor. Many patients have a bony prominence (Haglund deformity) on the calcaneus.

Symptoms and Signs

Symptoms and signs develop at the top edge of the posterior shoe counter. Early symptoms may be limited to redness, pain, and warmth. Later, superficial skin erosion may occur. After months or longer, a fluctuant, tender, cystic nodule 1- to 3-cm in diameter develops. It is red or flesh-colored. In chronic cases, the bursa becomes fibrotic.

Diagnosis

• Symptoms and a small, tender, and flesh-colored or red nodule

The presence of the small, tender, and flesh-colored or red nodule in a patient with compatible symptoms is diagnostic. Rarely, an Achilles tendon xanthoma develops at the top edge of the posterior shoe counter but tends to be pink and asymptomatic. Achilles tendon enthesopathy causes pain mainly at the tendon's insertion but may also cause pain at the top edge of the posterior shoe counter. Enthesopathy is differentiated by the absence of a soft-tissue lesion.

Treatment

• Modification of footwear

Properly fitting shoes with low heels are essential. A foam rubber or felt heel pad may be needed to lift the heel high enough so that the bursa does not contact the shoe counter. Padding around the bursa or the wearing of a backless shoe until inflammation subsides is indicated. Foot orthotics may enhance rear foot stability and help reduce irritating motion on the posterior calcaneus while walking. Warm or cool compresses, NSAIDs, and intrabursal injection of a local anesthetic/corticosteroid solution offer temporary relief; the Achilles tendon itself must not be injected. Surgical removal of a portion of the underlying bone may rarely be necessary to reduce soft-tissue impingement.

Last full review/revision December 2012 by Kendrick Alan Whitney, DPM

Content last modified January 2013