(See also Overview of Foot and Ankle Disorders Overview of Foot and Ankle Disorders Most foot problems result from anatomic disorders or abnormal function of articular or extra-articular structures (see figure ). Less commonly, foot problems reflect a systemic disorder (see... read more .)
Bursitis in the Heel
Normally, only one bursa is in the heel, between the Achilles tendon and the calcaneus. This bursa may become inflamed, swollen, and painful, resulting in anterior Achilles tendon bursitis.  |
Bursitis is due to friction/irritation, trauma (eg, caused by rigid or poorly fitting shoes), or inflammatory arthritis (eg, rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is a chronic systemic autoimmune disease that primarily involves the joints. Rheumatoid arthritis causes damage mediated by cytokines, chemokines, and metalloproteases.... read more 
, gout Gout Gout is a disorder caused by hyperuricemia (serum urate > 6.8 mg/dL [> 0.4 mmol/L]) that results in the precipitation of monosodium urate crystals in and around joints, most often causing recurrent... read more 
). On occasion, small calcaneal erosions may result from severe inflammation.
Symptoms and Signs of Anterior Achilles Tendon Bursitis
Symptoms and signs of bursitis caused by trauma or gout develop rapidly; those caused by another systemic disorder (eg, rheumatoid arthritis) develop gradually. Pain, swelling, and warmth around the heel are common, as are difficulty walking and wearing shoes. The bursa is tender. Initially, the swelling is localized anterior to the Achilles tendon but in time extends medially and laterally.
Diagnosis of Anterior Achilles Tendon Bursitis
Clinical evaluation and x-rays
Fracture of the posterolateral talar tubercle usually causes tenderness anterior to the insertion of the Achilles tendon. Bursitis is often differentiated from the fracture by the localization of warmth and swelling contiguous to the tendon and pain localized primarily in the soft tissue. Also, using the thumb and index finger, compressing side-to-side anterior to the Achilles tendon causes pain. The presence of a symptomatic os trigonum, an accessory ossicle, is included in the differential diagnosis, as well as flexor hallucis longus tendinopathy (1 Diagnosis reference Anterior Achilles tendon bursitis is inflammation of the retrocalcaneal bursa, located anterior (deep) to the attachment of the Achilles tendon to the calcaneus. Diagnosis is mainly clinical... read more ).
Radiographs are taken to rule out fracture and to reveal erosive calcaneal changes characteristic of chronic rheumatoid arthritis, gout, or other systemic rheumatic diseases. MRI is helpful to distinguish between a posterior talar process fracture and os trigonum syndrome.
Diagnosis reference
1. McAlister JE, Urooj U: Os Trigonum Syndrome. Clin Podiatr Med Surg 38(2):279-290, 2021. doi:10.1016/j.cpm.2020.12.011
Treatment of Anterior Achilles Tendon Bursitis
Padding/protecting the area, open back shoes
Intrabursal injection of a soluble corticosteroid/anesthetic solution
A corticosteroid/anesthetic injection, nonsteroidal anti-inflammatory drugs (NSAIDs), and warm or cold compresses may be effective in patients with bursitis. Care must be taken to inject only the bursal sac and not the tendon proper because tendon injection may lead to tendon weakening or tearing, predisposing to subsequent rupture (see Considerations for Using Corticosteroid Injections Considerations for Using Corticosteroid Injections Most foot problems result from anatomic disorders or abnormal function of articular or extra-articular structures (see figure ). Less commonly, foot problems reflect a systemic disorder (see... read more ).
