In the ankle, 2 bursae are found at the level of insertion of the Achilles tendon. The superficial one is located between the skin and the tendon, and the deep one is located between the calcaneus and the tendon. The latter is the one more commonly affected by bursitis.
Improper foot wear, tight shoes or shoes that do not fit properly can cause extra pressure and friction on the back of the heel. Overtime, this pressure causes irritation of the bursae that protects the Achilles tendon causing one or both to swell and become inflamed. Athletes who overtrain or runners that increase their distance to quickly are at greater risk of experiencing Achilles bursitis. With over use, the Achilles bursae and tendon can become irritated and inflamed leading to thickening of the bursae lining and wearing of the tendon. Fluid builds in the bursa when it becomes irritated causing swelling of the Achilles bursa and pain at the back of the heel.
Posterior heel pain is the chief complaint in individuals with calcaneal bursitis. Patients may report limping caused by the posterior heel pain. Some individuals may also report an obvious swelling (eg, a pump bump, a term that presumably comes from the swelling's association with high-heeled shoes or pumps). The condition may be unilateral or bilateral. Symptoms are often worse when the patient first begins an activity after rest.
On physical examination, patients have tenderness at the site of the inflamed bursa. If the bursa is superficial, physical examination findings are significant for localized tenderness, warmth, edema, and erythema of the skin. Reduced active range of motion with preserved passive range of motion is suggestive of bursitis, but the differential diagnosis includes tendinitis and muscle injury. A decrease in both active and passive range of motion is more suggestive of other musculoskeletal disorders. In patients with chronic bursitis, the affected limb may show disuse atrophy and weakness. Tendons may also be weakened and tender.
Non Surgical Treatment
In addition to R.I.C.E., there are a number of other treatments to reduce swelling and any associated pain or discomfort due to heel bursitis. Orthotics or change of footwear. Wearing an orthotic device such as a heel insert can encourage better mechanics in the foot and reduce irritation of the retrocalcaneal bursa. Some people do not need special orthotics but simply need to stop wearing shoes with rigid heel and ankle construction and instead wear more supportive, comfortable shoes. Shoes with an "Achilles notch," a groove in the collar at the back of the shoe to protect the Achilles tendon, can be particularly helpful. (Almost all running shoes are designed with an Achilles notch.) Stretching and physical therapy. Stretching the Achilles tendon often helps alleviate pain. Once the pain is resolved it is important for the patient to continue a regular stretching program. Regular stretching reduces the chance of recurrence.
Do not run if you have pain. When you begin running again, avoid running fast uphill or downhill until the tendon is fully healed. Start exercising when caregivers say that it is OK. Slowly start exercise such as bicycling when caregivers say it is OK. When doing exercises that put pressure on the ankles, such as running or walking, exercise on flat, even surfaces. Avoid doing these exercises on very hard surfaces such as asphalt or concrete. Stretch before exercising. Always warm up your muscles and stretch gently before exercising. Do cool down exercises when you are finished. This will loosen your muscles and decrease stress on your heel. Wear heel protectors. Use soft foam or felt heel pads (wedges or cups) to help decrease pressure against your heel. Ask your caregiver which heel pads are the best for you. Wear well-fitting shoes. Buy running or exercise shoes that support and fit your feet well. Do not wear low-cut shoes. Talk to your caregiver or go to a special exercise footwear store to get well-fitting athletic shoes. Ask your caregiver if you should wear specially-made shoe inserts called orthotics (or-THOT-iks). Orthotics can line up your feet in your shoes to help you run, walk and exercise correctly.