Bursitis, the inflammation of a bursa, can occur in the ankle and is a common cause of heel pain. A bursa is a small, fluid-filled sac found throughout the body. These sacs contain fluid that reduces friction between bones, tendons, and muscles near a joint. When a bursa becomes irritated or inflamed, it causes localized pain, swelling, and difficulty with movement.
Specific Bursae Affected in the Ankle Region
The ankle and heel area contains several bursae, two of which are most frequently involved in bursitis. The first is the retrocalcaneal bursa, situated deep within the heel between the Achilles tendon and the calcaneus (heel bone). Its function is to allow the Achilles tendon to glide smoothly over the heel bone during ankle movements.
The second common site for inflammation is the subcutaneous calcaneal bursa, which is positioned more superficially. This bursa lies between the skin and the back of the Achilles tendon, near where the tendon inserts. Inflammation in this bursa is sometimes referred to as Achilles bursitis. The subcutaneous bursa minimizes friction from external sources, such as the back of a shoe rubbing against the heel.
Primary Causes and Identifying Symptoms
Ankle bursitis typically develops from either chronic overuse or repetitive mechanical friction. Repetitive activities, such as running, jumping, or dancing, can place excessive stress on the Achilles tendon, which irritates the underlying retrocalcaneal bursa. A sudden increase in the intensity or duration of an activity is a frequent trigger, especially in athletes who increase their training load too quickly.
Friction from poorly fitting or stiff footwear is a common cause of subcutaneous calcaneal bursitis. Tight dress shoes, high heels, or skates that continuously rub against the back of the heel can lead to irritation and inflammation. This pressure can also be exacerbated by a bony prominence on the heel bone, known as Haglund’s deformity, which is often associated with retrocalcaneal bursitis.
The symptoms of ankle bursitis are typically localized and distinct from general ankle sprains or strains. Individuals commonly experience pain and tenderness focused at the back of the heel. Visible swelling or a lump may be present, and the skin over the inflamed area can feel warm and appear red. Pain often increases when pressure is applied, such as when wearing tight shoes or pushing off the foot during walking or running.
Medical Evaluation and Management
A healthcare provider diagnoses bursitis through a physical examination, noting localized tenderness, swelling, and warmth over the bursa. They also take a detailed medical history to determine potential causes, such as changes in activity level or footwear. Differentiation from other conditions like Achilles tendonitis or a heel fracture is important, as the symptoms can overlap.
Imaging tests are often used to confirm the diagnosis and rule out other underlying issues. An X-ray is useful for identifying any bony abnormalities, like a heel spur or Haglund’s deformity, which may be contributing to the friction. An ultrasound or magnetic resonance imaging (MRI) scan can provide clear visualization of the soft tissues, confirming a swollen, fluid-filled bursa. If an infection (septic bursitis) is suspected, a fluid sample from the bursa may be aspirated and sent for laboratory testing.
Initial management focuses on non-invasive conservative measures aimed at reducing inflammation and relieving mechanical stress. Rest and avoiding activities that aggravate the condition are recommended to allow the bursa to heal. Applying ice to the affected area helps to reduce swelling and pain, and over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help manage both pain and inflammation.
Modifying footwear is a practical intervention, often involving switching to shoes with an open back or a wider heel cup to eliminate rubbing. Physical therapy can also be beneficial, incorporating stretching exercises to improve flexibility in the ankle and calf muscles. This reduces tension on the Achilles tendon and the retrocalcaneal bursa.
Corticosteroid Injections and Surgery
For cases that do not respond to conservative approaches, a physician may recommend a corticosteroid injection directly into the bursa. Injections are typically guided by ultrasound to ensure accurate placement, particularly for the deeper retrocalcaneal bursa. Steroid injections are generally not recommended for the superficial subcutaneous bursa due to a higher risk of complications, including infection or skin changes. If bursitis becomes chronic, recurrent, or resistant to all other treatments, a surgical procedure called a bursectomy may be performed to remove the inflamed bursa entirely.