How to Treat Achilles Bursitis: From Self-Care to Surgery

Most cases of Achilles bursitis respond well to conservative treatment, and surgery is only needed when months of non-operative care fail to bring relief. The condition involves inflammation of the retrocalcaneal bursa, a small fluid-filled sac wedged between the Achilles tendon and the back of the heel bone. Treatment typically follows a stepwise approach: rest and footwear changes first, then physical therapy and possibly injections, with surgical removal of the bursa and any bony prominence reserved for stubborn cases.

What Is Actually Inflamed

The retrocalcaneal bursa sits in a tight space between the back of the calcaneus (heel bone) and the Achilles tendon. Its job is to reduce friction when the tendon glides over the bone during walking, running, and pushing off. When this bursa becomes irritated and swollen, the space gets even tighter, and every step compresses inflamed tissue. Cadaveric research has shown that the anatomy here is more complex than many textbooks suggest. Superficial synovial tissue “islands” have been found on the posterior surface of the Achilles tendon, and the surrounding fat pad has a compartmentalized architecture that connects with the crural fascia.

The condition frequently overlaps with Haglund’s deformity, a bony bump on the back of the heel that narrows the retrocalcaneal space further. When Haglund’s deformity, retrocalcaneal bursitis, and Achilles tendon changes all coexist, the combination is sometimes called Haglund’s syndrome. You don’t need the bony bump to develop bursitis, but having one makes it more likely. Interestingly, research on endoscopic calcaneoplasty has found that the size of the bony bump doesn’t strongly predict how well someone does after surgery, suggesting that decompression of the inflamed soft tissue itself is more important than how much bone gets removed.

Symptoms and How It Gets Diagnosed

The hallmark symptom is pain at the back of the heel, right where the Achilles tendon meets the bone. You’ll typically notice swelling, warmth, and sometimes redness in that spot. Dorsiflexing the ankle, pulling the foot upward, tends to worsen the pain because it compresses the inflamed bursa between tendon and bone. Some people develop a visible bump on the posterior heel, which may be the bony prominence of a Haglund’s deformity, soft tissue swelling, or both.

A plain lateral X-ray can reveal a bony prominence on the upper back corner of the calcaneus, along with any calcification at the tendon insertion. MRI goes further, showing soft tissue inflammation including synovitis in the bursa and any accompanying tendon changes. Ultrasound is also a useful tool. A prospective study comparing MRI and ultrasound for Achilles tendon conditions found no significant difference in overall diagnostic accuracy between the two imaging methods, with both achieving accuracy rates in the high 80s to mid-90s percent range depending on the specific measurement technique used.¹ Ultrasound has the advantage of being cheaper, faster, and allowing the clinician to see the structures in real time while you move your foot.

Self-Care and First-Line Treatments

Before anything else, the goal is to calm down the inflammation and take pressure off the retrocalcaneal space. This starts with simple, low-cost measures you can begin at home.

Activity modification: Cut back on whatever aggravates the heel. For runners, that often means reducing mileage or switching temporarily to non-impact exercise like cycling or swimming. For everyday sufferers, it might mean avoiding prolonged walking or standing in flat shoes.
Ice: Applying ice to the back of the heel for 15 to 20 minutes several times a day helps reduce swelling. A frozen water bottle rolled under the foot works as a convenient option.
Heel lifts: A small wedge placed inside the shoe raises the heel, which changes the angle between the tendon and the bone. Pilot data from a study on in-shoe heel lifts showed that the lift increased the distance between the Achilles tendon and the calcaneus in a static standing position, which correlated with an immediate and short-term decrease in pain and symptoms.²
Footwear changes: Stiff-backed shoes and high heels that press directly into the Haglund’s bump or the inflamed area are the worst offenders. Open-backed shoes or those with a softer heel counter can make a real difference. Some people find relief simply by switching to shoes with a slightly elevated heel drop.
Anti-inflammatory medications: Over-the-counter NSAIDs like ibuprofen or naproxen can help manage pain and inflammation in the short term. These aren’t a long-term fix, but they can make the early weeks more bearable.

These measures sound unremarkable, but for many people they are enough, especially when the bursitis is caught early and isn’t accompanied by significant tendon degeneration or a large Haglund’s deformity. Give conservative care at least three to six months before concluding it hasn’t worked. Jumping to more aggressive treatment too early is a common mistake.

Physical Therapy

When basic self-care doesn’t fully resolve the problem, structured physical therapy is the next step. A therapist will typically focus on eccentric strengthening of the calf muscles, which involves slowly lowering the heel below a step. Eccentric exercises are the most studied intervention for Achilles tendon conditions broadly, and evidence supports their use for insertional problems as well, though the approach needs some modification. With insertional bursitis or tendinopathy, exercises that push the ankle into full dorsiflexion can actually compress the irritated area, so therapists often limit the range of motion early on, keeping the heel raise on a flat surface rather than off a step edge.

Beyond strengthening, therapy addresses contributing factors: tight calf muscles, weak hip stabilizers, and movement patterns that overload the posterior heel. Manual therapy, dry needling, and instrument-assisted soft tissue work may also be used, though the evidence for each varies. The key takeaway from the rehabilitation literature is that conservative management with physical therapy shows strong evidence for effectiveness, but it takes time.³ Patients who expect quick results tend to give up on therapy prematurely and push for injections or surgery sooner than necessary.

The Role of Foot Mechanics

If your feet overpronate, meaning the arch collapses inward excessively when you walk or run, the Achilles tendon experiences a different kind of loading that may make bursitis more likely or harder to resolve. Research using Doppler ultrasound has found that individuals with overpronated feet have significantly reduced blood flow in the Achilles tendon, particularly at the mid-tendon level, compared to those with normal foot alignment.⁴ Reduced blood supply to the tendon can slow healing and increase vulnerability to injury in the surrounding structures, including the bursa.

This is why some clinicians prescribe custom orthotics or motion-control insoles alongside physical therapy. The idea is to correct the abnormal foot mechanics that are continually stressing the heel. Whether orthotics alone can resolve established bursitis is debatable, but they make sense as part of a comprehensive approach, especially for people whose foot structure is clearly contributing to the problem.

Corticosteroid Injections and Their Risks

Corticosteroid injections into or near the retrocalcaneal bursa are commonly used when conservative care stalls but surgery seems premature. The steroid reduces inflammation quickly, and many patients feel substantial relief within days. A large retrospective study evaluating 218 image-guided injections found that roughly 63% of patients achieved an excellent or good response in the short term.⁵ About 14% eventually went on to have elective Achilles surgery, and the presence of increased blood flow (Doppler signal) in the bursa at the time of injection was associated with a higher likelihood of eventually needing surgery.

The relief, however, comes with a real risk that sets this injection apart from steroid shots in other joints. Corticosteroids can weaken tendon tissue by inhibiting collagen production and impairing local blood supply. In rare but serious cases, this can lead to Achilles tendon rupture. That same study of 218 injections documented four complete Achilles ruptures, a rate of about 1.8%, each occurring 15 to 59 days after injection and associated with an acute injury event.⁵ Case reports have described patients experiencing complete Achilles rupture shortly after steroid injections for retrocalcaneal bursitis, with the mechanism believed to involve both a direct toxic effect on collagen and worsening of already poor local blood supply.⁶

Image guidance makes a difference here. Injections performed under ultrasound or fluoroscopy allow the clinician to place the steroid precisely into the bursal space and away from the tendon itself. A blind injection carries more risk of inadvertently depositing the steroid into or against the tendon.⁷ If a corticosteroid injection is on the table, insist on image guidance and understand that even with it, repeat injections increase cumulative risk.

Platelet-Rich Plasma as an Alternative

Platelet-rich plasma (PRP) has gained attention as an injection alternative that may promote healing rather than simply suppressing inflammation. PRP is prepared from your own blood: a small sample is drawn, spun in a centrifuge to concentrate the platelets, and re-injected into the affected area. The platelets release growth factors that theoretically stimulate tissue repair.

A comparative study found that PRP injections for retrocalcaneal bursitis reduced pain and improved function compared to steroid injections, and the benefits lasted longer.⁸ PRP also avoids the tendon-weakening side effects of corticosteroids, which is a significant practical advantage when you’re injecting millimeters from the Achilles tendon. A case report of arthroscopic calcaneoplasty combined with PRP injection for Haglund’s syndrome showed substantial functional improvement, with ankle-hindfoot scores rising from 65% before surgery to 87% afterward.

The limitations are worth acknowledging. PRP is less well-studied than corticosteroids for this specific condition, and preparation methods vary widely between clinics, which makes it hard to compare results across studies. It also typically costs more than a steroid injection and is less likely to be covered by insurance. Still, for patients who have already tried one round of steroids or who have signs of tendon degeneration that make steroid use risky, PRP is a reasonable option to discuss.

When Surgery Becomes Necessary

Surgery enters the conversation when you’ve tried conservative treatment for several months, typically at least three to six, with no meaningful improvement. The primary surgical goal is to decompress the retrocalcaneal space by removing the inflamed bursa and, when present, shaving down or removing the Haglund’s bony prominence. Whether this is done through an endoscopic (camera-guided) technique or a traditional open approach depends on the surgeon’s expertise and the extent of the problem.

Endoscopic Calcaneoplasty

The endoscopic approach uses two small portal incisions on either side of the Achilles tendon. A camera goes in through one portal and instruments through the other. The surgeon removes the inflamed bursal tissue, shaves the bony bump under direct visualization, and can use fluoroscopy to confirm adequate bone removal. One study of 15 patients treated with endoscopic calcaneoplasty and bursectomy found that pain scores dropped from an average of 7.6 before surgery to 2.3 at follow-up, and these improvements held at one year. Functional outcome scores were rated excellent or good in most patients, and there were no complications such as infection, nerve injury, or delayed tendon rupture.⁹

A separate study of 25 heels treated with endoscopic decompression found that 16 had excellent outcomes and six had good outcomes, with average functional scores jumping from about 58 preoperatively to 89 postoperatively. The same study noted that patients who already had degenerative changes in the Achilles tendon before surgery had poorer results, an important consideration for anyone with longstanding disease.¹⁰

Open Surgery

Open approaches are sometimes necessary when the Haglund’s deformity is very large, when the Achilles tendon needs to be detached and reattached (for debridement of calcified or degenerated portions), or when endoscopic expertise is unavailable. The tendon-splitting approach goes directly through the midline of the Achilles tendon to access the bursa and bone, while the lateral approach goes alongside the tendon. A comparison of these two open techniques found that both provided symptomatic relief, but the tendon-splitting group returned to normal function faster, with a median of about four months compared to roughly six months for the lateral group.¹¹

An emerging middle ground is ultrasound-guided minimally invasive resection, which allows the surgeon to remove the bony prominence and bursal tissue through a small incision with real-time ultrasound guidance. Preliminary data suggest that patients treated this way can begin walking and start a rehabilitation program within about two weeks after surgery.¹²

Recovery After Surgery

Recovery timelines vary with the technique and the extent of what was done. After endoscopic procedures, many surgeons allow partial weight bearing in a boot within the first week or two, and patients may begin gentle range-of-motion exercises early. The progression through rehabilitation typically follows a phased approach: early protected motion, then strengthening, and eventually a return to sport-specific activities. For open procedures that required Achilles detachment and reattachment, recovery is longer. A period of immobilization and non-weight bearing often lasts four to six weeks before therapy begins in earnest.

Across surgical approaches, return to normal function generally falls somewhere between three and six months for most patients, though outliers in both directions exist. The comparison of tendon-splitting versus lateral approaches found a range as wide as three to 20 months for full recovery.¹¹ Athletes aiming to return to high-level sport should expect a longer process and should work with a physical therapist who understands the demands of their activity.

Tracking Your Progress

One frustrating aspect of Achilles bursitis is that improvement happens slowly, and it’s hard to judge whether things are actually getting better from day to day. Clinicians use standardized questionnaires to track outcomes, and knowing about these can help you calibrate your expectations. The VISA-A questionnaire is the most widely used tool. It asks eight questions covering pain, daily function, and sporting activity, generating a score from 0 to 100 where 100 represents no symptoms.¹³ Asking your clinician what your VISA-A score is at baseline and then repeating it every month or two gives you an objective way to measure whether your treatment is working, rather than relying on memory alone.

Conditions That Look Like Achilles Bursitis

Not all posterior heel pain is retrocalcaneal bursitis, and a misdiagnosis can mean months of the wrong treatment. The superficial bursa, sometimes called the “pump bump” bursa, sits between the skin and the Achilles tendon rather than between the tendon and bone. It produces a visible swelling that’s more superficial and usually more lateral than true retrocalcaneal bursitis. This distinction matters because the superficial bursa responds to different footwear modifications and rarely requires the kind of surgical decompression that retrocalcaneal bursitis does.

Insertional Achilles tendinopathy, involving degeneration or calcification of the tendon at its attachment to the calcaneus, can produce nearly identical symptoms and frequently coexists with bursitis. When both are present, treating the bursitis alone won’t fully resolve the problem. MRI helps distinguish the two, and treatment planning should address both conditions.

Less commonly, systemic inflammatory diseases can cause heel pain that mimics mechanical bursitis. Seronegative arthritis conditions, including psoriatic arthritis, can produce enthesopathy, inflammation where tendons and ligaments attach to bone, at the heel. A case report described a 50-year-old recreational athlete with insidious heel pain and no history of skin conditions who was ultimately diagnosed with psoriatic arthritis after clinical suspicion led to further testing.¹⁴ If your heel pain doesn’t follow the typical mechanical pattern, doesn’t respond to standard conservative treatment, or if you notice pain in multiple joints, it’s worth asking your clinician about inflammatory causes. Blood tests and imaging can usually sort this out.

What Research Is Questioning About the Bony Bump

For decades, the Haglund’s prominence has been treated as the central villain in retrocalcaneal bursitis. The thinking was straightforward: bigger bump, more impingement, worse symptoms. But newer research is starting to challenge that framing. A prospective study examining the relationship between the size of the Haglund’s bump and postoperative outcomes after endoscopic calcaneoplasty found no significant association between the height of the bump, or the bump-to-calcaneus ratio, and how well patients did after surgery.¹⁵ The authors suggested that decompression of the retrocalcaneal space and removal of inflamed soft tissue may matter more for symptom relief than how much bone is taken away.

This finding has practical implications. It suggests that aggressive bone removal isn’t necessarily better, and it may explain why some people with prominent Haglund’s deformities on X-ray never develop symptoms while others with modest bumps have severe bursitis. The inflammation itself, in the bursa and surrounding soft tissues, may be driving the pain more than the anatomy alone. For patients considering surgery, this is worth discussing with your surgeon: the goal is adequate decompression, not necessarily the most dramatic reshaping of the calcaneus.