Achilles Bursitis

by PhysioAdvisor Staff

Injuries > Achilles & HeelAchilles Bursitis

What is Achilles bursitis?

Achilles bursitis is a condition characterized by tissue damage and inflammation of the Achilles bursa (a small fluid filled sac located at the back of the heel) causing pain in the heel region.

A bursa is a very thin fluid filled sac found in various places throughout the body. Bursae are filled with lubricating fluid and are designed to reduce friction between adjacent layers of tissue. They are located in regions of the body where tissue layers may rub against each other or against bony prominences (figure 1).

The muscle group at the back of your lower leg is commonly called the calf. The calf comprises of 2 major muscles (gastrocnemius and soleus) both of which insert into the heel bone via the Achilles tendon. Between the Achilles tendon and skin lies a bursa known as the Achilles bursa (figure 1).

Achilles Bursitis Anatomy

Figure 1 – Relevant anatomy for Achilles Bursitis

During contraction of the calf, tension is placed through the Achilles tendon and this rubs against the Achilles bursa. Rubbing of objects against the heel such as excessively tight shoes can also increase friction on the Achilles bursa. When this friction is excessive due to too much repetition or high force, irritation and inflammation of the bursa may occur. This condition is called Achilles bursitis.

(N.B. Achilles bursitis is not to be confused with the more commonly seen Retrocalcaneal Bursitis which also presents in a similar region of the Achilles).


Signs and symptoms of Achilles bursitis

Patients with Achilles bursitis typically experience pain at the back of the ankle or heel during activities requiring strong or repetitive calf contractions such as walking (especially uphill), going up and down stairs, running, jumping or hopping. Often pain may be worse with rest after these activities (especially that night or the following morning). Pain may also increase when wearing either loose or excessively tight shoes that rub against the Achilles bursa. Other symptoms may include swelling in the local area and tenderness on firmly touching the Achilles bursa.


Causes of Achilles bursitis

Achilles bursitis is often caused by excessive friction on the skin overlying the Achilles tendon, such as from wearing poorly fitted shoes. Overuse activities involving repetitive calf contractions, such as walking or running excessively, can also contribute to the development of the condition. Occasionally the condition may develop following trauma such as a direct impact to the Achilles Bursa.


Diagnosis of Achilles bursitis

A thorough subjective and objective examination from a physiotherapist may be all that is necessary to diagnose Achilles bursitis. Diagnosis may be confirmed, most commonly with an ultrasound investigation, or sometimes with a MRI or CT scan.


Treatment for Achilles bursitis

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Prognosis of Achilles bursitis

Most patients with Achilles bursitis heal well with appropriate physiotherapy. Minor cases that have not been present for long can usually recover within a few weeks. In patients with severe symptoms or those who have had their condition for a long period of time, recovery can be a lengthy process and may take a number of months if not managed appropriately. Early treatment is therefore vital to hasten recovery and improve the outcome.


Contributing factors to the development of Achilles bursitis

There are several factors which can predispose patients to developing Achilles bursitis. These need to be assessed and corrected with direction from a physiotherapist and may include:

  • inappropriate or poor footwear (e.g. excessively tight fitting shoes)
  • abnormal foot biomechanics
  • poor flexibility (particularly of the calf muscles)
  • muscle weakness
  • joint stiffness (particularly the ankle, subtalar joint or foot)
  • bony anomalies of the heel bone
  • inappropriate or excessive training or activity
  • inadequate recovery periods from sport or activity
  • inadequate warm up
  • inadequate rehabilitation following a previous Achilles injury
  • change in training conditions or surfaces
  • inappropriate running technique
  • inadequate fitness
  • poor pelvic and core stability
  • poor proprioception or balance
  • being overweight

Physiotherapy for Achilles bursitis

Physiotherapy treatment is vital in all patients with Achilles bursitis to hasten the healing process, ensure an optimal outcome and prevent recurrence. Treatment may comprise:

  • footwear advice
  • orthotics prescription
  • soft tissue massage
  • dry needling
  • stretches
  • electrotherapy (e.g. ultrasound)
  • anti-inflammatory advice
  • the use of crutches
  • the use of heel wedges
  • arch support taping
  • the use of a compression bandage
  • ice or heat treatment
  • joint mobilization
  • exercises to improve strength, flexibility and balance
  • education
  • activity modification advice
  • biomechanical correction
  • a graduated return to activity program

Other intervention for Achilles bursitis

Despite appropriate physiotherapy management, some patients with Achilles bursitis do not improve adequately. When this occurs the treating physiotherapist or doctor can advise on the best course of management. This may include corticosteroid and anesthetic injection into the Achilles bursa, drainage of the bursa, further investigations such as an ultrasound, X-Ray, MRI or CT scan, pharmaceutical intervention or review by a specialist or podiatrist who can advise on any treatment that may be appropriate to improve the condition. The podiatrist may sometimes recommend an orthotic or shoe insert to modify the biomechanics of the foot or shoe.


Exercises for Achilles bursitis

The following exercises are commonly prescribed to patients with Achilles bursitis. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 2 – 3 times daily and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.


Initial Exercises

Foot & Ankle Up & Down

Move your foot and ankle up and down as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 2). Repeat 10 – 20 times provided there is no increase in symptoms.

Exercises for Achilles Bursitis - Ankle Up & Down

Figure 2 – Foot & Ankle Up & Down (left foot)

Foot & Ankle In & Out

Move your foot and ankle in and out as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 3). Repeat 10 – 20 times provided there is no increase in symptoms.

Exercises for Achilles Bursitis - Ankle In & Out

Figure 3 – Foot & Ankle In & Out (right foot)

Foot and Ankle Circles

Move your foot and ankle in a circle as large as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 4). Repeat 10 – 20 times in both clockwise and anticlockwise directions provided there is no increase in symptoms.

Exercises for Achilles Bursitis - Foot & Ankle Circles

Figure 4 – Foot & Ankle Circles


More Initial Exercises

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Intermediate Exercises

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Advanced Exercises

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Other Exercises

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Rehabilitation Protocol for Achilles bursitis

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Physiotherapy Products for Achilles Bursitis   Physiotherapy products for Achilles bursitis

Some of the most commonly recommended products by physiotherapist for patients with Achilles bursitis include:

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Relevant Physiotherapy Exercises for Achilles Bursitis   Relevant physiotherapy exercises


Recommended Reading for Achilles Bursitis   Recommended Reading


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