There are two main bursae involved in heel bursitis, the subtendinous calcaneal bursa and the subcutaneous calcaneal bursa. Both of these bursa are located near the Achilles tendon. The subtendinous calcaneal bursa, which is also referred to as the retrocalcaneal bursa, is on the back of the heel and is deeply situated between the Achilles tendon and the calcaneus. The subcutaneous calcaneal bursa, which is commonly referred to as the Achilles bursa, is located near the bottom of the heel between the skin and the distal aspect of the Achilles tendon. It?s much more superficial to the Achilles tendon than the subtendinous calcaneal bursa.
Inflammation of the bursa causes synovial cells to multiply and thereby increases collagen formation and fluid production. A more permeable capillary membrane allows entrance of high protein fluid. The bursal lining may be replaced by granulation tissue followed by fibrous tissue. The bursa becomes filled with fluid, which is often rich in fibrin, and the fluid can become hemorrhagic. One study suggests that this process may be mediated by cytokines, metalloproteases, and cyclooxygenases.
Patients with this condition typically experience pain at the back of the ankle and heel where the Achilles tendon attaches into the heel bone. Pain is typically experienced during activities requiring strong or repetitive calf contractions (often involving end of range ankle movements) such as walking (especially uphill), going up and down stairs, running, jumping or hopping (especially whilst wearing excessively tight shoes). Often pain may be worse with rest after these activities (especially that night or the following morning). The pain associated with this condition may 'warm up' with activity in the initial stages of injury. As the condition progresses, patients may experience symptoms that increase during sport or activity, affecting performance. In severe cases, patients may walk with a limp or be unable to weight bear on the affected leg. Other symptoms may include tenderness on firmly touching the affected bursa and swelling around the Achilles region.
Your doctor will take a history to find out if you have the symptoms of retrocalcaneal bursitis. By examining your ankle, he or she can generally tell the location of the pain. The physician will look for tenderness and redness in the back of the heel. The pain may be worse when the doctor bends the ankle upward (dorsiflex), as this may tighten the achilles tendon over the inflamed bursa. Alternatively, the pain may be worse with toe rise, as this puts stress on the attachment of the achilles tendon to the heel bone. Imaging studies such as X-ray and MRI are not usually necessary at first. If initial treatment fails to improve the symptoms, these studies may be obtained. MRI may show inflammation.
Non Surgical Treatment
Specific treatment for bursitis will be determined by your doctor based on your age, overall health, and medical history. Extent of the condition. Your tolerance for specific medications, procedures, or therapies. Expectations for the course of the condition. Your opinion or preference. The treatment of any bursitis depends on whether or not it involves infection. Aseptic bursitis. A noninfectious condition caused by inflammation resulting from local soft-tissue trauma or strain injury. Treatment may include R.I.C.E. Rest, Ice, Compression, and Elevation. Anti-inflammatory and pain medications, such as ibuprofen or aspirin. Aspiration of the bursa fluid for evaluation in the laboratory. Injection of cortisone into the affected area. Rest. Splints.
Only if non-surgical attempts at treatment fail, will it make sense to consider surgery. Surgery for retrocalcanel bursitis can include many different procedures. Some of these include removal of the bursa, removing any excess bone at the back of the heel (calcaneal exostectomy), and occasionally detachment and re-attachment of the Achilles tendon. If the foot structure and shape of the heel bone is a primary cause of the bursitis, surgery to re-align the heel bone (calcaneal osteotomy) may be considered. Regardless of which exact surgery is planned, the goal is always to decrease pain and correct the deformity. The idea is to get you back to the activities that you really enjoy. Your foot and ankle surgeon will determine the exact surgical procedure that is most likely to correct the problem in your case. But if you have to have surgery, you can work together to develop a plan that will help assure success.
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