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Bursitis Ankle

In this article we provide you with everything you need to know about the causes of ankle bursitis and the most effective ways to treat the condition.

Bursitis is a painful condition characterized by the inflammation of the bursa. These are small fluid-filled spaces found between the bones and tendons. They are there to help reduce the friction between these structures and prevent injury to the bone and tendon. The bursae located in the ankle region of the foot are known as the Achilles Bursa, Retrocalcaneal Bursa, and the medial malleolus bursa. When the inflammation in the ankle bursa occurs at a more superficial level, it may also be referred to as the Subcutaneous Bursitis or the Pre Achilles Bursitis.

They can become inflamed due to overuse, a direct blow, repeated stress, or even a fall directly on the bursa or heel bone. Other conditions that may increase the risk of Bursitis include infection, rheumatoid arthritis, osteoarthritis, and gout. The major symptom of an inflamed bursa is the presence of pain and discomfort while moving the corresponding ankle.

As the name suggests, the Achilles Bursa is found at the level of the Achilles tendon, which is located at the back of the ankle joint. When the pain is coming from the Retrocalcaneal bursa, it usually originates from the heel’s back. (1) (2) On the other hand, pain from the Medial Malleolus bursa is mainly felt on the outside area of the ankle. Ankle Bursitis includes Achilles Bursa, Medial Malleolus Bursa, and Retrocalcaneal bursa, which may occur independently or may be associated with tendinitis.

What are the Symptoms of Ankle Bursitis?

There are two main types of Bursitis, based on their onset and duration. These are known as Acute Bursitis and Chronic Bursitis. The symptoms of the two differ from each other as each has its unique characteristics. Acute Bursitis may be differentiated from Chronic Bursitis through detailed medical history taken by the health professional, which may include their health status and their daily routine.

While Acute Bursitis usually arises as a result of an injury, trauma, infection, or joint disease, Chronic Bursitis has a different mechanism of onset. Chronic Bursitis usually arises due to repeated micro-injuries caused by overuse and repeated pressure. The symptoms of acute Bursitis may usually consist of pain in palpation of the bursa and a reduction in the joint’s range of motion due to intense pain felt by the individual on movement. This pain on movement may usually vary from location to location due to the changes in the biomechanics of the bones, muscles, and tissues of that particular region of the body. However, in the majority of the area, the pain is acute. In addition, Bursitis is felt by active motion, which is when the muscle gets activated and contracts. The contraction of the muscles leads to compression of the bursa, which causes pain. Another symptom that is often associated with Septic bursitis, which is caused by the infection in the bursa, includes a temperature rise over the skin of the affected bursa. This temperature rise may be as much as 2.2 degrees.

Unlike Acute Bursitis, Chronic Bursitis is usually painless, as, over time, the bursa gets time to take place in the body for its expansion by the increased fluid. This may present with swelling and thickening of the affected bursa. (3)

The most common symptoms reported t to be experienced by individuals with Ankle bursitis include:

  • Heel Pain and Pressure
  • Swelling in the the back of the heel area
  •       Pain triggered by pressing back on the heels
  • Supporting soft tissues pain
  • Stiffness in the ankle joint
  • Redness and Warmness of the overlying skin
  • Crackling sounds on flexing the foot
  • Limited range of motion

Causes Of Bursitis Ankle

The most common causes of Ankle Bursitis include overuse of the ankle joint, wearing poorly fitted shoes, and infection and inflammation in the surrounding structures of the bursa. Overuse injuries may be caused by physical activities like running for long periods of time. A lack of warm-up may also cause it before imposing sudden stress on the ankle through sports or physical activities.

Wearing Poorly fitting shoes may cause uneven pressure and load to be imposed on the ankles, which can lead to inflammation of the bursa. Moreover, the painful symptoms caused by this are also seen to worsen when individuals continue to wear high heels and ill-fitting shoes for long periods of time.

Even though it is not as common, Bursitis of the ankle may also be caused by an infection. This is known as Septic Bursitis. The most common organisms responsible for Septic Bursitis include Staphylococcus Aureus and Streptococci. Certain fungi and algae may also cause it. (4)

Other conditions which may put an individual at increased risk for Ankle Bursitis include Psoriatic Arthritis, Reactive Arthritis, Pseudogout, and Gout.

How is Ankle Bursitis Diagnosed?

The diagnosis of ankle bursitis may either be made on the basis of history and physical examination or may also include different forms of imaging. While history and physical examination help the health professional list out all the possible causes for the symptoms experienced by day individuals, radiographic imaging allows them to reach a definite diagnosis. This is because it allows the doctor to view the inside of the affected bursa and the possible changes to its structures and the surrounding structures.

The doctor may opt for an x-ray in order to assess the bursa when there is a history of trauma or injury to the area. On the other hand, magnetic resonance imaging is another form of imaging that allows the doctor to evaluate the bursa in more detail. Another form of imaging that may be opted by the health professional includes ultrasound, which is a valuable tool for visualizing the fat on the bursa. This can allow them to detect cobble stoning of the fat and differentiate the infectious Bursitis from cellulitis.

When there are doubts about possible infection and the presence of septic bursitis, the doctor may opt for aspiration of the bursa. The fluid that is aspirated from the inflamed bursa is then sent to the lab for cell counting, culture, and gram staining. Results showing the aspirated fluid to contain a white blood cell count of less than 500 usually indicate a non-infectious form of Bursitis. (5)

A diagram of ankle bursitis

Ankle Bursitis Treatment Options

Conservative or surgical approaches may treat ankle Bursitis like Retrocalcaneal Bursitis or Achilles Tendon Bursitis. While the conservative or non-operative approaches include changing shoes and using analgesia for pain relief, surgical treatment may be opted by the doctor in some cases, like Haglund’s deformity. (6) Studies conducted to test the effectiveness of conservative approaches for Achilles tendinitis showed significant improvements in 82% of the individuals who went for non-operative treatment options. (7)

Conservative Treatment

The most commonly recommended conservative treatments for ankle bursitis include:

  • Resting of the heels and ankles
  • Elevation of the foot in order to prevent swelling
  • Icing or application of cold packs to the ankle area numerous times a day
  • Taking non-steroidal anti-inflammatory drugs (NSAIDs) like Ibuprofen and Aspirin

The healthcare provider may also advise the individual to use custom heel wedges, as these fit perfectly under the heel area, allowing both sides to be raised. This helps reduce excessive stress on the heel as an individual walks.

The health professional may also educate the individual about the different physical exercises that can exacerbate the symptoms. The individual may also be told about the importance of padding to avoid trauma and excessive pressure on the ankle area. In addition, the doctor may recommend the patient to visit a physiotherapist regularly, where they may be told about the different strengthening exercises to help them heal faster. These exercises also help improve the range of motion of the associated joint and strengthen the surrounding muscles. The physiotherapist may also analyse the footwear that the individual wears and educate them about the importance of using proper fitting footwear. This helps relieve the excess pressure on the foot while walking and prevent inflammation of the bursa. Some physicians also recommend the use of a brace or cast, along with physical therapy.

The patients may be prescribed certain pain killers to help relieve pain and discomfort associated with Bursitis. These include NSAIDs or Acetaminophens. However, if the inflammation is at a deeper level and affects the deeper bursa, Corticosteroid injections may also be used. These steroid injections cannot be used for the superficial bursa, as they may increase the chances of tendon injury, atrophy of the skin, drainage of sinus tracts, and septic bursitis. Another reason for not prescribing corticosteroid injections is the immediate pain relief it causes, which may delay the diagnosis of any other associated injuries and conditions.

If the cause of the ankle bursitis is the presence of a systemic condition, it is important to treat the conditions before treating the symptoms associated with Bursitis. For example, if Bursitis is caused by an infection, which is known as septic Bursitis, antibiotic therapy may be given to the patient to help treat the infection. These patients are not required to be admitted to the hospital and maybe treated effectively in an outpatient setup.

Surgical Treatment

Certain types of Bursitis may not be treated by conservative treatment and may require a non-conservative approach such as surgery. An example of such a condition is Haglund’s deformity, which may be recommended to be treated using Calcaneal Ostectomy. This may be associated with debridement of the Achilles tendon and excision of Retrocalcaneal bursa and Calcaneal osteotomy or conducted without it based on the patient’s unique condition. (8)

By removing the source of irritation through the surgical procedure, a majority of the individuals experience immediate relief. For Achilles Bursitis, the surgical approach found to be the most effective is the Achilles tendon splitting approach which provides the greatest exposure to the tendon and the bursa.

Prolotherapy

Many of the structures around the ankle have a poor blood supply, which is why it struggles to heal properly on it’s own. It is the oxygen and nutrients in our blood supply that help to heal ankle injuries.

Prolotherapy involves the injection of a regenerative solution into the tendon to provide a direct supply of what is needed to heal the tendon and provide pain relief.

As the treatment is helping to treat the root cause of the problem, it is deemed to be a permanent fix.

Frequently Asked Questions About Ankle Bursitis

How Do You Treat Bursitis Of The Ankle?

Bursitis of the ankle is most commonly treated by resting e affected joint, icing it, and compressing the area with an elastic bandage. Rest the joint. Elevating the affected ankle from time to time may also help the healing process. The doctor may also recommend a steroid injection for the deeper bursae if these don’t work.

How Long Does Bursitis Last In The Ankle?

Individuals with ankle bursitis and heel bursitis can see improvement after only 2 to three weeks of their treatment. However, the more serious cases may take up to 12 months. (9)

What Causes Bursitis To Flare Up?

The factors which may cause the ankle bursitis to flare up include infections, trauma, or crystalline joint diseases. While these lead to acute Bursitis, chronic Bursitis may be triggered by micro-traumas that occur over time due to repetitive use or overuse. (9)

Can Bursitis Heal On Its Own?

Although the majority of cases of Bursitis can heal on their own, there are some that may require extra attention and medical interventions. The modalities that may be recommended to help the bursa heal efficiently include resting the affected ankle, icing it, compressing the bursa using cold packs and elastic bands, and elevating the foot. The individuals should also try to keep away from activities, practices, or postures that can cause the exacerbation of symptoms. The healing process may also be further improved by undergoing strengthening exercises under the supervision of an experienced physiotherapist.

Is Walking Good For Bursitis?

Walking is generally considered safe for Bursitis and may also help improve the symptoms. However, it is important to use the right walking shoes and not overdo this, as these may worsen the symptoms rather than improve them. The individual may consult an expert regarding the ways and durations for which they should undergo physical activity to improve their symptoms and accelerate the healing process. (10)

What Happens If Bursitis Is Left Untreated?

If Bursitis is left untreated, it may lead to permanent thickening and enlargement of the affected bursa. This enlargement will continue to suppress the structures around it and cause pain to the individual every time they move. In addition, the pain caused by movement may eventually lead to the individual using the area less, which can cause atrophy of the surrounding muscles.

References

  1. Canoso, J. J., Liu, N., Traill, M. R., & Runge, V. M. (1988). Physiology of the retrocalcaneal bursa. Annals of the rheumatic diseases, 47(11), 910–912. https://doi.org/10.1136/ard.47.11.910
  2. Doral, M. N., Alam, M., Bozkurt, M., Turhan, E., Atay, O. A., Dönmez, G., & Maffulli, N. (2010). Functional anatomy of the Achilles tendon. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 18(5), 638–643. https://doi.org/10.1007/s00167-010-1083-7
  3. Williams CH, Jamal Z, Sternard BT. Bursitis. [Updated 2022 Feb 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513340/
  4. Truong J, Mabrouk A, Ashurst JV. Septic Bursitis. [Updated 2022 Feb 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470331/
  5. Foster, Z. J., Voss, T. T., Hatch, J., & Frimodig, A. (2015). Corticosteroid Injections for Common Musculoskeletal Conditions. American family physician, 92(8), 694–699.
  6. Fiamengo, S. A., Warren, R. F., Marshall, J. L., Vigorita, V. T., & Hersh, A. (1982). Posterior heel pain associated with a calcaneal step and Achilles tendon calcification. Clinical orthopaedics and related research, (167), 203–211.
  7. McGarvey, W. C., Palumbo, R. C., Baxter, D. E., & Leibman, B. D. (2002). Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach. Foot & ankle international, 23(1), 19–25. https://doi.org/10.1177/107110070202300104
  8. Pauker, M., Katz, K., & Yosipovitch, Z. (1992). Calcaneal ostectomy for Haglund disease. The Journal of foot surgery, 31(6), 588–589.
  9. InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Bursitis: Overview. 2018 Jul 26. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525773/
  10. InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. How can Bursitis be treated? 2018 Jul 26. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525763/

 

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