Retro Achilles bursa

Findings

There may be a history of pain at night and in the morning, initially feeling better with activity but then becoming increasingly painful. There is painful, reduced, active and passive dorsiflexion of the ankle. Active plantar flexion is painful and there may be palpable tenderness bilaterally over the bursa, which may be slightly swollen.

Cause

Inflammation of the bursa. The bursa is bounded by the Achilles insertion below, the upper one-third of calcaneum in front, the overlying Achilles tendon behind, and the fat pad cranially. The bursa may be flared by a large calcaneum, possibly from calcaneovalgus or an overlying Achilles lesion. It may be part of Haglund’s syndrome.

Note: Retro Achilles bursa can be associated with seronegative or seropositive arthropathies.

Treatment

a)      Steroid injection of the bursa.

b)      Electrotherapeutic modalities to settle inflammation, such as ultrasound and laser.

c)      Treat any accompanying features of Haglund’s syndrome.

d)      Treat any systemic cause.

e)      Remove, or alter, a tight heel cup or “Achilles tag” from the shoes, and consider a heel raise which moves the tendon away from the calcaneal boss.

f)       Use a gel second skin.

g)      Avoid Achilles stretching exercise and “heel drops”.

Sports

        Athletics – a sudden increase in speed, or distance, may create too much load for the tendon. Camber running encourages lateral movement of the calcaneum and bowing of the tendon. Repetition sprints, with too little recovery time, can fatique the quadriceps, causing an upset in calf/quadriceps coordination. Uphill running may produce overload of the Achilles.                             

       Hill walking and climbing – when climbing using the forefoot, the heel may drop too low, increasing the forces on the Achilles. However, by using “high heels”, i.e. finding a rock to support the heel, or zig-zagging up the hill using the sides of the foot, this problem is prevented.

        Cricket – very often an Achilles tendon tears when a back foot shot is played to mid-wicket, and a quick single is run. The weight is on the ball of the back foot activating the calf and then the knee straightens for the run, upsetting the calf/quadriceps coordination.    

       All sports – sudden acceleration from a bent knee position and a plantarflexed foot.

Perhaps more common than expected, and a surprising number are associated with systemic inflammatory problems.

"Concise guide to sports injuries, 2^nd edition",Churchill Livingstone, Malcolm T.F. Read,  foreword by Bryan English