Ankle Bursitis: Types, Causes, Symptoms, and Treatment

What are the different types of bursitis in the ankle?

Bursitis in the ankle region involves the inflammation of one or more of the small, fluid-filled sacs (bursae) that reduce friction between bones, tendons, and muscles around the ankle joint. While less common than in other major joints, several distinct types of ankle bursitis can occur, each associated with specific anatomical locations and biomechanical stressors.

Understanding Bursae and Bursitis

Bursae are small, slippery sacs lined with a synovial membrane that produces synovial fluid. Their primary function is to act as cushions, reducing friction and facilitating smooth movement between moving structures like tendons, muscles, and bones. When a bursa becomes inflamed, a condition known as bursitis, it can lead to pain, swelling, tenderness, and restricted movement in the affected area. This inflammation is typically caused by repetitive motion, prolonged pressure, direct trauma, or underlying inflammatory conditions.

The ankle joint, while seemingly compact, is surrounded by several critical bursae that can become inflamed. Understanding the specific location of these bursae is key to identifying the different types of ankle bursitis.

Anatomy of Ankle Bursae

The ankle region houses several bursae, some of which are more commonly affected by bursitis than others. The most clinically significant bursae around the ankle include:

• Retrocalcaneal Bursa: Located deep between the Achilles tendon and the posterior surface of the calcaneus (heel bone).
• Subcutaneous Calcaneal Bursa: Situated superficially between the Achilles tendon and the skin at the back of the heel.
• Anterior Ankle Bursae: A less distinct group, but bursae can exist anteriorly (front) to the ankle joint, often near the tibialis anterior tendon or talotibial joint capsule.
• Malleolar Bursae: Bursae can develop over the prominent medial (inner) and lateral (outer) malleoli (the bony protrusions of the ankle).

Different Types of Bursitis in the Ankle

Based on the bursa affected, ankle bursitis is categorized into several distinct types:

Retrocalcaneal Bursitis

Description: This is one of the most common forms of ankle bursitis. It involves inflammation of the retrocalcaneal bursa, which lies deep to the Achilles tendon and superior to the calcaneus. This bursa protects the Achilles tendon from friction against the heel bone during ankle movement.

Causes:

• Overuse and Repetitive Stress: Common in runners, dancers, and athletes involving repetitive ankle dorsiflexion and plantarflexion.
• Tight Footwear: Shoes with rigid heel counters can press on the bursa.
• Haglund's Deformity: A bony enlargement on the back of the heel bone (calcaneal exostosis) can irritate the retrocalcaneal bursa, often referred to as "pump bump" when associated with the subcutaneous calcaneal bursa.
• Achilles Tendinopathy: Co-existing inflammation or degeneration of the Achilles tendon can contribute.

Symptoms:

• Pain at the back of the heel, especially with activity or when rising on toes.
• Tenderness to touch on either side of the Achilles tendon just above the heel.
• Swelling that may not be externally visible due to the deep location.
• Pain worse with tight-backed shoes.

Subcutaneous Calcaneal Bursitis (Achilles Bursitis)

Description: Also known as Achilles bursitis or sometimes associated with "pump bump" (though "pump bump" more accurately describes the bony prominence of Haglund's deformity, which can cause this bursitis), this type affects the bursa located superficially between the skin and the Achilles tendon at its insertion point on the heel.

Causes:

• Direct Friction: Primarily caused by friction from the back of shoes (e.g., high heels, stiff athletic shoes) rubbing against the skin and Achilles tendon.
• Direct Trauma: A direct blow to the back of the heel.
• Haglund's Deformity: The bony prominence associated with Haglund's deformity can also irritate this superficial bursa, leading to inflammation.

Symptoms:

• Visible swelling and redness at the back of the heel.
• Pain and tenderness over the swollen area.
• Pain exacerbated by wearing shoes that rub the area.
• Warmth to the touch.

Anterior Ankle Bursitis

Description: This is a less common but recognized form of bursitis affecting the bursae located at the front of the ankle joint, typically superior to the talus and inferior to the distal tibia, or near the tibialis anterior tendon.

Causes:

• Repetitive Dorsiflexion: Activities involving repeated upward bending of the foot (e.g., squatting, hiking uphill, certain sports).
• Tight Footwear: Shoes that press down on the front of the ankle.
• Direct Trauma: A direct impact to the front of the ankle.

Symptoms:

• Pain at the front of the ankle, particularly with dorsiflexion.
• Localized swelling at the anterior ankle.
• Tenderness to palpation over the affected bursa.

Malleolar Bursitis (Medial and Lateral)

Description: Bursitis can occur over the bony prominences of the malleoli – the medial malleolus (inner ankle bone) and the lateral malleolus (outer ankle bone). These bursae are typically subcutaneous.

Causes:

• Direct Trauma: A fall or direct impact to the ankle bone.
• Prolonged Pressure: Leaning on the ankle bone for extended periods.
• Friction from Footwear: Shoes or boots that rub excessively against the malleoli.

Symptoms:

• Visible swelling and redness directly over the affected malleolus.
• Pain and tenderness when touching the area.
• Pain exacerbated by pressure or friction from footwear.

General Symptoms of Ankle Bursitis

While specific symptoms may vary by type, common indicators of ankle bursitis generally include:

• Pain: Often localized to the bursa, worsening with movement or pressure.
• Swelling: May be visible (superficial bursae) or detectable through tenderness and a feeling of fullness (deep bursae).
• Tenderness: The affected area is painful to touch.
• Redness and Warmth: Indicative of inflammation.
• Limited Range of Motion: Pain may restrict the ability to move the ankle fully.

Diagnosis and Treatment

Diagnosis typically involves a physical examination, assessment of symptoms, and sometimes imaging like ultrasound or MRI to confirm the presence of bursal inflammation and rule out other conditions (e.g., tendonitis, fracture, arthritis).

Treatment strategies for ankle bursitis generally follow conservative measures, similar to bursitis in other joints:

• Rest: Limiting activities that aggravate the bursa.
• Ice: Applying ice packs to reduce swelling and pain.
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Over-the-counter or prescription medications to manage pain and inflammation.
• Activity Modification: Adjusting footwear or movement patterns to reduce friction or pressure.
• Physical Therapy: Exercises to improve ankle flexibility, strength, and biomechanics, and modalities like ultrasound or phonophoresis.
• Corticosteroid Injections: In some cases, a corticosteroid injection directly into the bursa may be used to reduce inflammation.
• Surgery: Rarely required, but bursectomy (surgical removal of the bursa) may be considered for chronic, unresponsive cases.

Prevention

Preventing ankle bursitis involves addressing the root causes:

• Proper Footwear: Wear shoes that fit well, provide adequate support, and do not rub or put excessive pressure on the ankle or heel.
• Gradual Training Progression: Avoid sudden increases in activity intensity or duration, especially in running or jumping sports.
• Stretching and Strengthening: Maintain good flexibility in the ankle and calf muscles, and strengthen surrounding musculature to support proper biomechanics.
• Address Biomechanical Issues: Correcting foot mechanics or gait abnormalities with orthotics if necessary.
• Padding: Use protective padding or moleskin in areas prone to friction from footwear.

Understanding the specific type of bursitis affecting the ankle is crucial for accurate diagnosis and effective management, allowing for targeted interventions to alleviate pain and restore function.