The human ankle is a multifaceted joint complex comprised of three separate joints in the region where the foot and the leg meet. It is necessary for these joints to possess a certain degree of strength as they support the weight of the entire body. Increased strength translates into increased stability leading to higher standards of weight bearing, mobility and adaptability for the entire body. The ankle, in conjunction with the foot, allows us to perform basic human functions such as standing, walking, running and jumping while serving as connection to the ground. Its physiology allows it to withstand the stress of our body weight as well as the ability to adapt to and quickly react to changes in environment and walking surface.
A bursa is a fluid filled sack that serves to reduce friction between tendons, and between tendons and bone. Bursa are important structures in both the ankle joint and the subtalar joint, because they ensure that the structures of the joint move smoothly. Bursa can become inflamed due to overuse or stress, causing pain when moving. The major bursa located in the ankle region are the Achilles bursa, retrocalcaneal bursa and the bursa of the medial malleolus.
- Achilles bursa: Also called the subcutaneous calcaneal bursa, the Achilles bursa is located between the skin and the posterior aspect of the distal Achilles tendon. Like the retrocalcaneal bursa, the Achilles bursa is located superior to the insertion of the Achilles tendon. Pain from an injury to this bursa will occur along the back of the ankle, near the heel.
- Retrocalcaneal bursa: Sometimes called the subtendious bursa, the retrocalcaneal bursa is located between the anterior aspect of the Achilles tendon and the calcaneous bone (heel). Like the Achilles bursa, the retrocalcaneal bursa is located superior to the insertion of the Achilles tendon. Pain from an injury to this bursa is concentrated at the back of the ankle by the heel.
- Medial Malleolar Bursitis: Also called the subcutaneous bursa of the medial malleolus, this bursa is located between the skin and the medial malleolus. Injury to this bursa can cause pain along the outside of the ankle at the medial malleolus bone.
- A direct blow to the bursa can produce inflammation and irritation.
- A fall where one lands improperly on the ankle or bursa.
- Constant pressure on the bursa from use of the ankle.
- Repeated stress injury to the bursa and tendons (particularly the Achilles) from a high level of activity, which may also cause tendinitis in addition to bursitis.
- Complications from rheumatoid arthritis, osteoarthritis or gout.
- Infection of the bursa or ankle.
- Bursa can become swollen as a response to other ankle injuries the individual may have sustained.
- Pain and tenderness over the location of the bursa
- Loss of motion of the ankle
- Pain with activities that stress the bursa like walking, jumping, running or activities that cause stress on the tendons that are lubricated by the bursa.
Avoiding the activities that produce the pain or stress the involved bursa is the first line of treatment.
- Avoiding activities that produce pain or stress of the bursa and associated tendons (jumping, running, etc.).
- RICE: (Rest, Ice, Compression, Elevation) should be used to reduce the stress on bursa.
- The use of ice to reduce inflammation and pain.
- NSAIDS (non-steroidal anti-inflammatory drugs)
- Physical Therapy
- Drainage of the fluid in the bursa for severe cases. Fluid should be checked for possible infection.
- Antibiotics in the case of infections of the bursa.
- Steroidal injections in non responsive cases.
- Surgery to remove the bursa may be needed in extreme cases if the problem becomes chronic.
It is important that once the discomfort and swelling is reduced, and motion and strength are restored that the patient gradually return back to full activities. Instruction in daily activities or sport performance is helpful to minimize a flare up of the ankle bursitis. In most cases, full return to activity will take from 2-6 weeks depending on the severity of the injury. As a preventive measure individuals should:
- Make modifications in work or daily activities
- Maintain strength and flexibility to reduce stress on the bursa
- Avoid highly repetitive activities that involve the ankle whenever possible.