Ultrasound Guided Heel Bursitis Steroid Injection

Insertional Achilles tendinosis

What is heel bursitis?

There are two bursae in the heel area. A bursa is a thin sac containing a tiny amount of fluid and acts to reduce the friction between a tendon and the adjacent bone. In the heel, the main bursa is the retrocalcaneal bursa, located between the Achilles tendon attachment and the heel bone (calcaneum). This bursa is a normal structure, but if there is inflammation or increased friction, the fluid contained within the bursa will increase.

Another small bursa, the pre Achilles bursa, can be seen between the Achilles tendon attachment and the skin. This is only seen if there is increased friction in the area.

What is bursitis?

Bursitis indicated bursa inflammation. This can happen if there is increased pressure or friction upon a bursa. The heel area contains two bursae. These thin sacs contain a small amount of fluid and are found in different anatomical locations within the human body, for example, the shoulder, hip, and ankle. Their purpose is to reduce friction between a structure (usually tendons) and a bone nearby. The main bursa in the heel is called the retrocalcaneal bursa, located between the Achilles tendon and the heel bone. This bursa is a normal structure but can become inflamed if there is increased stress, leading to an increase in fluid. Another bursa, known as the pre-Achilles bursa, can be found between the Achilles tendon and the skin, but it is only visible in cases of increased friction in the area.

What are the causes of heel bursitis?

There are different causes that can result in inflammation and thickening of the heel bursa. These mainly result in increased mechanical pressure upon the bursa, resulting in bursal inflammation. They include:

Increase friction and pressure upon the bursa. If you suddenly increase the intensity of your exercise, such as marathon training, or abruptly increase your walking distance, you may experience increased friction and pressure on the bursa. This can also be caused by using new shoes or changing the surface on which you exercise.
Local trauma/injury to the back of the heel can start heel bursitis.
The heel bone (calcaneum) shape. In some people, the heel bone has a slight bony prominence at the back, adjacent to the Achilles tendon insertion. This is referred to as (Haglund’s configuration). Although this is often seen incidentally on ankle X-rays in people without symptoms, it can cause pinching of the adjacent retrocalcaneal bursa and the Achilles tendon attachment, predisposing to bursitis and insertional Achilles tendinosis. This condition is different from mid-portion Achilles tendinopathy, which is discussed separately.
Inflammatory arthritis. This is a special group of conditions that includes rheumatoid psoriatic arthritis. Such conditions can be associated with inflammation of the tendon attachment, including the Achilles tendon attachment to the heel bone. The medical term used to describe this is “Enthesitis”.

How to tell if I have heel bursitis?

Pain. Heel bursitis pain is felt at the back of the heel bone (calcaneum). It is usually exacerbated by physical activities such as walking and running. Shoes can also press over the area and worsen the pain. Daily activities that put direct pressure upon the bursa, like the foot position while driving, might be painful.
Pain with calf stretching, particularly if there is associated insertional Achilles tendinosis.
The area at the back of the heel might become swollen, red, and tender to the touch.

What other conditions can mimic heel bursitis?

Conditions that can cause heel pain and are mistaken for heel bursitis include:

Heel bursitis vs Achilles tendinopathy

The Achilles tendon is an important tendon that runs at the back of the lower leg and attaches to the heel. Issues related to the Achilles tendon can be categorised into two types. The first type is non-insertional and affects the middle portion of the tendon, resulting in pain above the heel. The second type is insertional, affecting the tendon's attachment to the calcaneum. This type can often occur concurrently with heel bursitis, particularly in cases of inflammatory arthritis. It can be challenging to differentiate between the two conditions based on clinical examination alone, as both pain and swelling may be present. A dedicated musculoskeletal ultrasound assessment by a specialist radiologist is a valuable tool for accurate diagnosis, as it can accurately assess both the bursa and the Achilles tendon.

How to diagnose heel bursitis?

When the condition is suspected clinically, you will be referred for further imaging to establish the diagnosis. Ultrasound is a useful tool for this assessment. It can determine the type of inflamed bursa (retrocalcaneal or pre-Achilles), and the amount of inflammation, and assess surrounding structures such as Kager's fat pad and the shape of the bone (e.g. Haglund's configuration). Ultrasound can also evaluate the Achilles tendon for any tendinosis or tears. During the examination, Power Doppler ultrasound will detect increased blood flow to the affected area, indicating active inflammation. Ultrasound is often preferred over MRI due to its high resolution and ability to compare the affected and unaffected sides. Furthermore, ultrasound provides accurate guidance for injections into the inflamed bursa during imaging.

What is the treatment for heel bursitis?

Typically, treatment begins with conservative methods such as physiotherapy and podiatry assistance. This approach involves modifying activities, performing exercises to strengthen the calf muscles, and utilizing techniques such as ice packs and anti-inflammatory medication to reduce inflammation. It is also important to ensure you use the appropriate shoe type to avoid aggravating the problem.

Can steroid injection help with heel bursitis?

Heel bursitis can be a persistent and challenging condition to treat. If your symptoms are severe and interfering with daily activities, sleep or preventing effective physiotherapy, and conservative management isn't working, a steroid injection into the bursa can offer efficient pain relief and reduce inflammation. To ensure accuracy and safety, a combination of corticosteroid medication and local anaesthesia is administered under ultrasound guidance. Research suggests that the effect of corticosteroids can last up to three months on average, but it can be longer in some cases.

What is a cortisone injection?

Cortisone is a strong anti-inflammatory medicine routinely used to manage inflammatory conditions (like bursitis, arthritis, and tendinosis). A cortisone injection will reduce the inflammation in the injected area (i.e.: the heel bursa). It will allow effective rehabilitation and enable you to engage in a physiotherapy program. To find out more, please see our FAQs.

Should heel bursa injections be done under ultrasound guidance?

This is our routine practice, as plenty of evidence supports ultrasound guidance when performing musculoskeletal injections. Performing heel bursa injections under ultrasound/imaging guidance allows for direct visualisation of the needle to ensure accurate placement into the inflamed bursa, avoiding important adjacent structures, particularly the Achilles tendon. Ultrasound guidance results in more accurate, less painful, and faster procedures, with better outcomes than injections without guidance.

Do cortisone injections just hide/mask the pain?

Steroid injections do not just mask or hide the pain. They act by reducing the inflammation in the targeted area, thus providing a strong and local anti-inflammatory effect to help control the symptoms and allow the patient to manage the condition, usually by undergoing effective rehabilitation.

How many steroid injections do I need for heel bursitis?

We advise reducing the number of cortisone injections by combining any injection therapy with an effective physiotherapy programme to address the underlying cause. Limiting the number of steroid injections near tendons, especially the Achilles tendon, is important.