Ankle joint bursitis is an inflammatory disease of bursa positioned around the ankle joint. Bursa is a sac filled with viscous fluid. Ankle Joint Bursa acts as a cushion between tendon, ligament, muscles and ankle joint bones. Viscous fluid within bursa is produced by synovial membrane. Soft sac of bursa filled with greasy viscous fluid act as lubricant resulting in decreased friction between bone and soft tissue like muscles, tendon and ligaments.
Causes of Ankle Joint Bursitis
Overuse of Ankle Joint
- Cycling and jogging causes bursitis around ankle joint because of overuse of the muscles, ligaments and tendons, which are in contact with bursa.
- Repeated movement of tendon, ligament and muscles against bone causes continuous friction of bursa resulting in bursitis.
Septic Bursitis (Infection of Bursa)
- Infection rrof bursa causes Septic Ankle Joint Bursitis.
- Cellulitis of suounding soft tissue may spread into bursa causing septic bursitis.
Injury of the Ankle Joint Bursa
- Accidental injury caused by auto or work accident of ankle joint may cause laceration or blunt trauma of bursa resulting in Ankle Joint Bursitis.
Poor Fitting Shoes
- Ankle joint movements while wearing tight fitting shoes causes additional pressure over ankle joint bursa.
- Friction of bursa against bone initiates inflammation resulting in Ankle Joint Bursitis.
Anatomical Location of Bursa
Several ligaments, tendons and muscles support ankle joint. There are several bursas small and large located around ankle joint. Ankle Joint Bursitis is often seen in following three bursae.
Subcutaneous Bursa Under Medial Malleolus
- Bursa is located between medial ankle ligament and medial malleolus.
- Bursa helps to create smooth dorsiflexion (foot moved upward) and plantar flexion (foot moved toward floor) movements of ankle joint.
- Inflammation of bursa causes severe pain during flexion and extension of ankle joint.
- Bursitis is often seen following injuries and trauma involving ankle joint. Bursitis is also common among athletes involved in contact sports like football, hockey or wrestling.
- Retrocalcaneal Bursa lies between Calcaneus Bone and Achilles Tendon.
- Bursa helps to prevent injuries to Achilles Tendon.
- Retrocalcaneal bursitis mostly observed in athletes involved in soccer, tennis and basketball games.
Subcutaneous Calcaneal Bursa
- Subcutaneous calcaneal bursa is located between posterior (back) surface of calcaneal bone and subcutaneous tissue.
- Bursitis is often observed after tight shoes are worn for substantial time in spite of pain.
- Subcutaneous bursitis is also associated with injuries of achilles tendon following work and auto accident.
Symptoms of Ankle Joint Bursitis
Pain Associated With Ankle Joint Bursitis
- Acute Pain- Duration of less than 3 to 6 months.
- Chronic Pain- Duration of over 3 to 6 months.
- Pain at Rest- Mild to moderate pain at rest
- Intensity of Pain- Severity of pain increased with joint movements.
Tenderness Associated With Ankle Joint Bursitis
- Severe pain is felt following palpation of bursa or area around the anatomical location of bursa.
- Fever is observed when bursitis is caused by bacterial infection.
Signs of Ankle Joint Bursitis
Swelling Caused by Ankle Joint Bursitis
- Inflamed bursitis often secretes more viscous fluid within the sac and causes swelling of bursa.
- The swelling around ankle joint caused by bursitis is tender, painful, soft and fluctuating in consistency.
Loss of Movement of Ankle Joint
- Joint movement is extremely painful when bursa is inflamed. Pain causes self- limitation of joint movement.
Red and Hot Bursa around Ankle Joint
- Infection of bursa results in pus or abscess collection within the sac of bursa.
- Abscess aggravates inflammation and increases blood flow to the inflamed tissue resulting in warm sac and hot discoloration of skin.
- Red and hot inflamed sac suggests Septic Ankle Joint Bursitis.
Limping Associated With Ankle Joint Bursitis
- Bursitis causes severe pain in ankle joint during walking and also with change of position from sitting to standing.
- Pain is severe when weight is transmitted through painful ankle joint.
- Patient often has tendency to limp while walking because of putting half steps while walking to prevent occurrence of severe pain.
- Joint stiffness is oassociated with limited or restricted joint movements. Joint movements are restricted as long as bursitis pain is inadequately treated.
- Continuous restrictionf joint movement results in joint stiffness.
Investigation to Diagnose Ankle Joint Bursitis
- X-RAY does not visualize soft tissue like bursa.
- X-ray is useful to rule out ankle joint dislocation or fracture as a cause of pain.
- MRI is routinely used to diagnose Ankle Joint Bursitis. Swelling of the bursa is observed under MRI films and compared with normal ankle.
- MRI is also used to rule out fracture, dislocation or arthritis of ankle joint.2
- Fluid from bursa is collected using CAT scan, X-ray or Ultrasound.
- Fluid is studied for infection and inflammation.
- Antibiotic sensitivity test is performed. Test evaluates sensitivity of bacteria to particular antibiotics. Most effective antibiotics thus can be selected to treat bacterial infection.
White Blood Cell Count
- White blood cell (WBC) count is increased in septic ankle joint bursitis.
- Normal WBC count suggests bursitis is not infected.
Erythrocyte Sedimentation Rate (ESR)
- ESR is increased in septic bursitis.
- Normal ESR suggests bursitis is not infected.
Treatment of Ankle Joint Bursitis
Conservative Treatment for Bursitis of Ankle Joint
- Shoe Inserts- Use loose fitting shoes and shoe inserts to prevent friction and pressure over area of inflame bursa.
- Rest- Few days rest is advised while inflammation is treated with anti-inflammatory medications.
- Ice- Is used during initial phase of inflamed bursitis. Ice helps to decreased swelling and pain.
Physical Therapy to Treat Bursitis of Ankle Joint
- Initial Phase- Physical therapy is useful during initial phase of inflammation while patient is being treated with anti-inflammatory medication. Physical therapy prevents joint stiffness.
- Recovery Phase- Physical therapy is prescribed in later stage to treat joint stiffness and improve joint mobility.
Medications for Ankle Joint Bursitis
NSAIDs for Ankle Joint Bursitis
- Prescribed for inflammation and pain.
- Medications most often prescribed are Motrin, Naproxen and Celebrex.
Opioids for Ankle Joint Bursitis
- Prescribed for pain not responding to NSAIDs
- Often prescribed with NSAIDs. NSAIDs are prescribed for inflammation and opioids for severe pain not responding to NSAIDs.
Muscle Relaxants for Ankle Joint Bursitis
- Ankle Joint Bursitis causes severe intractable pain which results in muscle spasm of surrounding muscles supporting joint.
- Muscle relaxants are prescribed to treat joint stiffness and muscle pain. Joint stiffness is often associated with muscle spasm.
Antibiotics for Ankle Joint Bursitis
- Results of fluid culture and antibiotic sensitivity tests suggest the choice of antibiotics to treat Septic Ankle Joint Bursitis.
Interventional Pain Therapy for Ankle Joint Bursitis
- Aseptic inflamed bursitis is often treated with corticosteroid injection of bursa.
- Corticosteroid is anti-inflammatory medication and helps to treat septic bursitis.
Surgery for Ankle Joint Bursitis
- Surgery is performed when all other treatments fail.
- Surgery is advised to prevent further spread of inflammation and infection to surrounding tissue.
- Endoscopic Excision of Bursa- Surgery is performed to remove entire inflamed or infected bursa.3
- Excision of Bursa and Surrounding Bone- Septic ankle joint bursitis is treated with complete removal of bursa and surrounding bone attached to bursa.
Complications Involving Ankle Joint Bursitis
- Long Term Bursitis
- Spread of Infection To Ankle Joint
- Spread of Infection To Distant Organs As Septic Emboli, If Not Treated.
Preventing Ankle Joint Bursitis
- Sporting Activities- Stretch and warm up before the any active contact sports or repeated ankle joint movements.
- Exercise- High intensity lower leg exercises like weight lifting should be performed at same intensity. Change of exercise or new routine involving ankle joint should begin with minimum effort to prevent injury to bursa, muscle, tendon and ligament.
- Shoes- Avoid tight fitting shoes.
- Four common types of bursitis: diagnosis and management.
Aaron DL, Patel A, Kayiaros S, Calfee R.
J Am Acad Orthop Surg. 2011 Jun;19(6):359-67.
Department of Orthopaedics, Alpert Medical School at Brown University, Providence, RI, USA.
- Painful syndromes around the ankle and foot: magnetic resonance imaging evaluation.
Top Magn Reson Imaging. 1998 Oct;9(5):311-26.
Department of Radiology, University of California San Francisco, 94143-0628, USA.
- Surgical treatment of chronic retrocalcaneal bursitis.
Wiegerinck JI, Kok AC, van Dijk CN.
Arthroscopy. 2012 Feb;28(2):283-93. doi: 10.1016/j.arthro.2011.09.019.
Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, T