Achilles Bursa Injection

Chronic bursitis

Causes and findings:
• Overuse - runners and dancers
• Pain posterior to tibia and anterior to body of Achilles tendon
• Painful: resisted plantarflexion, especially at end range full passive plantarflexion

Equipment:
Syringe - 1ml
Needle - 25G 1.25 inches (30mm) blue
Kenalog 40 - 20 mg
Lidocaine - 1.5 ml 2%
Total volume - 2 ml

Anatomy:
The Achilles bursa lies in the triangular space anterior to the tendon and posterior to the base of the tibia and the upper part of the calcaneus. It is important to differentiate between tendinitis and bursitis here because both are caused by overuse. In bursitis there is usually more pain on full passive plantarflexion when the heel is pressed up against the back of the tibia, thereby squeezing the bursa. Also, palpation of the bursa is very sensitive and the pain is usually felt more at the end of rising on tip-toe rather than during the movement. The best approach is from the lateral side to avoid the posterior tibial artery and nerve.

Technique:
• Patient lies prone with foot held in some dorsiflexion
• Identify and mark tender area on lateral side of bursa
• Insert needle into bursa avoiding piercing the tendon
• Deposit solution as bolus

Aftercare:
Avoid overuse activities for at least 10 days, then start a stretching and eccentric exercise programme. Female ballet dancers need to avoid overplantarflexing the ankle when on point.

Comments:
It is important to avoid penetrating the Achilles tendon and depositing the solution there. Any resistance to the needle requires immediate withdrawal and repositioning well anterior to the tendon.