Rheumatol Int (2016) 36:875–880
DOI 10.1007/s00296-016-3440-4
OBSERVATIONAL RESEARCH
Ultrasound‑guided retro‑calcaneal bursa corticosteroid injection
for refractory Achilles tendinitis in patients with seronegative
spondyloarthropathy: efficacy and follow‑up study
Puja Srivastava1 · Amita Aggarwal1 
Received: 21 October 2015 / Accepted: 8 February 2016 / Published online: 19 February 2016
© Springer-Verlag Berlin Heidelberg 2016
Abstract  Ultrasound (US)-guided corticosteroid injec-
tion has been shown to be safe and effective for varied
causes of plantar fasciitis; however, its use for Achil-
les tendinitis is controversial. We studied the efficacy and
changes in US findings at Achilles enthesitis after corticos-
teroid injection in patients with spondyloarthropathy (SpA).
Patients with SpA with symptomatic Achilles enthesitis,
refractory to 6 weeks of full-dose NSAIDs, were offered
US-guided local corticosteroid injection. Injected entheses
were examined by US (both B mode and power Doppler) at
baseline and 6 weeks after injection. Standard OMERACT
definitions were used to define enthesitis. Achilles tendon
thickness >5.29 mm, 2 cm proximal to insertion in long
axis, was considered thickened. Twenty-seven symptomatic
Achilles tendons (in 18 patients) were injected with 20 mg
methylprednisolone under US guidance baseline, and
6-week follow-up US features were compared. All patients
reported improvement in pain (VAS) in the affected tendon
after injection (p < 0.0001). Simultaneously, improvement
in local inflammatory changes were noted, in the form of
significant reduction in tendon thickness (p < 0.0001), vas-
cularity (p < 0.0001), peritendinous oedema (p  = 0.001),
bursitis and bursal vascularity (p < 0.001 and < 0.0001,
respectively). There was no change in bone erosions and
enthesophyte. None of the patients had tendon rupture or
other injection-related complications at 6 weeks of follow-
up. US-guided local corticosteroid injection is an effec-
tive and safe modality for refractory Achilles enthesitis in
* Amita Aggarwal
aa.amita@gmail.com; amita@sgpgi.ac.in
1 only few can afford anti-TNF agents, leaving local cor-
Department of Clinical Immunology, Sanjay Gandhi Post
Graduate Institute of Medical Sciences, Lucknow, Uttar
Pradesh 226 014, India
Rheumatology
INTERNATIONAL
patients with SpA and leads to reversion of acute changes
at entheseal site.
Keywords  Enthesitis · Achilles tendinitis ·
Spondyloarthropathy · Heel pain · Ultrasound · Steroid
injection
Introduction
Enthesitis is the unifying clinico-pathological feature for
all seronegative spondyloarthropathies (SpAs) [1]. Periph-
eral enthesitis is observed in almost all forms of SpAs at
some point in time, and in few patients, it may be the only
persisting manifestation over prolonged periods. Overall,
lower limb entheses are involved much more frequently
than those of upper limbs, and heel entheses are the most
commonly affected [1]. Pain at the affected entheseal site
may vary from mild to moderate, but sometimes can be
severe and disabling.
There is no evidence for efficacy of traditional disease
modifying drugs such as methotrexate and sulfasalazine
in enthesitis [2]. Treatment modalities used for enthesi-
tis include stretching exercises, shoe inserts, NSAIDs
and local injections of steroid or platelet rich plasma [3,
4]. Recent studies have demonstrated efficacy of anti-
tumour necrosis factor (anti-TNF) therapy, by show-
ing greater reduction in ultrasound enthesitis scores [5].
Local injections of etanercept [6] and adalimumab [7] at
the inflamed entheses have shown comparable efficacy to
corticosteroid injections, with more prolonged response
in anti-TNF group. However, in developing countries,
ticosteroid injections as the only second-line option for
most patients.
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Injection at inflamed tendon site may be performed
either by blind palpation [8–10], scintigraphic [11] or under
US guidance [8–10]. Palpation-guided injections are more
likely to fail due to inaccurate needle localisation, and some
patients end up getting multiple injections [8, 9]. Similarly,
anatomical localisation by scintigraphy is far from accurate
[11]. Sonography allows real-time imaging of tendo-achil-
les (TA) and thus helps in precise placement of injection
without causing injury to the tendon fibres. Further, recent
meta-analysis [10] has shown US-guided steroid injections
to be more efficacious than palpation-guided injections.
Side effects of steroid injection at entheses include local
site infection, tendon rupture, skin depigmentation and fat
pad atrophy in cases of plantar fascia injections [11, 13].
Tendon rupture, the most serious complication, is relatively
rare with reported incidence of 2.5–6.7 % in case of injec-
tion for plantar fasciitis [12, 13] and is more associated
with recurrent and blind palpation-guided injections. US
guidance significantly decreases complication rates [11].
Local corticosteroid injection is an effective and safe
modality for treatment of plantar fasciitis of varied causes
[3, 4, 8–10]; however, only few studies [6, 7] have evalu-
ated this modality for treatment of Achilles tendinitis.
Further, most studies have included both degenerative and
inflammatory entheses together; only a few [6] have evalu-
ated the soft tissue changes in inflamed entheseal sites
after local steroid injection exclusively in patients of SpA,
which is the most common cause of enthesitis in general
population. In the present study, we have addressed both
these issues, by studying both acute and chronic soft tissue
changes (by US) after local steroid injection, in inflamed
Achilles tendon, exclusively in patients with SpAs.
Patients and methods
Patients with SpA [satisfying European Spondyloarthrop-
athy Study Group (ESSG) criteria] with symptomatic TA
enthesitis refractory to 6 weeks of full-dose NSAID ther-
apy were offered local corticosteroid injection. A total of
40 symptomatic TA entheses (in 29 patients) were injected
with 20 mg methylprednisolone, under US guidance during
the study period (January 2013–October 2014). Twenty-
seven injected TA entheses (in 18 patients, who consented
for participation in the study) were re-examined by US at
6 weeks; baseline and follow-up clinical and US features
were compared.
Clinical evaluation
All patients were clinically assessed by experienced rheu-
matologists, and their baseline BASDAI and BASMI scores
were recorded. Pain score on visual analogue scale (VAS)
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Rheumatol Int (2016) 36:875–880
at the affected tendon was documented before and 6 weeks
after the local steroid injection.
Sonography
US evaluation was performed by a rheumatologist, trained
in musculoskeletal ultrasound. The machine used was a
Esaote system (MyLab40, Genova, Italy), equipped with
12–18 MHz linear array transducer. Same rheumatologist
performed baseline and 6-week follow-up US assessment
for all patients. B mode US was used to study anatomical
changes such as tendon thickness, echogenicity, periten-
dinous oedema, bursitis and erosions. Blood flow signals
were examined using power Doppler (PD), with stand-
ardised settings of pulse repetition frequency (PRF) of
0.5 MHz and Doppler gain of 64 %.
Standard OMERACT definitions for enthesopathy [14]
and recent report on baseline thickness of TA in patients
with SpA [15] were used to identify abnormal tendon. Achil-
les tendon thickness was measured at the point of maximal
thickness proximal to the bony insertion in long axis, and
thickness >5.29 mm was considered abnormal. Bursitis was
defined as well circumscribed, localised anechoic or hypo-
echoic area at the site of an anatomical bursa. Bursal dimen-
sions >2 mm in either long or short axis was considered
inflamed. Vascularity (PD signals) was graded as 0 = no PD
signals, grade 1 (≤3 PD signals), grade 2 (>3 signals occu-
pying <50 % of the lesion) and grade 3 (PD signals occupy-
ing >50 % of the lesional area). Bony erosion was defined as
the presence of cortical break on the bony surface with a step
down contour defect, detectable in two perpendicular planes
while enthesiophyte was defined as step up bony prominence
at the end of the normal bone contour.
Procedure used
The Achilles tendon was examined with the patient lying
in prone position with the feet hanging over the edge
of the examination couch at 90° of flexion. A 21 G nee-
dle was placed in the retro-calcaneal bursa (RCB), from
lateral approach, under US guidance, and 20 mg methyl-
prednisolone was injected with strict aseptic precautions.
All patients were asked to avoid weight bearing for next
48 h and to continue their baseline medications (included
NSAIDs in all and sulfasalazine in few).
Statistical analysis
SPSS software (16th version) was used for statistical anal-
ysis. Differences in clinical and US features of enthesitis
were compared using Wilcoxon sign-rank test (numerical/
ordinal data) and Fisher’s exact test (categorical data). p
value < 0.05 was considered significant.
Rheumatol Int (2016) 36:875–880 877

Results Adverse events

Demographic profile
Baseline and 6-week follow-up clinical and US evaluation
of 27 TA entheses (in 18 patients) treated with US-guided
corticosteroid injection were compared. Study group mostly
constituted of young males (M:F = 8:1), with mean age of
26.1 ± 11.9 years and represented all subcategories of SpA
including ten patients with ankylosing spondylitis, five with
Juvenile SpA and one each with psoriatic arthritis, inflamma-
tory bowel disease-associated arthritis and undifferentiated
SpA. All patients had fairly active disease, with high mean
BASDAI (5.8 ± 1.6) and BASMI (1.4 ± 0.9) scores. All
except one patient had peripheral arthritis and 50 % patients
had a positive family history of spondyloarthropathy.
Baseline sonographic features
All symptomatic tendons were thickened; hypoechoic with
moderate (Grade 2–3) PD signals and two-thirds had para-
tendinous oedema. Almost 90 % entheses demonstrated the
presence of inflamed retro-calcaneal bursa and erosions and
11.1 % demonstrated enthesiophyte.
Follow‑up assessment at 6 weeks after local steroid
injection
All patients reported reduction in pain at the affected enthe-
ses and were also found to have improvement in acute
inflammatory changes at the entheses on US (Table 1;
Fig.  1). There was no change in chronic damage features
such as erosions and enthesiophyte. Although improve-
ment in both clinical and US features were noted, there was
no clear correlation between reduction in pain scores and
reduction of entheseal thickness on US (Fig. 2).
All patients experienced pain at local site during injection
procedure. No patients developed any major injection-
related complications such as local site infection, skin
depigmentation or tendon ruptures till last follow-up visit
(3–12 months).
Discussion
Our results confirm that US-guided local corticosteroid
injection is an effective and safe modality for treatment of
inflammatory TA enthesitis in patients with SpA. Improve-
ment in pain at local site goes hand in hand with reversion
of acute inflammatory changes in the entheses. Further, use
of US in this study helped in accurate placement of injec-
tion in the RCB, which may have avoided any injection-
related tendon rupture or skin depigmentation, as the lat-
ter occurs due to leakage of corticosteroid injection in the
superficial skin.
Our patient population was younger than most studies
on plantar fasciitis [9, 10], but was comparable to another
study on Achilles enthesitis in SpA patients [6]. Baseline
mean tendon thickness, bursitis, bony erosions and enthe-
siophyte in our group were comparable to those reported
by Huang et al. [6]. Similar to previous studies [6, 7], all
patients had significant local pain relief along with signifi-
cant reduction in tendon thickness, paratendinous oedema,
bursitis and vascular flow signals in tendon substance as
well as bursa. Also, in line with the previous study [6],
we also noted that pain reduction at the injected entheses
was much more impressive than improvement in sono-
graphic features, without a clear correlation between two
parameters. This could be explained by the fact that pain
can decrease to zero with treatment, but tendon thickness

Table 1  Clinical and Features (n = 27) Before injection 6 weeks after injection p value
ultrasound features at baseline
and 6 weeks after local Clinical assessment
corticosteroid injection
Median pain VAS of the affected entheses (range) 7 (4–10) 3 (0–7) <0.0001
Ultrasound B mode
Median entheseal thickness in mm (range) 6.9 (5.6–9.8) 6.1 (4–9.8) <0.0001
Entheseal hypoechogenicity (n, %) 27 19 0.002
Peritendinous oedema (n, %) 17 5 <0.001
Bursitis (n, %) 26 15 <0.001
Cortical bone erosion (n, %) 24 24 ns
Enthesiophyte (n, %) 3 3 ns
Ultrasound power Doppler
Median entheseal PD signal (0–3 scale) 2 (0–3) 0 (0–3) <0.0001
Median bursal PD signal (0–3 scale) 2 (0–3) 0 (0–3) <0.0001

VAS visual analogue scale, PD power Doppler signals (graded from 0 to 3)

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Fig. 1  Images of inflamed Achilles tendon before and 6 weeks after
local corticosteroid injection. Thickened hypoechoic tendon with
retro-calcaneal bursa (RCB) before and after corticosteroid injection;
note less hypoechoic tendon with shrunken RB (a, b). Moderate PD
cannot reduce below a certain baseline value; therefore, the
magnitude of change in two parameters is expected to be
different.
No injection-related adverse events in our cohort were
in line with other report on TA injection [6] and recent
meta-analysis [10], where not a single case of tendon rup-
ture was reported. Although local corticosteroid injection
is widely practiced for plantar fasciitis [10], injection for
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Rheumatol Int (2016) 36:875–880
signals in RCB and tendon substance before injection (c) and nil to
minimal PD signal after injection (d). Cortical bone erosion in calca-
neum before and after injection (e, f). Enthesiophyte before and after
local injection (g, h)
Achilles tendinitis is controversial, and a group of phy-
sicians strongly recommend against it. This is because
Achilles tendon is an important structure for the motion of
ankles and feet, and once the tendon ruptures secondary
to injection into the substance of tendon or needle injury,
the ankle movements would be severely compromised.
At the same time, if we focus on the anatomy of Achil-
les tendon [16], a natural distensible space is available in
Rheumatol Int (2016) 36:875–880 879
Fig. 2  Comparison of change
in pain at entheses and tendon
thickness after local corticoster-
oid injection
form RCB, which lies between the Achilles tendon and
the calcaneal bone. The volume of RCB varies from 1 to
1.5 ml [17], which should allow for pressure dissipation
at the time of local injection. Further, the Kager’s fat pad
which lies in front of the bursa may further minimise the
pressure changes [18]. However, the safety of injection at
this site is still dependent on the experience of the physi-
cian and accuracy of needle placement in the bursa. Fur-
ther, repeated injections and puncture of tendon substance
increase the risk, which is more likely to occur with blind
palpation-guided injection.
Though the sample size of our study was small, it was
larger than the previous study on Achilles tendinitis in SpA
patients [6]. Different studies have shown marked vari-
ability in the time period of both clinical and sonographic
improvement, ranging from 1 to 30 weeks [6, 19, 20].
However, according to these studies, significant difference
is appreciable by 4–6 weeks, though some patients may
continue to achieve additional long-term benefits up to
6 months after local injection. In the light of above knowl-
edge, we performed only one post-injection US evaluation
at 6 weeks of follow-up, as we expected to observe signifi-
cant and appreciable changes in tendon thickness and other
inflammatory changes at the local site by this time.
The main strengths of our study are inclusion of homog-
enous group of patients with inflammatory enthesitis and
no inter-observer variability as all US were performed by a
single rheumatologist, on the same machine. The main lim-
itations are the open label design of our study, small sample
size, lack of US evaluation at multiple and an early time
point and lack of control group.
In conclusion, US-guided steroid injection is a relatively
safe and effective treatment modality not only for plantar
fasciitis, but also for Achilles tendinitis, especially when
performed by an experienced physician. It can serve as
the second-line treatment modality for refractory Achilles
enthesitis, more so in resource-poor countries, where very
few can afford costly biologic therapies. However, large
randomised controlled trials are needed to validate our
results.
Compliance with ethical standards 
Conflict of interest  The authors declare that they have no conflicts
of interest.
Ethical approval  All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki Declaration and its later amendments or comparable ethical
standards. The study was approved by the institutional ethics commit-
tee (IEC Code No. 2012-156-DM-EXP5).
Informed consent  Informed consent was obtained from all individ-
ual participants included in the study.
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