bursitis

It is an inflamed bursal sac. A bursal sac is a sac filled with fluid that acts to lubricate and reduce the friction between two surfaces in the body, usually muscles and tendons as they glide over bony prominences, however their purpose in not limited to just muscles and tendons. They may also be found in various pressure points in different parts of the body.

The body contains literally hundreds of bursal sacs but in the foot there is just one naturally occurring (non-adventitious) bursal sac. It is located between the Achilles tendon and the heel bone (calcaneaus), otherwise known as an Achilles tendon bursal sac. Note the yellow circle in the picture below. In this instance the Achilles tendon is protected from the pressure of the heel bone pressing against it when we walk.

In the foot we have a unique situation in that between the shoes that we wear, and the ground that we walk on various parts of the foot are constantly being “micro” traumatized, otherwise known as repetitive stress, meaning that every time we take a step we do a small amount of damage to a particular part of the foot and eventually that part of the foot begins to hurt.

The body’s response to this micro-trauma is to create a bursal sac to initially protect, by cushioning, the area, but if micro-traumatized enough the bursal sac itself becomes inflamed and we have a bursitis.

In the two pictures below, the red circles represent the most common, but not only, sites for inflamed bursal sacs.

• Bursitis Secondary to Hammertoes: Constant rubbing on the tops of the toes from tight shoes can cause an inflamed sac. If left untreated, these can burst or become infected. Learn more about hammertoes.
• Bunion & Tailor's Bunion Bursitis: Commonly found on the side of the big toe joint or the pinky toe joint, caused by pressure against the bony prominences of the foot. See bunion treatments.
• Heel Bursitis (Pump Bump): Occurs on the back of the heel, often due to the pressure of women's dress shoes against an enlarged heel bone.
• Ball of Foot Bursitis: Caused by excessive pressure during walking or running. This often presents as a burning sensation and must be distinguished from a neuroma or capsulitis.
• Bottom of the Heel: Deep inflammation under the fat pad of the heel that often worsens the more a patient walks. Compare with other heel pain causes.

When diagnosing heel pain many times I include heel bursitis as one of the causes of heel pain. In the symptomatic heel if the patient complains that the more they walk, the more the heel hurts, then I have to consider a bursal sac in the heel as part of the problem. Over the years I have actually removed an inflamed bursal sacs from the heel during heel spur surgery.

Symptoms may vary depending of the particular location. Redness and swelling may be evident in a more superficial bursitis such as seen in a bunion or hammertoe, not so much in a deeper bursitis. When first removing your shoes the redness and swelling may be quite evident, but over the course of the next few hours the swelling and redness will subside to some extent, only to return when wearing shoes again. The pain may also have a burning component to it.

CONSERVATIVE CARE

MODIFY YOUR SHOE SELECTION-If the bursitis pain is occurring on the toes, bunion or back of the heel area the smart money would be on eliminating the shoes that seem to aggravate the condition. This means wearing a more conservative shoe that reduces pressure points on your foot. Eliminating these shoes may not in itself clear up the problem but you can be sure that if you continue to wear the offending shoes nothing you or your doctor do will permanently “fix” the problem. A recurring theme that I use throughout this site that if you put an abnormally shaped foot in a dressy shoe it is literally the same as trying to put a square peg in a round hole; it will not fit.

ORAL ANTI-INFLAMMATORY MEDICATION- OK, so you threw away those dressy shoes and the foot still hurts, now what? Depending on the severity of the pain, over the counter anti-inflammatory medication may do the trick. The key here is to take the medication on an ongoing basis, according to the directions on the package to build up therapeutic blood levels. Assuming you can tolerate this type of medication, (see warnings about anti-inflammatory medication under my arthritis section, along with alternative treatments you can try). take the medication for 10-14 days. Stop if the symptoms have not dramatically improved. Keep in mind, this therapy should be considered a short term solution, not a long term solution.

TOPICAL PAIN RELIEVER-Over the counter pain relievers applied topically can be very helpful in reducing the pain. Keep in mind, this is not a cure, but just another option to reduce the discomfort.

ICING-The area during this period may also help reduce the symptoms.

ORTHOPEDIC PADDING-Applying padding around the area will reduce the pressure directly on the inflamed spot and that will help reduce the pain.

ORTHOTICS-If the bursitis is occurring on the bottom of the foot, trying an over the counter arch support may help in an effort to redistribute body weight and take pressure off the painful area, as well as cushion the affected area. If that only affords you some relief, you may have to consider orthotics.

HOW DO DOCTORS TREAT BURSITIS?

• Draining the Bursitis: If the bursal sac is very superficial, a foot specialist can often drain the fluid. While this provides immediate relief, the problem may return if the "offending" cause—such as shoe pressure—is not eliminated.
• Cortisone Injections: These can be highly effective at reducing the inflammation and pain within the bursal sac. In some cases, more than one injection may be required for full relief.
• Prescription Medication: If over-the-counter options aren't enough, stronger anti-inflammatories or oral steroids like prednisone may be prescribed to bring down the swelling.
• Physical Therapy: Often recommended for deeper types of bursitis, physical therapy helps manage inflammation and improve the mechanics of the foot.
• Surgical Intervention: For some, correcting the underlying structural issue—like a bunion or hammertoe—is the only way to permanently stop the bursitis. It is always best to try conservative treatments first before considering surgery.

REFERENCES

Mayo Clinic

Merck Manual

Medscape

Want more information? CLICK HERE