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Thursday, November 12, 2015

Plantar Heel Bursitis: Email Advice

Hi there, 

After seeing your video "Physical Examination of Heel Pain" and reading your "Plantar Heel Bursitis: General Treatment Thoughts", I strongly believe this is what I am suffering from and wanted to get your advice.
I have suffered from heel pain in both heels for around 4 years now, and it has gotten worse over time. My pain is directly under the heel and I can feel some sort of lump that can be moved by pressing it. I have been to 2 different podiatrists, they both told me I have plantar fasciitis without really checking anything or asking any questions. I had 2 different custom orthotics made and modified many times as well as having tried many many insoles. None of that helped. I tried the recommended stretching, icing etc, didn't help. I also had shockwave therapy done, didn't help. Then I had an x-ray and dignostic ultrasound done and they didnt show anything, but I was recommended to go to physiotherapy. I went to physio and they did several things including manual therapy, more shockwave, laser therapy, etc. None of that helped. Then I went to my doctor who referred me to a specialist who sent me for MRI, which again showed nothing. Now I am taking NSAID's which dont seem to be helping. The specialist also assumed I have plantar fasciitis and when I asked about infracalcaneal bursiitis she didnt seem to know what that was and said "there's no bursa under the heel."
She was going to give me corisone injections after I asked for it, but I ended up changing my mind and not getting it since if I really do have bursiitis, then perhaps the injection should be put in a different place?

Theres a few reasons I think I have bursitis and not fasciitis:

1) My pain is directly under the heel and not where the plantar fascia attaches.
2) There is a noticeable lump under each heel that can be felt and moved with pressure.
3) My pain isn't in the morning but hurts after being on my feet for some time and gets worse the longer I stand.
4) None of the usual plantar fasciitis treatments have helped at all or only very little.

So the issue i'm faced with now is that I can't seem to find any practitioner in my area that is familiar with bursitis or even knows what it is in order to tell me whether I have that or not. None of the doctors I've seen have even seemed to be sure if I have plantar fasciitis or not. I'm wondering if I should just go ahead with the cortisone shots even if the doctor is giving me shots thinking it's plantar fasciitis or should I try to find someone who can diagnose me first?

I live in Toronto so if you know anyone in the area that you could recommend that would be greatly appreciated. Or if you have any other advice that would be great.

Dr Blake's response: 
     I am so sorry. Plantar heel, or infracalcaneal, bursitis is extremely common in sports. You have described the place and symptoms perfectly. I typically design an insert to transfer weight to the arch and soften the heel. Yet, I can use OTC inserts, especially Sole or Powerstep, and with a little modifications get this weight transferrance to work. Then, I start the patient doing rolling ice massage 5 minutes with a frozen sports bottle twice daily. If after 2 weeks progress is not being made, 2 times per week PT of Ultrasound, deep friction massage, and EGS with ice is started. Cupping recently has been added to my protocol. The PTs are told to focus on the bursitis, which everyone can feel, and nothing else. If they are not causing the bursa to shrink, I will definitely start the first of 3 cortisone shots (some only need one or two). I use a mixture of 1 ml of 0.5% Sensorcaine and l ml of Kenolog 10. You need to stay away from the plantar fascia attachments and the skin. Each part of this treatment can be essential, so I rarely break that routine. Hope this helps you. See the docs in Toronto from my beloved AAPSM.


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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.