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Tuesday, April 17, 2018

Heel Bursitis: Plantar

Hello Dr. Blake,

Kara's (name changed) stress fracture seems to have healed, unfortunately, she has a new problem.  She has pain in her right heel. Her physical therapist has told us that it is bursitis. She is now wearing Birkenstocks.  Is there anything you can do for bursitis?


Dr. Blake's response: 
Here is the section of my book. Rich
Say hello to Kara!!

5. Plantar Heel Bursitis
    A bursa is a sac between the skin and bone that, if the area is traumatized, can fill up with fluid (called bursitis) to protect the underlying bone. Bursitis is common in the feet, knees, hips, elbows, and shoulders. I once had 7 months of shoulder bursitis from incorrect biomechanics while painting a cathedral ceiling in my house. Plantar heel bursitis is often confused from plantar fasciitis. Acute plantar heel bursitis can develop suddenly from impact, but bursitis can also develop slowly from chronic inflammation (typically secondary to plantar fasciitis or calcaneal bone injuries. If you have plantar heel bursitis, you typically can not walk on your heels without pain. Having my patients first walk down the hall barefoot normally, then on their toes, and then on their heels only, can make the diagnosis of bursitis (although a small stress fracture on the heel bone may still be present. One of the treatments for heel bursitis (not initially) is a cortisone shot. Because bursitis can be secondary to something else that the shot may hurt, I try not to do a shot unless I have an MRI if possible. And, sometimes, you just have to take your chances if it does not make sense that anything but bursitis exists. Always consider that you may have bursitis, with plantar fasciitis, if treatment of the plantar fascia alone is not helping.

The top 8 treatments for plantar heel bursitis:
1. 5-minute frozen sports bottle roll just under the heel 3 times daily
2.  Heel cushions to protect the heel (sometimes used alone, and sometimes an arch support to transfer weight off the heel is vital)
3.  Physical therapy to break down the bursa sac with a combination of ultrasound to superheat, deep tissue massage to break down or move fluid, and electrical stim to push fluid out.
4. Cortisone shot, if the above is not eliminating the problem, and an MRI has ruled out any other problem. These shots are given from the side of the heel, not from directly under, which makes them less painful. A series of cortisone shots may be necessary (see the section on cortisone shots). This is the only heel pain diagnosis that a cortisone shot is used for.
5. Avoid barefoot for continual irritation
6. Use some heeled shoe, like a Dansko clog, around the house.
7. Use wedges instead of straight heels to distribute the weight better.
8. Also, consider wearing Crocs for their shock absorption

Heel Bursitis (Plantar/Bottom of Heel): Typical Physical Therapy Regimen

Hi Dr. Blake!
I hope you have a fun-filled long weekend planned! I'm checking in at the two-week mark as we discussed. My stubborn little calcaneal bursitis is still causing me grief. I did try the contrast bath - but it seemed to irritate it, so I've stuck with icing. I have not been jumping in dance class or standing in spin. In fact, releve (going up on the ball of the foot) seems to bug it as well, so I've eliminated turning. Since I wasn't making the progress I'd hope to on my own, I thought I'd finally book the PT. I work in SF so I would consider coming over to St. Francis, but if you know of another good place in the East Bay, it might be more convenient.Thanks so much! It really is wonderful having someone I've known for 24 years (!!) I can come with these bothers. And even though it's an injury that brings me in to see you, it is always great to see you! ;-)
Have a fabulous weekend and talk soon,
Dr. Blake’s response:
    Physical Therapy for calcaneal bursitis (under the heel) should be done twice weekly for 4 weeks and should include in this order: Ultrasound as a way of producing deep heat to the bursitis tissue making it vulnerable to the next two treatments. The ultrasound is following by deep friction massage to break down the bursae. The deep tissue work is following by 5 minutes of vigorous ice massage to calm down any aggravation of the inflammation and further the breakdown process. Since plantar fasciitis is normally part of the problem, the PT may address part of the treatment for that also. If calcaneal bursitis is a major part of the pain, make sure that the 3 components in the order of ultrasound, deep friction massage, and icing are the central part of the treatment. I will see you following the first 4 visits to make sure we are all on the same page. Good luck, and great to see you again as always. Rich
PS. During the time you are in physical therapy, you must continue to ice massage 3 times a day (since the contrast bathing did not help), and do as much physical activity as you can without flaring up the symptoms. It is normally a mistake to go to physical therapy at the same time you are resting an injury completely. The physical therapist never gets a good feel for your improvement or lack of improvement. Use the information on Good Pain vs Bad Pain to base your Activity Modification Program.
Also, the next step with calcaneal bursitis is cortisone shots, but that requires 2 weeks off activity/shot and could require up to 3 shots (the response to the shot is evaluated in 2 weeks), so most athletes try to avoid with a passion. Good luck Tracy, email me after 4 physical therapy visits.

Add from Dr. Blake,
     MRIs are crucial before any thought of cortisone since it can weaken the tissue, especially the plantar fascia. I have given a cortisone shot and had the plantar fascia tear afterward. I have given 100's of these shots though without problems, but I think this possibility should be in the discussion before a shot is done. 

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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.