Image: Heel Horseshoe for Infra-calcaneal Bursitis

1/4 inch Poron used to Create Plantar Heel Bursitis Protection 

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. 

https://youtu.be/plbBvPASXwM

http://www.drblakeshealingsole.com/2015/01/plantar-heel-bursitis-general-treatment_21.html
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." 
https://nwfootankle.com/foot-health/drill/3-problems/159-bursitis-infracalcaneal
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. 

http://www.aapsm.org/members.html#other

Plantar Heel Bursitis: General Treatment Thoughts

Plantar Heel Bursitis

    A bursae 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 a 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 make still be present. One of the treatments for heel bursitis (not initially) is a cortisone shot. Because the 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 make have a bursitis, with plantar fasciitis, if treatment of the plantar fascia alone is not helping.

Elbow bursitis (aka students bursitis from chronic leaning on elbows while studying. Many times heel bursitis looks like the skin wants to explode releasing the fluid trapped.

The top 8 treatments for plantar heel bursitis:

1.  5 minute frozen sport 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 breakdown the bursal sac with a combination of ultrasound to super heat, 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 problem, and a 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 to 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,

Tracy

Dr Blake’s response:

Tracy,

    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 of 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.