Bursitis is an inflammatory condition that can occur at virtually any joint. When bursitis affects the foot, the most common joints affected are those of the forefoot or ball of the foot. The most common site that bursitis occurs is beneath the second metatarsal head as shown in the picture to the right. The plantar (bottom) aspect of each of the metatarsal heads is marked and numbered. The blue area adjacent to the second metatarsal head is the most common area of the forefoot where we find bursitis occurring.

Bursitis is the result of disproportionate loading of the metatarsal bones of the forefoot (see anatomy below).  When one metatarsal bone is subjected to more load than the adjacent bones, the soft tissue between the head of the bone and the floor will become compressed and will often become inflamed.  Bursitis is the term used to described this form of forefoot inflammation.

Other areas in the foot that are common locations for bursitis include the bottom of the heel and back of the heel at the insertion of the Achilles tendon.

Treatment of bursitis.

Forefoot bursitis -

The first step in treating forefoot bursitis is to find ways to off load the forefoot. Off loading is a simple technique that can be accomplished in many different ways. Felt metatarsal pads and forefoot gel cushions are by far the most popular ways to off load the forefoot. Proper placement of metatarsal pads can be a little tricky at first. We often use Pedag Comfort and Pedag Holiday inserts as a reference for patients trying to place metatarsal pads in shoes. The advantage of the Pedag products is that these particular inserts have the met pad positioned in the correct location in relationship to the metatarsal heads. Simply place the insert in the shoe and the metatarsal pad is properly placed. Once you know how a metatarsal pad should feel, you can use individual felt or foam metatarsal pads much more easily.

Shoes design can also be used to off load the forefoot and relieve symptoms of bursitis. One simple example would be clogs. The rocker sole on clogs has been used for years to off load the forefoot. Orthotics are another method used to off load the forefoot.

Should the methods mentioned for off loading fail to relieve the pain, an injection of cortisone can do wonders to treat bursitis. It's important to realize that forefoot bursitis is a mechanical problem caused by focal loading on one metatarsal head. Logic says that off loading is necessary to decrease load applied to the metatarsal head. Cortisone addresses forefoot bursitis in a little bit different manner. I often compare a shot of cortisone to throwing a wet blanket over the fire without actually knowing why the fire's there. But the bottom line is that cortisone often helps. In many instances, a shot of cortisone can make a problem of bursitis disappear indefinitely.

And lastly, surgical procedures may help in recalcitrant cases of forefoot bursitis. In particular, a metatarsal osteotomy can be used. An osteotomy is a surgical fracture in the metatarsal bone to raise the metatarsal head up and away from the ground thus reducing the forces that contribute to bursitis.

Bursitis of the heel -

Bursitis on the bottom of the heel (infracalcaneal bursitis) is common in heels where the fat pad has tinned over time. The most successful method of treatment is to restore the cushion to the bottom of the heel with a gel heel cushion or custom prescription orthotic modified with a horse shoe cut out and extra foam in the heel.

Bursitis of the posterior heel (retrocalcaneal bursitis) can be helped by avoiding situations where you're barefoot or in just your socks. The lower the heel, the tighter the Achilles tendon becomes. The tighter the Achilles tendon, the more tendency there is to compress the bursa of the posterior heel. Use of a heel lift or shoe with an elevated heel is imperative to the success of treatment. One new product that we've recently been using to treat Achilles tendonitis is a product called AirHeel from Aircast. AirHeel uses an two air bladders that massage the bottom and back of the heel with each step. Intermittent compression from the AirHeel help massage the bursitis and decrease pain.

Both infracalcaneal and retrocalcaneal bursitis may benefit from use of anti-inflammatory medications. On rare occasions, surgery may be required to excise a painful bursa.

Metatarsal - there are five metatarsal bones in each foot. Each metatarsal bone runs from the arch to the ball of the foot. When load is applied to the forefoot, the metatarsal bone carries that load.

Itis - the suffix applied to any inflammatory condition.

Capsule - the soft tissue layer that surrounds any joint. The inner lining of the capsule is called synovium and produced synovial fluid, the fluid that lubricates the joint.

Capsulitis - capsulitis and bursitis are often used interchangeably.  Although one refers to extra-articular tissue and the other refers to articular tissue (capsule), both are used to described peri-articular inflammation.

MPJ (metatarsal phalangeal joint) - the joint between the metatarsal and the toe bone (phalanx, pl., phalange, single.)

Bursa - a small sack that forms as the result of chronic, repetitive inflammation

Bursitis occurs most commonly at the 2nd metatarsal phalangeal joint of the forefoot. This joint consists of the head of the metatarsal, which is covered in cartilage, and the base of the proximal phalanx, or bone of the toe. Numerous tendons traverse the joint and pull like the reins of a horse to guide the motion of the toe. Blood vessels and nerves also pass the joint as they travel to the end of the toe.

The development of bursitis is very dependant upon the relative length of each metatarsal bone. The longer the metatarsal bone, the greater the tendency for bursitis to occur. In the picture to your left, the horizontal yellow lines define the relative length of the first, second and third metatarsal bones of the left foot.  This picture shows how much longer the second metatarsal bone is.  Why is this important?  Let's use a silly example to describe why; take two bamboo poles, one five foot long and another ten feet long. Hook them under your arms and hold them out in front of you , parallel to the ground. Now slowly lower the poles. The longer of the two poles, the ten foot pole is going to hit the ground first, followed by the shorter five foot pole. This is essentially how the long metatarsal bones of the forefoot carry our body weight. With each and every step, this load is repeated. Ideally, we'd like to see that load applied to the foot is applied in such a way that it is equally distributed. Equal, even distribution of load helps to prevent focal loading on any one bone or soft tissue structure. But often we'll see that the bone behind the second toe, called the second metatarsal, is long, just like the ten foot bamboo pole. Repetitive loading of the second metatarsal results in inflammation of the tissue structures beneath the metatarsal head (ball of the foot) and bursitis begins.

Over time, the metatarsal that is sustaining increased load will have one of two outcomes.  In abrupt cases of loading, the metatarsal may sustain a stress fracture.  A stress fracture is the method by which the metatarsal accommodates the load by changing the structure of the bone.  But more common than a stress fracture is an increase in the size and girth of the metatarsal.  The image above shows red markings that define the girth of the second and third metatarsals.  In this x-ray view, the second and third metatarsals should be approximately the same girth.  You can see in the image how the second metatarsal is not only longer (yellow lines) but also larger, (red lines).  This particular image shows how a metatarsal, when subjected to increased load will increase in size to accommodate that load.

The symptoms of forefoot bursitis are particularly noticeable when patients are barefoot on hard surfaces such as hardwood floors or bathroom floors. Pain increases with the time spend on hard surfaces.

It's common to find the symptoms of bursitis in conjunction with other forefoot pathology such as Morton's neuroma and capsulitis. One of the greatest challenges of treating forefoot pain is to differentiate the percentage of symptoms and how those conditions contribute to forefoot pain; how much is due to a neuroma or bursitis, etc.

The symptoms of retrocalcaneal and infracalcaneal bursitis increase with the duration of time on the feet. Pain is relieved by rest. Swelling with retrocalcaneal and infracalcaneal bursitis can be significant.  And in severe cases, a slip or pop can be felt when the bursa moves beneath direct pressure to the back or bottom of the heel.

Forefoot bursitis -

Arthritis

Capsulitis

Forefoot stress fractures

Freiberg's infraction

Gout

Metatarsalgia

Morton's neuroma

Sesamoiditis

Sesamoid fracture

Heel Bursitis -

Achilles tendonitis

Achilles tendon partial rupture

Calcaneal fracture

Gout

 

• Mortons Neuroma

• Metatarsalgia

• Capsulitis

• Forefoot Pain

• Metatarsal Fractures

This article was written by Jeffrey A. Oster, DPM and last updated 10/23/09. No additional information is available for this topic.