Treatment of capsulitis

The primary goal in treating forefoot capsulitis 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 capsulitis. One example of a shoe that can aid in the treatment of capsulitis would be a clog. The rocker sole on a clog has been used for years to off load the forefoot.

Prescription orthotics are another method used to off load the forefoot. Special modifications can be built into orthotics to accommodate areas of capsulitis.

Should the methods mentioned for off loading fail to relieve the pain, an injection of cortisone can do wonders to treat capsulitis. It's important to realize that forefoot capsulitis 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 capsulitis 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 capsulitis disappear indefinitely.

And lastly, surgical procedures may help in recalcitrant cases of forefoot capsulitis. In particular, a metatarsal osteotomy is used to elevate the metatarsal and reduce the symptoms of capsulitis. An osteotomy is a surgical fracture in the metatarsal.

The following images show the steps used to complete a Jacoby osteotomy of the second metatarsal. Variations to this procedure may include the type of osteotomy or methods of fixation. Image 1 shows the location of the metatarsal head and planned incision. Image 2 shows the dissection of the extensor tendons and capsule of the second metatarsal phalangeal joint. Images 3 and 4 show isolation of the second metatarsal in preparation for the osteotomy. Image 5 and 6 show the V shaped osteotomy completed and ready for fixation. And image 7 shows final closure of the surgical wound.

This procedure is completed in a hospital or surgery center using a general anesthetic or local with sedation. The procedure takes about 30 minutes to complete. Patients may be partial to full weight bearing following this surgery. Most patient will require some form of walking cast to protect the osteotomy. Fixation is removed at three weeks. Most patients are back to 100% of full activities by 12 weeks post-op.

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.

The distal portion of the forefoot consists of the 1st mpj and the lesser mpj's (2-5).  The great toe joint (1st mpj) is a bit unique in that the anatomy of the great toe joint is a bit different than that of the lesser mpj's.  To a degree, the lesser mpj's act independently of the 1st mpj.  Therefore , any discussion of forefoot conditions should be broken into those problems specific to the 1st mpj and those problems specific to the lesser mpj's (2-5).

The following is a list of common forefoot conditions.  To find more information about these conditions, follow the highlighted link.

Forefoot conditions specific to the 1st mpj.

    1. Bunion
    2. Gout
    3. Hallux limitus
    4. Hallux rigidus
    5. Pseudogout
    6. Sesamoiditis and sesamoid fractures
    7. Turf toe

Forefoot conditions specific to the lesser mpj's (2-5).

    1. Bursitis
    2. Capsulitis
    3. Freiberg's Infraction
    4. Metatarsalgia
    5. Morton's Neuroma
    6. Metatarsal stress fractures