Background & Etiology
There are 28 bones in the foot, and over 30 joints. The bones in the foot include the phalanges, the metatarsals, three cuneiform bones, the cuboid bone and the navicular bone, which make up the arch of the foot, the calcaneus (heel bone), and the talus bone. Joints the foot include the joint, the talonavicular joint, the calcaneocuboid joint, the metatarsocuneiform joints, and the metatarsophalangeal joints.
A bursa is a fluid filled sack that serves to reduce friction between tendons, and between tendons and bone. Bursa are important structures in the joints of the foot because they ensure that the structures of each joint move smoothly. Bursa can become inflamed due to overuse or stress, causing pain and trouble moving the joint comfortably. The major bursa in the foot are the calcaneal bursa, metatarsal bursa, intermetatarsal bursa, and the metatarsophalangeal bursa.
- Calcaneal bursa (Heel): There are two bursa in the back of the foot, near the calcaneus (heel) bone; they are the retrocalcaneal bursa (called the subtendinous calcaneal bursa) and the Achilles bursa (called the subcutaneous calcaneal bursa.) Pain from inflammation of either of these bursa will occur in the back of the foot and heel area.
- Metatarsal bursa: There are bursa located in the metatarsal joints. There are five metatarsal bones in the body of the foot, each of which meets the cuneiform bones at one of the metatarsocuneiform joints. The metatarsal bones play an important role in the propulsion and support of the foot, and damage to the bursa can inhibit motion of the foot.
- Intermetatarsal bursa: There are four intermetatarsal bursa. These are located between the interosseous tendons of the foot, above the deep transverse metatarsal ligament, in the body of the foot. Wearing shoes that are too tight or narrow can cause swelling of these bursa.
- Metatarsophalangeal bursa: The metatarsophalangeal joints occur where the metatarsal bones meet the phalanges or toes. The big toe joint, or first metatarsophalangeal joint, is prone to injury. The bursa associated with these joints can become inflamed causing pain in the toes and front of the foot.
- A direct blow to the bursa can produce inflammation and irritation.
- A fall where one lands improperly on the foot or bursa.
- Constant pressure on the bursa from use of the foot or tight footwear.
- Repeated stress injury to the bursa and tendons (particularly the Achilles) from a high level of activity, which can also cause tendinitis in addition to bursitis.
- Complications from rheumatoid arthritis, osteoarthritis or gout.
- Infection of the bursa or foot.
- Bursa can become swollen as a response to other foot conditions.
- Pain and tenderness over the location of the bursa
- Loss of motion of the foot
- Pain with activities that stress the bursa like walking, jumping, running or activities that cause stress on the tendons that are lubricated by the bursa.
Avoiding activities that produce pain or stress of the bursa and associated tendons (jumping, running, etc.)
- RICE: (Rest, Ice, Compression, Elevation) should be used to reduce the stress on bursa
- The use of ice to reduce inflammation and pain.
- NSAIDS (nonsteroidal anti-inflammatory drugs)
- Physical Therapy
- Drainage of the fluid in the bursa for severe cases. Fluid can be checked for possible infection.
- Antibiotic in the case of infections of the bursa
- Steroidal injections in non responsive cases
- Surgery to remove bursa may be indicated in extreme cases if the problem becomes chronic.
Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals. Physical therapy for a foot bursitis must remain conservative at the onset in order to not aggravate the condition. Emphasis will be in rest, reducing the inflammation and increasing the blood circulation for healing. Once the initial inflammation has reduced a program of stretching and light strengthening will be initiated to restore full motion and improve strength to reduce stress on the tendons and foot joints.
Common Physical Therapy interventions in the treatment of Foot Bursitis include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to regain mobility and range of motion of the foot. Use of mobilization techniques also help to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen muscles of the foot to support, stabilize, and decrease the stresses place on the bursa and tendons of the foot joints.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity and improve movement techniques and mechanics (for example, running, or jumping) of the involved lower extremity to reduce stress on bursa and tendons in daily activities.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold laser and others to decrease pain and inflammation of the involved bursa.
- Home program including strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
In general, patients respond well to conservative treatment of foot bursitis. It is important that once the pain and inflammation is reduced and motion and strength are restored that the patient gradually returns back to full activities. Instruction in daily activities or sport performance is helpful to reduce the chance of a reoccurrence of the bursitis. In most cases full return to activity will take from 2-6 weeks depending on the severity of the condition. As a preventive measure individuals should:
- Make modifications in work or daily activities such as avoiding positions that stress the bursa or wearing protective equipment to avoid prolonged pressure or unexpected blows on the bursa.
- Maintain strength and flexibility to reduce stress on the bursa and tendons of the foot.
- Avoid highly repetitive activities whenever possible.
- The use of appropriate footwear to reduce stress on the tendons, joints and bursa of the foot.