Bursitis is an inflammatory condition that can occur at any joint. When bursitis effects the foot, the most common joints effected 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 on this page. 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.

Treatment of 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 achieved in many different ways. Pads and cushions are by for the most popular ways to off load the forefoot. A trip to any shoe repair shop will be a valuable lesson for anyone with forefoot capsulitis. The shoe repair shop can explain the size, placement and logic behind the use of a metatarsal pads. Shoes desgn can also be used to off load the forefoot. 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 mentions for off loading fail to relieve the pain, an injection of cortisone can do wonders to treat bursitis. It's important to realize that bursitis is typically a mechanical problem caused by focal loading on one metatarsal head. Logic says that off loading is necessary. Cortisone approaches the problem from a little bit different direction. 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 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.

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.

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

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

Bursitis most commonly occurs at the 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 length of each metatasal bone. The longer the metatarsal bone, the greater the tendency for capsulitis to occur. 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 reoccurs. 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 benind the second toe, called the second metatarsal, is long, just like the ten foot bamboo pole. Repetative loading of the second metatarsal results in inflammation of the tissue structures beneath the metatarsal head (ball of the foot) and bursitis begins.

The symptoms of bursitis are particularly noticable when patients are barefoot on hard surfaces such as hardwood floors or bathroom floors. Pain increases with the time spend on hard surfaces and seems to decrease with padding. It is by no means unusual to find the symptoms of bursitis in conjunction with other symptoms 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.

Bursitis
Mortons' neuroma
Forefoot stress fractures
Arthritis

This article was written by Jeffrey A. Oster, DPM, C.Ped and last updated 3/24/05.

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