Many of the injuries that hamper runners are the result of small, seemingly insignificant bits of tissue becoming aggravated. This is certainly the case with bursitis, an injury that can affect a number of different locations in the runner’s lower body. As much as we convince ourselves that we are being smart with our training, most of the time, we know deep in our hearts that this hip pain, knee pain, or heel pain while running is something that we cannot just ignore. A bursa is a small, fluid-filled, sac-like structure that serves to lubricate the motion of tendons and joints during activity. As is the case with any biological structure, when subjected to excessive stress, a bursa can become aggravated. Today we are going to look at the three types of bursitis; hip, knee, and heel. We will describe the symptoms of bursitis in your foot, knee, and hip, and give you the best way to treat bursitis from running. Realistically, all we want to know about is can I continue to run with bursitis? The treatment for bursitis as well as the recovery time will vary depending on whether it is hip, knee, or heel bursitis, but let’s see how specific we can make it for you. In distance runners, bursitis is sometimes provoked by acute injury—tripping on the curb and landing on your hip, for example—but it more often arises from overuse. A 1996 paper in the Mayo Clinic Proceedings cites data showing that between 23 and 64% of patients with greater trochanteric bursitis can recall a specific injury that set off their problems; much of the remaining proportion can be ascribed to being overuse injuries.1 This proportion is likely far greater in runners. There are over 150 bursae (the plural of bursa) in the human body,2 but distance runners tend to aggravate just three of them: Greater trochanteric bursa at the hip Retrocalcaneal bursa at the back of the heel Pes anserinus bursa along the inside of the knee Greater Trochanteric (Hip) Bursitis As noted by Mohammad Shbeeb and Eric Matteson at the Mayo Clinic,1 greater trochanteric bursitis can involve any one of three bursae that lie close to the greater trochanter of the femur, the angled point where the bone turns inward towards your hip. These bursae function to lubricate the IT band, the gluteal muscles, and the tensor fascia lata, which converge at the greater trochanter. Hip bursitis symptoms and causes of trochantertic bursitis Greater trochanteric bursitis causes aching, long-standing pain centered around the greater trochanter of the femur. Various hip motions might aggravate the pain, as can sleeping on the affected side. One hallmark sign is tenderness to the touch over the greater trochanter of the femur.1 Of course, hip pain while running is another symptom of bursitis in the hip that many runners are familiar with. Among the bursa injuries sustained by runners, greater trochanteric bursitis appears to be the most common. According to a review of 2,002 cases of running injures seen at a sports medicine clinic in Canada, greater trochanteric bursitis from running was seen 23 times, representing 1.1% of all running injuries.3 Though it’s hard to be certain with such a small sample, trochanteric bursitis appears to be more common in women than men—14 versus nine cases of the injury were seen in women and men, respectively. This female/male ratio of 61% to 39% is approximately in line with the sex differences seen in other injuries linked to faulty hip mechanics, like IT band syndrome (62% to 38%) and patellofemoral pain syndrome (also 62% to 38%), which intimates that greater trochanteric bursitis could be linked to weak hip abductors and external rotators. This, combined with data from a 2005 study by researchers at the University of Minnesota which found that running injury rates overall were linked with hip weakness,4 indicate that hip strength, particularly of the abductors and external rotators, should be a core part of any rehab program for greater trochanteric bursitis. Shbeeb and Matteson’s review of the injury also notes that a number of other injuries can be associated with greater trochanteric bursitis, though it’s hard to establish causality given how little research there is on the condition.1 Iliotibial band syndrome, hip and thigh weakness, leg length discrepancies, and tendonitis of the abductor and external rotator muscles are all mentioned as possible contributing factors to greater trochanteric bursitis. How to treat hip bursitis from running When it comes to what to do for hip bursitis, Shbeeb and Matteson reiterate that physical therapy, especially strengthening and stretching of the hip muscles and lower back, should be an integral part of rehab. In some cases, they recommend an injection of a mixture of a corticosteroid and a local anesthetic—typically methylprednisolone and lidocaine, respectively. Shbeeb and matteson reported that approximately 60% of patients experienced relief after an initial injection (some other patients required multiple injections). A 1985 report published in the Scandinavian Journal of Rheumatology reports similar success rates—two-thirds of patients treated by a corticosteroid injection reported excellent results, though these patients were mostly older women who were not athletes.5 Surgery is an option as a last resort for recalcitrant cases of greater trochanteric bursitis. Surgery might involve releasing the IT band to take pressure off the bursa, or removing the bursa itself. It’s unclear how this would affect your ability to return to running; that’s something you’d need to talk about with a trusted doctor. Can I run through trochanteric bursitis? It is not recommended, but if your hip pain running symptoms do not get any worse, proceed with caution and pay attention to how your hip reacts following a run. If you can find a medical professional you can trust in your area, they will be able to give you the best advice on whether you can run through your hip pain from trochanteric bursitis. Retrocalcaneal (Achilles Heel) Bursitis The retrocalcaneal bursa sits along the back of your heel, just above where your Achilles tendon inserts into your heel bone. Like the greater trochanteric bursa, its role is to allow the tendon above it to glide along without friction. Retrocalcaneal bursitis often occurs in conjunction with insertional Achilles tendonitis. Running with bursitis in your heel becomes especially tricky as once your achilles is aggravated, it can require months of treatment to calm it back down. Heel bursitis symptoms and causes of retrocalcaneal bursitis The principle symptoms are pain at the base of the heel, especially when accompanied by swelling, redness, or warmth in the area. Pain can sometimes be reproduced by pinching the Achilles tendon at its insertion.6 One possible contributing factor to retrocalcaneal bursitis is presence of Haglund’s deformity, a bony spur that projects from the back of the heel. This bone growth can, in some cases, aggravate the bursa. Traditionally, Haglund’s deformity was seen as an ipso facto cause of retrocalcaneal bursitis and insertional Achilles tendonitis, but more recent research has demonstrated that plenty of healthy people have Haglund’s deformity too.7 Regardless, you should be aware that a prominent bump on the back of your heel can impinge on your retrocalcaneal bursa if you wear shoes with a rigid heel counter or high heels. Kristin Marvin talked about this in further detail on our podcast, where she discussed how our lifestyles are in fact what cause our injuries, rather than the training itself. High and rigid heels are so well-known as an aggravator of the retrocalcaneal bursa that a prominent Haglund’s deformity is sometimes known as a “pump bump.”8 Injuries to the insertion of the Achilles tendon make up 20-24% of all Achilles tendon injuries.9, 10 How to treat heel bursitis from running It is not clear what proportion of insertional Achilles tendon problems involve the retrocalcaneal bursa, since it can be very hard to disentangle the two conditions, given the proximity of the tendon insertion to the bursa. Because of this, the ideal treatment protocol for retrocalcaneal bursitis is different to knee and hip bursitis. In this case, injecting corticosteroids is a decidedly bad idea—evidence from both animal studies11 and case reports in humans12 testifies that corticosteroids injected into or near the Achilles tendon degrade its structural integrity, increasing your risk of a tendon rupture. Ouch. One possible alternative that may not increase the risk of rupture is iontophoresis, a process that uses electricity to drive anti-inflammatories into your skin. A 1999 study in the Southern Medical Journal demonstrated that corticosteroid iontophoresis did not have the same tendon-degrading effects as a corticosteroid injection on rabbit tendons.13 Ultimately, treatment should be similar to that of insertional Achilles tendonitis, which is best treated with a rehab program centered around the flat eccentric heel drop. This exercise was devised by researches in Sweden who were attempting to figure out why the standard eccentric heel drop used to treat midpoint Achilles tendonitis with great success was so ineffective at treating insertional Achilles tendonitis.14 The researchers hypothesized that doing heel drops on a flat surface as opposed to off a step could be the key—by preventing the heel from dropping below the ankle, the maximum tensile stress is directed to the Achilles insertion. Here’s the deal: Because retrocalcaneal bursitis, Haglund’s deformity, and insertional Achilles tendonitis tend to occur in various combinations with each other, the pilot study examining the flat eccentric heel drop included patients with all three problems, so long as they all had long-standing pain at the Achilles insertion. The protocol (three sets of 15 flat eccentric heel drops twice daily, adding weight once the exercise is pain-free) worked quite well. Ready for the good news? Researchers found that 67% of the patients were able to return to their pre-injury activity levels within four months—far better than the 32% seen in other studies. If you are wondering about running with bursitis in your foot or heel, this will depend on how severe your heel pain is, and to what extent it is combined with achilles tendonitis. If running makes either your bursitis or achilles tendonitis worse, stop running until you are able to run without pain. This could take as much as a few weeks or as little as a few days. We have advice for how to find a medical professional you can trust in your area, and will be able to assess the severity of the damage to give you the best advice on whether you can run through your heel pain from retrocalcaneal bursitis. In the meantime, we would recommend you get started on the treatment for insertional achilles tendonitis to give that a chance to help you. The last thing you want is a ruptured achilles, and Brad Beer has some great advice on how to know what pain to run through, and when to stop and rest. RunnersConnect Insider Bonus Struggling with Retrocalcaneal bursitis? Download our Achilles Injury Prevention Routine inside your Insider Members area. It’s a PDF with images and descriptions of the 10 most effective prevention and rehab exercises for runners with Achilles issues. Not a RunnersConnect Insider member? It’s FREE to join. Click here to get your guide and get started Pes Anserinus (Knee) Bursitis The pes anserinus bursa lies underneath the “goose foot” where the tendons of your adductor muscles attach to the inside of your knee. As with the other often-injured bursa in runners, the pes anserinus bursa allows these tendons to glide along as you run. Like with retrocalcaneal bursitis, knee bursitis from running, or damage to the pes anserinus area is often more complex than a simple irritated bursa. Some authors advocate the term “anserine syndrome” because bursitis often coexists with injury or aggravation in the tendons as well.15 Knee bursitis symptoms and causes of pes anserinus bursitis Pes anserinus bursitis causes pain along the inside edge of the knee. There may be tenderness or swelling at the inside of the knee, and any weight-bearing exercise that involves repeated knee flexion and extension, like climbing or descending stairs, can be painful.16 As noted by W.J. Rennie and A. Saifuddin in the United Kingdom, this pain can mimic that of a medial meniscus tear. Now: Pain directly along the “line” of the knee joint may in fact be a meniscus tear instead of pes anserinus bursitis—the bursa lies slightly further down your leg.17 If you are unsure, you should find a medical professional you can trust using our guide and get an MRI, which can rule out a meniscus tear. How to treat knee bursitis from running Given the rarity of pes anserinus bursitis and the limited research on athletes, how to treat knee bursitis from running is not clear, nor is the knee bursitis recovery time. So what’s the best way to treat knee bursitis? It stands to reason that a physical therapy program consisting of stretching and strengthening exercises should help. A 2010 article by Milton Helfenstein Jr. and Jorge Kuromoto in the Portuguese medical journal Revista Brasileira de Reumatologia recommends treatment with ice packs, physical therapy, and anti-inflammatory medication. The authors also mention that using a pillow or cushion between your legs while sleeping may take some pressure off the affected area if you sleep on your side.15 As for rehab exercises, Helfenstein and Kuromoto recommend stretching and strengthening the adductors and the quadriceps, particularly in the final 30 degrees of knee extension (from a straight knee to a 30-degree knee bend). In the admittedly limited scientific literature on treating pes anserinus bursitis, anti-inflammatory injections seem to be the most common treatment. Helfenstein and Kuromoto write that corticosteroid injections may be used, but caution that they must not be injected into the substance of the pes anserinus tendons themselves—presumably because of the well-known risk of rupture. As a last resort, surgery to drain or excise the bursa is also an option. You might be wondering, can I continue to run with knee bursitis? As there is so little research on pes anserinus bursitis, whether you can run through it will depend on your individual circumstance, and how your body reacts to running. Listen to this podcast episode with Brad Beer, who describes how to know which pain to run through and when to stop running. However, for most runners, continuing to run will just increase the inflammation (and no, taking ibuprofen will not help!) and it will mean it takes longer to recover. Better to rest up now, than take longer later. It may not give you answer you are looking for, but will get you back to running healthy sooner. RunnersConnect Insider Bonus Download our full Knee Pain Prevention Routine inside your Insider Members area. It’s a PDF with images and descriptions of the 10 most effective prevention and rehab exercises for runners with Knee issues. Not a RunnersConnect Insider member? It’s FREE to join. Click here to get started What’s the Best Way to Treat Bursitis for Runners? When dealing with greater trochanteric, retrocalcaneal, or pes anserine bursitis, the location of the injury makes a big difference when it comes to the optimal treatment. Though there is an aggravated bursa involved in the injury process of all three, the underlying causes and nearby tissue necessitate a unique approach to each. What exercises should you do if you have hip pain? Greater trochanteric bursitis should be treated by stretching and strengthening the hip and low back muscles, with an injection of a local anesthetic or corticosteroid if the pain does not abate after conservative treatment. You should also be aware of other injuries that can contribute to or coexist with greater trochanteric bursitis, like IT band syndrome and gluteal muscle tendonitis. In the case of retrocalcaneal bursitis, a corticosteroid injection could have harmful effects, given the proximity of the Achilles tendon: the risk of a rupture is well-documented in the literature. Iontophoresis of a corticosteroid is a possible alternative, but the mainstay of treatment should be the flat eccentric heel drop protocol devised by Jonsson et al. Three sets of 15 eccentric heel drops on flat ground twice daily, adding weight once the exercise is pain-free. Try to avoid shoes that aggravate your retrocalcaneal bursa, like high heels and anything with a stiff, rigid heel counter. Pes anserinus bursitis appears to be the rarest and least-well-understood of the three common bursa injuries in runners. Stretching and strengthening the quadriceps and adductor muscles is a good place to start, and case reports cite success using a corticosteroid injection into the bursa to relieve pain and inflammation. It’s unknown whether the pes anserinus tendons are at risk of damage from corticosteroid injections, so talk to your doctor about the potential for degradation or rupture of the tendon. The pes anserinus bursa is close to the skin’s surface, so iontophoresis may also be an option. In all three cases, surgery should be reserved for long-standing recalcitrant cases that do not respond to several months of conservative treatment. If you seek out this option, see a trusted doctor who works with runners or other athletes. Original article and pictures take https://runnersconnect.net/running-injury-prevention/bursitis-pain-running/ site
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