BURSITIS
Bursae are closed sacs or pouches containing fluid, found in all
parts of the body, covering and protecting exposed or prominent bony
surfaces, and interposed between tendons and parts over which they
play. They serve as protective cushions to prevent physiologic wear and
tear.
There are two varieties of bursae found in the human body: the bursae
mucosae, those secreting a mucous or a gelatinous substance, and the
bursae synovia, those secreting a thin, viscid substance, and which are
similar in structure to synovial membranes.
The principal form of bursae found in the foot is of the synovial type
and for this reason the treatment of this variety is that discussed
in this chapter. Bursae may be either deep-seated or subcutaneous and
the latter variety are those which, through trauma, usually become
inflamed and troublesome in the regions of the foot. The deeper seated
bursae, however, often become involved in a pathologic process, and
the podiatrist is called upon to treat these cases as well as those
involving subcutaneous variety.
=Definition.= Bursitis is an inflammation of the bursa sac. The
inflammation may be acute, subacute or chronic. Acute bursitis is a
condition in which the general inflammatory symptoms are active, the
course short, and in which the overproduction of synovial fluid has
found an outlet and is discharging on the surface of the skin. Subacute
bursitis is a condition in which the inflammation has not reached a
true acute stage, but in which it is more in evidence and more active
than in the chronic form. Chronic bursitis is a condition in which the
inflammation is long standing and of an inactive nature and where no
great amount of overproduction of synovia is in evidence. In chronic
cases the walls of the sac itself are generally found thickened and
leathery; where this condition occurs in the bursa over the first
metatarsophalangeal joints it is often inadvertently called a “bunion”.
[Illustration: ACUTE BURSITIS]
=Etiology.= Bursitis occurring in the foot is in nearly every instance
due to trauma. A blow, a knock, a part being stepped on, or the
continued pressure of an ill-fitting shoe, may be the exciting causes
of this disturbance. Malalignment of a joint may be a secondary cause,
such as would occur in hallux valgus. In this instance the deep-seated
bursa would be affected. Bursitis would hardly develop from this alone,
however, and the exciting cause is found in the pressure of footgear or
some other injury to the part.
=Location.= As bursa sacs are only found covering a bony prominence,
or interposed between the sheaths of tendons and muscles, or between
these structures and the skin, serving in each capacity to prevent
physiologic wear and tear, bursitis occurring in the foot will be found
in these locations.
The first and fifth metatarsophalangeal joints (metatarsophalangeal
bursitis); the interphalangeal joints of the toes (interphalangeal
bursitis); the posterior and outer surfaces of the os calcis
(retrocalcaneal bursitis); and the tarsometatarsal region on the dorsum
of the foot (dorsal bursitis) are the principal sites of occurrence.
The base of the fifth metatarsal is also a spot over which bursal
inflammation will occasionally develop.
=Pathology.= The pathology of bursitis is primarily that of any
inflammation. Due to trauma, the parts are subjected to a severe
irritation which causes an engorgement of blood in that location.
Serous infiltration of the tissues takes place and the functional
activity of the sac is increased. Materials from the blood for the
production of synovia, are secreted in abnormal amounts, and in
consequence the sac becomes distended from the superabundance of fluid.
In time this fluid must find some outlet, for synovia is secreted
so rapidly that the lymphatic system cannot absorb the excess. This
outlet must naturally develop toward the point of least resistance,
which, in these cases, is outward toward the periphery. The tissue
is broken down to a small extent and a minute sinus is formed which
permeates the tissues and opens upon the surface of the skin. From the
peripheral opening the excess of fluid is thrown off, and when this
stage is reached the distension in the part is naturally lessened and
the patient is fairly comfortable.
=Symptoms.= _Objective Symptoms._ The parts will be found considerably
swollen, red and hot. Loss of function is noted and fluctuation is
present.
_Subjective Symptoms._ Pain on slightest pressure and at times upon
forced movements; impaired function; heat, and a feeling of fullness or
distension in the part.
=Characteristics.= The characteristics of bursitis, whether acute or
chronic, are so plain that no error in diagnosis should ever be made.
However, many of these cases are mistaken for suppurated helomata,
probably through the fact that both are conditions in which a discharge
is present. Why this error should be made is a mystery, for while it is
true that there is an exudation in both instances, the characteristics
of the discharges are so different that only a careless or
inexperienced person could mistake one for the other. The important
characteristics are:
(1) The distension in the bursa sac proper causes a swelling of the
parts adjacent and superjacent so that the whole area over and around
the affected part will be found enlarged and puffy. Fluctuation is
present and often the sac itself may be grasped in the fingers, so
distended are its walls.
(2) Removal of the overlying calloused area, should one be present,
brings to view the sinus opening, in the acute stage. The tissues
are blanched in appearance and are leathery and hard to digital or
instrument touch. The opening of the sinus is usually very small
and its edges are circumscribed and even. The sinus itself has the
appearance of a healthy granulating surface and at no time is there
apparently any membranous lining. Probing will determine that the sinus
follows an almost vertical course with no sub-borrowings or offshoots
in any direction. There is no loss of tissue upon the surface of the
skin, such as would be found in connection with an heloma involved in a
suppurative process, except at the opening of a canal.
(3) Digital pressure exerted laterally and anterio-posteriorly usually
is rewarded by the oozing of a thickish, viscid, almost colorless
fluid from the sinus opening. There is nothing in the appearance of
this fluid that should lead one to mistake it for pus. Very often this
fluid oozes from the part of its own volition, due probably to the
pressure of the excess fluid in the sac beneath. The fluid causes no
active decomposition of hydrogen dioxide and the ebullition caused by
the contact is almost negative. This constitutes one more point of
differentiation between the changed synovial fluid discharged from an
acute bursitis and a pyogenic exudation.
=Treatment.= The treatment of bursitis varies according to the degree
of inflammation, and the general conditions present. We may divide the
treatment into three classes: the radical operative, the non-radical
operative, and the palliative. The first mentioned is a purely surgical
procedure, complete in itself, and consists in the removal or curettage
of the inflamed sac. The last two are usually combined and are
procedures which are generally practised by the podiatrist.
=The Radical Operative Treatment.= Under proper aseptic conditions an
incision is made in the overlying tissues and the sac is removed in its
entirety; the parts are then sutured, and a few days rest and elevation
of the foot brings complete union. This method may be varied in that
the sac is not removed, but a free incision is made into it and the
parts thoroughly curetted. One other of the purely surgical procedures
is to make a free incision into the sac to accomplish thorough
drainage. This latter procedure is generally practised in cases of
infected bursitis.
Inasmuch as the non-radical operative and the palliative methods of
treatment are purely podiatry procedures and are usually combined, they
will be discussed as one subject.
=The Non-Radical Treatment.= There are several methods by which
bursitis in its various stages may be successfully treated. They vary
in some details but all agree on two most important points: rest and
the absence of pressure.
A bursitis developing over a bony prominence upon the foot, usually
occurs in connection with some form of superficial callosity or an
heloma. The inflammation of the sac may be due to the neglect of a
growth of this nature, or, as previously explained, to some distinct
injury to this part.
To successfully treat a condition of this nature it is found necessary
at all times to accomplish the removal of the excrescence. This is done
in the usual manner by either the shaving or dissection method. These
growths must be removed for several reasons:
(1) To remove all hardened and thickened epidermis so that no further
irritation from that source will be present.
(2) To allow the operator a chance to effect drainage for the
overproduction of bursal fluid.
(3) To allow the medications used to come in direct contact with the
underlying tissues without the necessity of penetrating several layers
of epidermis and expending their action upon and through them.
Under proper aseptic conditions, the superficial thickened epidermic
layers are removed and the excess fluid is allowed to drain off. It
will often be found that the callous forms a “plug” which extends down
into the surface opening and prevents this excess fluid from being
thrown off. Once this drainage is accomplished, other procedures,
dependent upon conditions present, should be utilized for the
alleviation and cure of the bursitis.
=Rest.= By far the most effective means of bringing about a speedy
cessation of the inflammation occurring in the bursa sac is to procure
absolute rest for the part involved. It has been noted that in a number
of cases when no medical or surgical treatment has been afforded,
inflammations of this nature resolve themselves speedily upon complete
rest. There is nothing remarkable or supernatural about this for
inasmuch as the bursa is only used during the movements of a part, it
is easily understood why a trouble of this nature will clear up rapidly
if the part is kept immobile.
=Removal of Pressure.= There are many cases of bursal inflammation
which occur in people who are not able to lay up and give complete
rest to the affected part. The next most effective measure in these
cases is the judicious and proper use of shielding. In applying a
shield to a case of this nature it should always be remembered that
the parts affected are usually swollen to a considerable extent around
the tissues immediately overlying the sac itself. For this reason a
shield such as would be employed for the protection of an heloma in a
like situation, is not practical. This is more particularly the case
where the bursitis is located on one of the interphalangeal joints of
the toes. In this location an individual shield which is to rest on
the affected toe alone cannot be applied, for the whole area overlying
the inflamed sac will be found swollen and leathery and the tissues
anterior and posterior, as well as those covering the interdigital
surfaces of the toe, are ordinarily more or less involved in the
general inflammation. In this instance, then, we must resort to some
sort of shielding which will take the shoe pressure from the part, and
yet which will be distributed over the whole digital surface and not on
the diseased toe alone. A dorso-digital oval or crescent shield (see
chapter “Shields and Shielding”) answers the purpose and is entirely
effective in most instances.
Probably the most practical method of removing all pressure from the
inflamed areas is to have a circular portion of leather immediately
overlying the part removed from the shoe and another softer piece
adhered over the opening. The appearance of this will be inconspicuous
and the small pouch thus formed allows the patient to wear a shoe,
affording comfort, which, however, exerts no pressure upon the lesion.
It is wise to remove a piece of leather considerably larger than the
circumference of the affected part, otherwise the edges of the aperture
cut in the shoe may become depressed and press upon and irritate the
already inflamed areas.
=Strapping.= Enlarging upon the theory of rest, inasmuch as complete
absence of movement aids materially in reducing the local irritation,
strapping is a practical means of immobilization.
This procedure, although used in these situations, is not so practical
in bursitis occurring over the first and fifth metatarsophalangeal
joints, or over the interphalangeal joints, as it is in other locations
upon the foot.
Adhesive strapping is applied in such manner and at such tension as
to accomplish almost complete immobilization, and for this reason it
will be readily seen that this method cannot be used in cases where the
added pressure will produce additional irritation. Several lengths of
adhesive plaster are placed over the part and adhered tightly to the
surrounding integument so that very little or no movement is allowed in
the affected part.
Strapping, to prevent movement, is particularly effective when the
bursitis has occurred in the os calcis region between that bone and the
tendo Achillis (retrocalcaneal bursitis). The foot is placed in plantar
flexion and a long strip of 1¹⁄₂ or 2 inch plaster is anchored at the
centre of the upper part of the calf and is then carried down over the
heel on the plantar surface of the foot. This strip is then reinforced
by transverse straps applied over the heel at the insertion of the
tendon.
Aside from these general methods of procedure thus discussed, the
podiatrist must resort, in a majority of cases, to local treatment
which will hasten the ultimate resolution of the inflammatory process.
These local methods of treatment are conveniently divided into six
groups:
1. Hydrotherapeutic measures.
2. Moist and wet dressings.
3. Unguent dressings.
4. Counter-irritation.
5. Massage.
6. Electricity.
=Hydrotherapy.= Hydrotherapeutic measures may be resorted to in the
treatment of bursal inflammations and either thermal extreme may be
used with equal results. As one person will react to one extreme more
readily than to the other, the choice of heat or cold usually depends
upon the individual case.
=Hot Applications= are probably most practical in these instances in
the form of compresses. Several thicknesses of gauze, saturated in
water, as hot as can be borne, are applied over the affected areas, the
hot water being replenished as soon as the compress commences to cool.
Hot applications act as mild poultices and their action is similar to
them in a limited and modified form. They tend to hasten resolution
of the inflammatory process by accelerating absorption. It is unwise,
however, to continue hot applications for too long a period; it is
found preferable to have the patient apply hot compresses for periods
of one hour duration two or three times a day, allowing the part
complete rest in the intervals.
Hot compresses, applied continuously for some hours, are apt to bring
about an over-stimulation in the parts to such an extent as to produce
a slough. To be effective, it must be remembered that the compress
must be kept hot for the entire period of application. This may be
accomplished by immersion in hot water, by moistening intermittently,
or by keeping the compress covered with some heat-confining covering.
In the latter instance, oiled silk is in all probability the most
practical agent, but even the use of an impervious covering does not
relieve the patient of the necessity of remoistening the compress with
hot water, at frequent intervals.
[Illustration: INFECTED BURSITIS]
=Cold Compresses=, as here advised, are either applications of cold
water on a compress of gauze or some similar material, kept constantly
wet, the use of ice bags or packs, or a cold water drip. The surfaces
of the foot, particularly if the bursitis be on the toes, are so
small, however, that as a general rule, ice bags or packs are not
practical. The cold produces anemia of the parts by contracting
the calibre of the blood vessels, and forcing the blood from the
capillaries. They also tend to anesthetize the nervous sensibility
and are in that way also pain reducing. There is one bad feature,
however, in the use of cold as a hydrotherapeutic agent. The resulting
reaction, which is generally bound to occur, gives the patient
considerable annoyance and is apt in time to increase the infiltration
and distension in the part. Again, should the patient have any tendency
toward chilblains, the moist cold is almost always sure to develop the
tendency into a reality.
=The Poultice= is the older and now obsolete method of applying moist
heat to a part. The stimulative action of this form of application is
at times so severe as to cause deleterious effects upon the diseased
tissues. A cataplasma should never be used where a distinct loss of
tissue is in evidence, in the presence of pus, or where the vitality
of the parts is considered to be subnormal, either from the age or
condition of the patient, or because of the diseased condition of the
part.
The most generally used materials in this connection are flax-seed, and
slippery elm, and the most practical manner for preparing a poultice
for use in podiatry is to make several small bags (about two or three
inches square) from cheesecloth or some like material. These are filled
half full with the meal and are dropped into a vessel containing
boiling water. The bags and their contents are allowed to boil for
eight or ten minutes and are then applied to the part as hot as can
be borne. This method does away with the rather “messy” procedure of
laying a cloth on the part and then applying the warm mass by means of
a spatula, spoon or like implement; also the poultice, so made, may be
used again and again. The usual method of procedure in using poultices,
when recommended, is to have the patient apply them continuously for
about an hour during some part of the day. It is found much more
effective to have moist heat applied for a longer period at one time
than to apply three poultices a day, one in the morning, one at noon,
and the last at night. The patient removes one bag as soon as it starts
to cool and replaces it with another taken hot from the boiling water.
This form of treatment, of course, tends at first to increase the
overproduction of synovial fluid, and proper drainage must at all times
be preserved so that this excess may be carried off.
=Baking.= With the development of the modern baking apparatus,
this method of applying heat to a part has come into use in cases
of subacute or chronic bursal inflammations. The heat applied by
this means is dry, in contradistinction to that obtained from hot
applications of water and from poultices. As the synovial bursae are of
similar structure to the true synovial membranes of the joint cavities
and capsules, they are subjected to similar ailments. It stands to
reason, therefore, that if baking is beneficial in several forms of
arthritis, it is also beneficial in some forms of synovial bursitis.
Some podiatrists have baking apparatuses installed in their offices;
where this is not the case it is recommended that, when such treatment
is thought advisable, the patient be sent to some hospital or institute
where this treatment can be administered. Baking serves as a hyperemic
agent (to bring an abnormal supply of blood to the part) and in this
way to aid in the more rapid absorption of the exudates in the affected
region.
=Moist and Wet Dressings.= In conditions of acute bursitis, an
efficient means of reducing the inflammatory symptoms is found in
the use of wet dressings. Moist dressings (those with mackintosh
protection) should not be used in these cases when the skin is broken,
when there is any suspicion of a discharge, or where infection is
present.
The agents which may be used with such wet dressings are mercury
bichloride, liq. aluminum acetate, saturated solution of boric acid and
alcohol, equal parts, and lead and opium wash.
=Mercury Bichloride= may be used as a wet dressing in all cases of
acute bursitis, but more particularly where infection is present. It
should never be used with mackintosh covering, for even without the
confinement thus afforded, its action serves to macerate the skin to
a great extent. The solution may be used either hot or cold and in no
instance stronger than ¹⁄₄₀₀₀. This strength solution should only be
resorted to in cases where the infection is acute and has progressed
to some extent, weaker solutions, ¹⁄₅₀₀₀ or ¹⁄₁₀₀₀₀, being found
efficient in a majority of cases. Mercury bichloride, on account of its
toxic properties, should not be used after the infective process has
been reduced, and there are many arguments in favor of an efficient
substitute for it even in the initial instance. However, no solution
which is practical for use in these cases can be depended upon for
beneficent results as surely as corrosive sublimate. In chronic bursal
inflammations, corrosive sublimate is contra-indicated.
=Liq. Aluminum Acetate= can be used in place of bichloride of mercury
in many cases of acute bursitis. The solution is decidedly astringent,
and while this action is to be desired at times, nevertheless it
has been found detrimental in the treatment of some cases of acute
bursitis, because when it penetrates through the sinus into the bursal
sac it has been found to create a decided irritation upon these deeper
tissues. Liq. aluminum acetate, therefore, is shunned by many in the
treatment of these cases, but aside from this one detrimental feature,
the action of the acetate is efficient and is productive of good
results. The drug may be used plain, or diluted with sterile water to
reduce its irritant, astringent qualities. A dressing of liq. aluminum
acetate, like bichloride, should never be confined in a mackintosh
covering, as it will macerate the skin, quickly and thoroughly.
This solution is particularly effective in subacute cases where no
infection is present when its astringent action goes far to reduce the
infiltration in the parts. It should be applied cold.
=Boric Acid-Alcohol Solution= may be used in all cases of acute or
subacute bursal inflammations. It is efficient in septic cases and
its quality of rapid evaporation aids materially in reducing the
inflammatory symptoms, independent of the therapeutic action of the
component drugs. This solution, on account of its rapid evaporation,
must be renewed more often than either of the foregoing, but while this
demands more attention on the part of the patient, it is immeasurably
better for the general condition of the disease. The one disadvantage
in having the patients attend to the moistening of the dressing is
that often they will fail to carry out instructions properly; but a
condition of this nature, properly attended, will respond as quickly
to the boric-alcohol application as to aluminum acetate or to mercury
bichloride, and with none of the irritant or toxic tendencies of both
of these. This solution is applied cold.
=Lead and Opium Wash= may be used in the treatment of bursal
inflammations, usually in the subacute or chronic stages. In cases
where the integument is broken, avoid the use of this medication on
account of the irritant qualities of the lead it contains. Prolonged
applications are apt to develop a dermatitis, and if the skin is
broken, local lead poisoning will not only be more pronounced, but
will be manifest in a shorter space of time. Lead and opium wash, hot,
is an advantageous application in the treatment of chronic bursal
inflammations, the heated applications being continued for about thirty
minutes at a time, at intervals of two or three hours. It should always
be remembered in using this wash that it exhibits marked irritant
qualities upon prolonged application.
The choice of a moist dressing to be used in subacute or chronic cases,
especially the latter, should be carefully made. Boric acid, saturated
solution, is an efficient and safe drug to use under rubber, fish skin,
or oiled silk covering but, as before mentioned, mercury bichloride and
liq. aluminum acetate are contra-indicated in this connection.
=Unguent Dressings.= Ointment dressings are used in this instance
under the same rules and considerations which govern their application
in all other conditions. No ointment should be applied on any inflamed
bursa where there is a discharge of any nature. The operator must never
forget that the base of all ointments is either oily or fatty and a
serous discharge, coming from any surface, cannot be absorbed by the
fabric used as a dressing if even a thin unguent film is interposed.
Certain classes of drugs, however, which are known to be beneficial in
certain stages in the treatment of bursitis, can be readily applied
in unguent form and for this reason the question of using them may be
profitably discussed here. The action demanded of drugs to be used in
the treatment of bursal inflammations are antiphlogistic, analgesic and
antiseptic. The latter action is particularly demanded in cases where
surfaces denuded of epidermis are found. Some stimulant action is at
times desired and drugs which have properties of this nature may also
be included in this armamentarium. The following named ointments may be
used, therefore, with beneficial results in certain stages of bursal
inflammations: ichthyol, sulphur, menthol, balsam of Peru, scarlet red
and salicylic acid.
=Unguentum Ichthyoli=, 3% to 10%, is used in all cases where an
emollient action is desired. The stimulating action of the drug in
this form is negative, but it can be relied upon to reduce acute
inflammatory symptoms. Ichthyol may be combined best with either
lanolin or vaseline as a base; the former is preferred inasmuch as it
does not become rancid when exposed to a variety of conditions as does
the latter. Lanolin being a wool fat product is supposed to have a
beneficent action upon certain pathologic conditions of the skin, and
so it is used as the base of many ointments.
=Unguentum Sulphuris=, 10%, may be used in many conditions of subacute
or chronic bursitis. Its antiseptic action makes it a desirable
choice for use when the integument is broken or when a distinct
antiseptic action, in addition to the general action of sulphur as an
antiphlogistic, is sought.
=Unguentum Balsamum Peruvianum= is used in these instances, principally
when some loss of tissue in the part is noticeable and where
stimulation is required to accelerate granulation. Peruvian balsam is
sometimes combined with ichthyol (5% of each) in ointment form. In this
combination the ointment has marked stimulative and antiphlogistic
qualities. Balsam of Peru is used in strengths of from 3% to 10% in a
vaseline base.
=Scarlet Red= is a highly efficient stimulative ointment. It is used
alone, with zinc oxide or with borated vaseline, and should never
be applied in too thick a coating. The parts should first be made
thoroughly aseptic and dried, and then scarlet red applied on gauze in
a thin even coat. Care should be taken that the application of scarlet
red does not cause over-stimulation to the parts, and thus prove
detrimental to the general condition of the lesion.
=Unguentum Acidi Salicylici=, 2% to 5%, may be used to good advantage
where the parts overlying the thickened sac are found to be somewhat
calloused. One application of an ointment of this strength will serve
to disintegrate this overlying thickening, thus making the parts
flexible and soft. A stronger ointment than this should never be used
in these cases, as salicylic acid is a strong epidermic disintegrant
and will cause decided irritation if used in greater than 5% strength.
In such cases salicylic acid may also be combined with collodion in
the same percentage, 5 grains of ext. cannabis indica being added as
an anodyne. Unguentum salicylic should never be used when the skin is
broken or the tissues show any tendency to thinness. All ointments used
in the treatment of bursitis are applied and kept in place by the use
of a cocoon dressing. If a shield is to be used, it is first applied;
the ointment is then placed in the shield aperture and the cotton and
collodion dressing is made to cover the whole. The ointment should
be renewed at frequent intervals in order that the dressing may not
become hardened, and thus become an irritant.
=Counter-Irritation.= Counter-irritation means literally an
irritation which is developed to act against a previous irritation.
It would seem, theoretically, that in cases of bursitis, this form
of treatment is particularly advantageous. A bursal inflammation is
a fairly deep-seated condition which should readily respond to a
counter-irritation developed on the surface overlying the trouble.
Counter-irritant agents should be used only in subacute and chronic
cases, more particularly in the latter; for it is found that this form
of treatment applied to an acute bursal inflammation tends to intensify
rather than reduce the symptoms.
In treating such cases we have a number of counter-irritants which may
be used with consistently good results: iodine, capsicum, turpentine
and mustard, are the most important and most commonly used.
Iodine is today, in all probability, the most generally used agent to
induce counter-irritation in podiatry. Its present popularity as a
germicide, however, has over-shadowed its action as a counter-irritant.
To obtain the maximum counter-irritant action from tincture iodine (U.
S. P. 7%) it should be applied in a heavy coat at frequent intervals
until such time as the inflammatory symptoms have entirely subsided.
The continued use of iodine after this has been accomplished should be
avoided as the tincture is irritant and mildly corrosive, and numbers
of patients will be found whose skin will not stand its activities.
Churchill’s tincture of iodine (about 16%) has been advocated for
general use as a counter-irritant, but its action in many cases will be
found too irritant for ordinary use.
The theory of counter-irritation, simplified, is that a drug applied
at a spot more or less distant from an inflamed area will cause an
irritation in this new locality and thus aid the original condition,
inasmuch as it will draw away the excess blood in the original part and
allow the vessels to contract to normal calibre and the circulation
there to become normal. Realizing this, it is readily understood why
tincture of iodine should not be used as a counter-irritant in acute
cases. With a discharging sinus to contend with, applying iodine over
its opening at the periphery might be the cause of a severe irritation
in that location which would further increase the tissue loss and thus
prove a detriment to the general condition.
=Capsicum= is generally applied in these conditions in the form of
a plaster. It should never be used in acute cases as its greatest
efficacy is apparent in those cases with chronic characteristics.
Capsicum plaster is applied and renewed as necessary, until the
symptoms of the deep inflammation have subsided. Shields are usually
employed to remove the pressure while a chronic case is under
treatment, and this removal of all irritation which the shoe might
produce aids materially in the relief and cure of these conditions.
=Turpentine= may be massaged into the parts for the purpose of
counter-irritation although its action is at times severe; it should
never be used where the skin is broken or where a discharge is present.
It is not so desirable an application as either of the foregoing for it
is found impractical to give proper massage to the comparatively small
areas which are affected in bursal inflammations.
=Mustard= has been recommended for use in cases of chronic bursitis,
either in the form of a moderate local application or in a general
foot bath. It is decidedly energetic in action, and should be used
with great discretion and care. Every skin will not stand the action
of mustard and for this reason it is not advocated as a general
counter-irritant agent. Upon the failure of any of the other drugs
mentioned under this heading, however, it may be tried, and if properly
used, may prove conducive to good results.
=Massage.= Massage is at times a potent factor in aiding absorption in
chronic cases. There is no question but that the stimulation afforded
by this procedure is efficient and will aid materially in returning the
tissues to normal.
Some cases of bursitis which occur upon the foot, however, are confined
to such limited areas that massage is impractical.
Several drugs which are reputed to have great powers of penetration
are recommended as agents which can be safely massaged into the parts
and even if the action claimed for them is overestimated, their use at
least serves to reduce the friction upon the surface tissues.
Many of the so-called “petrogen compounds”--drugs in combination with
petroleum (mineral oil)--are recommended for use in these cases, and
are undoubtedly of some benefit. Petrogen iodine, 10%, and petrogen
camphor, 5%, (Wyeth) are the two most generally used, and have been
found to be productive of good results.
The compound is applied to the parts and then rubbed, first lightly,
then gradually increasing the pressure, by the fingers and palm of
the hand. It is found advantageous to massage the parts at first with
a circular movement, confining the energy to the areas immediately
overlying the enlarged sac. After about five minutes, the pressure is
increased and considerable of the surrounding integument is included in
the massage. The direction of the finger movements is then changed from
a rotary one to a series of long strokes under considerable pressure,
first toward the diseased sac, following as nearly as possible the
blood supply to the part, and then away from the sac, following the
outgoing vessels. This serves first, to increase the vascular supply,
and then to aid in its quick removal, and reduce the congestion in the
part. With this, the lymph activity is also increased so that it helps
to absorb the waste products more rapidly.
Massage should be recommended as a daily treatment and should
be continued until all signs of infiltration have disappeared.
Perseverance is necessary, for in chronic bursal inflammation, the
changes are not noticeable nor should they be expected to be rapid.
=Electricity.= Many forms of electrical application are recommended
in the treatment of chronic bursal inflammations. Among those most
commonly employed are the high frequency, and the faradic currents.
Vibration, induced by electric impulses, is also recommended and is
employed generally by the podiatrist.
=High Frequency Current=, more popularly known or rather misnamed
“violet ray,” is generally found efficient and is more generally used
than any other form of electric application. This current serves to
produce active stimulation in the parts and by this means tends to
accelerate all functional activities and to hasten absorption. Whether
the more popular priced and small sized high frequency machines on the
market today really do create any but a very superficial stimulation,
is a question, and for this reason a machine of greater power is
recommended. The parts are treated daily, the glass electrode being
applied for about eight or ten minutes at a time.
=Faradic Current= is also recommended for daily use being applied by
means of a moistened sponge electrode. The treatment is from five
to ten minutes duration. Stimulation is obtained by this treatment
which, as in the case of the high frequency current, aids the general
absorption in the affected areas.
=Vibration= used in these cases may be produced by electricity direct,
or through a modern air compressor, controlled by electricity.
Vibration is only recommended in chronic cases; it increases the
functional activities of the part. It should be applied daily.
Bursitis is a stubborn condition in any form, and can only be relieved
and finally cured by scientific and rational treatment. The operator
should bear in mind that rest and the absence of shoe irritation will
do as much or even more for the general improvement of the condition
than can be accomplished by drugs. Surgical procedure is certainly to
be recommended in cases where no improvement is shown under palliative
methods, even though this requires a cessation of activity on the part
of the patient, and means the transfer of the patient to the care of a
practitioner of surgery.