Q: I am a 35-year-old female and have had severe heel pain for about three weeks. I have been diagnosed with Plantar Fascitis. Kindly guide me about the condition and what is the Physiotherapy treatment.

A: Plantar fasciitis is an overuse injury. Accumulation of micro-damage leads to the degradation of the collagen fibers that make up the origin point of the plantar aponeurosis. This prevalent condition is the most common cause of heel pain. Risk factors include overpronation, high-arched feet, leg-length discrepancy, footwear, etc. A physical therapist assesses the patient and designs an exercise program, moreover, splints, orthoses, and supportive shoes may also be required depending on the case.

Q: My child is about 6 years old and has had a lot of swelling on his elbow for three weeks. What could be the reason for it?

A: The condition needs to be properly assessed by a medical professional for a definite diagnosis. It may be the case of Olecranon bursitis. It is a condition in which there is an inflammation of the bursa overlying the olecranon process at the proximal aspect of the ulna. The superficial location of the bursa, namely between the ulna and the skin is susceptible to inflammation from a variety of mechanisms, primarily either acute or repetitive trauma. It is also possible that the inflammation is due to an infection, called septic bursitis. Two-thirds of the cases are bursitis without an infection or non-septic bursitis. However, the olecranon bursa normally provides a mechanism with which the skin can glide freely over the olecranon process, consequently, the bursa prevents tissue tears. A bursa is a part of your body that allows two other parts to move smoothly together (outside of a joint). It’s a sac made of thin, slippery tissue. Bursae occur in the body wherever skin, muscles, or tendons need to slide over bone and are lubricated with a small amount of fluid inside that helps reduce friction from the sliding parts. The olecranon bursa is located between the tip, or point, of the elbow (called the olecranon) and the overlying skin. This bursa allows the elbow to bend and straighten freely underneath the skin, but when the bursa gets irritated, the sac fills up with fluid which leads to swelling of the elbow tip. Olecranon bursitis is a relatively common condition. The pain at the posterior elbow may cause morbidity, with limitation of some functional activities (e.g. writing). Two-thirds of cases are non-septic (i.e. without infection) and usually occur when trauma or repeated small injuries lead to bleeding into the bursa or release of inflammatory mediators. This condition can be caused by acute injuries (trauma) during sports activities because they can include any action that involves direct trauma to the posterior elbow. For example, falling onto a hard floor. Other common causes of olecranon bursitis, which are not related to sports activities, include repetitive microtrauma, like rubbing constantly the elbow against a table during writing. Such a trauma or those repeated small injuries lead to bleeding into the bursa or the release of inflammatory mediators. People in certain occupations are especially vulnerable, particularly plumbers or heating and air conditioning technicians who have to crawl on their knees in tight spaces and lean on their elbows. Finally, inflammation may be due to a systematic inflammatory process, like rheumatoid arthritis, or a crystal deposition disease, like gout and pseudogout.

Patients usually remark a focal swelling at the posterior elbow, the swelling is sometimes painless. Pressure, like leaning on the elbow or rubbing against a table while writing with the ipsilateral hand, are factors that can often exacerbate the pain. Chronic recurrent swelling is usually not tender. A typical symptom of olecranon bursitis is the frequent bumping of the swollen elbow because it protrudes further than it usually would. Bursal inflammation’s most classic finding is a swelling, at the posterior elbow. This swelling is marked off by its appearance as a goose egg over the olecranon process. There may be tenderness for palpation at the affected site. Cases in which infection is present may show a warm and red affected area. If the trauma has recently occurred, the inspection of the skin may reveal an abrasion or contusion. Generally, a patient with an advanced infection can have a fever.

The Range of motion (ROM) of the affected elbow is usually normal but now and then the end range of elbow flexion may be slightly limited due to pain. Patients suffering from systematic inflammatory processes (like rheumatoid arthritis) or crystal–deposition disease (like gout or pseudogout) may reveal evidence of focal inflammation at other sites. When you examine a patient who has rheumatoid arthritis, you may see rheumatoid nodules during inspection of the elbow. If the patient reports elbow pain during active or passive ROM and if a history of trauma exists, this may increase the clinical suspicion of an olecranon process fracture.

Most of the time physical and occupational therapy are not necessary but are often indicated to reduce recovery time. Patients who have often olecranon bursitis are recommended to apply the RICE method of treatment. Rice stands for Rest, Ice, Compression, and Elevation. Other physical therapy modalities could help reduce pain and inflammation. For example phonophoresis, and electrical stimulation. However, most patients with olecranon bursitis don’t necessarily need those modalities. The physical therapist can also take care of the patient's education and present compensatory strategies for resting the involved upper extremity while healing takes place. When the patient shows no response to conservative treatment and his condition deteriorates, then surgery may be indicated. When a patient undergoes a bursal excision (bursectomy), there might be a recommendation for physical therapy after the operation for regaining or maintaining the ROM and strength of the elbow.

The treatments that have been suggested in the past for non-septic olecranon bursitis include the following: Bursal aspiration alone, with or without compressive dressings, Nonsteroidal anti-inflammatory drugs for 10 to 14 days, Corticosteroid injections alone, after aspiration, “blood patch” injection, The temporary 3-day use of a percutaneous-intramural drainage catheter, Holding a needle in place with a hemostat, if aspirating and injecting, Intrabursal injections of tetracycline and talcum powder. However, the treatment and the suitable option are selected depending upon the patient's condition by a specialist.