Heel Blister: To Pop or Not To Pop?

 

Hi Dr. Segler,

I've had this blister on my heel for the past three days and it has gotten slightly larger.  I'm wondering if I should allow more time for it to heal or pop, drain, etc?  What's the fastest way to get it healed?

Sincerely,
Ryan M. 
San Francisco, CA

Answer:

Hello Ryan,

A blister on the inside of the heel can be painful when running or even walking.  If you are currently training for a marathon, the last thing you want to do is stop running just because you have a blister on your heel.  But obviously the blister has to stop getting bigger before it is going to heal.

There are only a couple of reasons that a blister continues to get bigger.

1. Friction. If you are continuing to rub the inside of the heel in the same way that cause the blister to form in the first place, the blister will continue to get bigger.

2. Compression. If you repeatedly press on the blister,  the fluid with in the blessed blister will try to disperse outward. Since the fluid is all contained inside the blister, this will continue to separate the layers of the skin from the pressure applied to the blister when the fluid tries to move. This causes the blister to continue to enlarge.

The redness at the border of blister tells me that the fluid is being compressed and further separating the layers of the skin (indicated by red arrows). This of course hurts and makes the heel blister bigger.

If you pop or drain the blister, it will increase the risk of infection. If you pop (or drain) the blister it will feel slightly better in the short term, but it might take slightly longer to completely heal.  As long as all of the irritation to the blister is removed, your body will resorb the blister fluid and heal the blister.

The blister in these images appears to be flat enough that it could be offloaded with some simple pads that could be obtained from a local pharmacy.  The idea is to place felt pads around the blister. By removing the pressure that is being applied to the blister when you walk, it will stop enlarging and it will start to calm down.

If a pad is applied to the heel, it will place all of the pressure around the blister, instead of on the blister. This will significantly decrease both the compression and friction of the blister.  If the oval pads that you find at the pharmacy are not large enough, you can simply cut two of them in half and then apply two separate half-oval pads to completely surround and protect the blister.

Here is an image of the proper pad placement with the red area indicating a blister:

Once the blister has completely healed your next task will be to identify the cause of the blister.  Obviously will not want this to happen again. If you have just gotten a new pair of shoes you want to make sure to break and then more gradually the next time. If your shoes were to loose, obviously want to tie them slightly tighter so that your heel isn't sliding around inside the running shoe. And if the blister happened after running a race (where you were dumping water on your head to stay cool) or from running in the rain, you want to make sure that you avoid getting your feet as wet the next time.

Heal that heel fast so that you can get back to running!

Dr. Christopher Segler, DPM is a runner, 11-time Ironman triathlon finisher and is Board Certified,  American Board of Podiatric Medicine.  His practice is limited to runners, triathletes and other active young adults. He travels frequently lecturing to other physicians at podiatry conferences about the treatment of complicated running injuries.  He performs remote consultations for runners all over the world via telephone and Skype. He also sees patients in person in both San Francisco, CA and Houston, TX.  If you have a question about a running injury that doesn't seem to be getting better, you can reach him directly at 415-308-0833. 

Can I Continue Running With This Blister?

We receivd an email inquiry from Julie who is currently training for a marathon. She recently injured on of her little toes and wants to resume her training.

She explains. "I have had this blister now for a week. I had also tripped over a bike rack which bruised my toe as well. I am on antibiotics and they took X-rays to confirm my toe was not broken. It was not broken but very infected. I was training for a marathon and want to know if I can continue running or do I need to wait longer for it to heal."

As a sports medicine podiatrist the primary concern with a blister is of course to help the blister heal as quickly as possible so that the patient can resume marathon training without any significant loss of fitness.

The basic tenets of blister treatment involve the following:

1. Provide mechanical protection of the blister. This means to use any combination of reduced activity, shoe modification, padding, etc. to stop rubbing and irritating the wound. If you continue to apply shear forces and friction, the blister will take much longer to heal, and could even get worse.

2. Optimize a moist environment of the wound to facilitate healing. This means that you want to keep the wound properly hydrated. The wound has to be moist, but not too moist. If a blister is actively draining, the dressing should absorb the exudate to prevent the excess moisture form breaking the tissue down further. If the wound is too dry, then a dressing should be used that will add moisture sufficent to promote healing.

3. Reduce the bioburden of the wound. "Bioburden" is a term used by wound care specialists that refers to the well-know negative effects of bacteria colonizing a wound, or worse yet, infecting a wound. Your skin is covered in bacteria. This not a comment on hygiene; it is a natural state. Any open wound will quickly become colonized with bacteria as well. If there is an excessive amount of bacteria feeding in the wound, the wound healing process slows. Many wound care products are designed to impede the growth of bacteria or wash the bacteria away. But not all are created equal. Some commonly used wound-cleansing substances such as dilute bleach, hydrogen peroxide and povidone-iodine kill off bacteria, but unfortunately are also toxic to the cells trying to heal the wound at the base and edges of the blister.

Much worse than a "colonized wound" is an "infected wound." The difference is that an infected wound is one where the bacteria is actually directly damaging the tissue. This is the case described above.

It appears from the picture and description provided that this runner's toe has not been caused by the exceeding common friction from running shoes, but is in fact a traumatic injury, more likely causes by a direct blow when tripping over a bike rack.

When this kind of injury occurs two things can happen.
1. The toe (or at least on of the phalanx bones within the toe) can easily break.
2. The nail plate can become separated from the nail bed leading to a nasty infection.

This type of injury has to be treated much differently than a standard friction blister.

The first concern is to treat the infection. This might be accomplished through the administration of prescription oral antibiotics, drainage of the blister and removal of pus in a podiatrist's office, and perhaps, even remove of the nail plate. Deciding which of these are appropriate would require an in-person evaluation with a podiatrist.

The second concern is the possibility of fracture. Little toes get broken all the time with the kind of injury described. The reason this is so worrisome is that if one of the bones in the toe is broken, the infection in the skin and surrounding soft tissue could easily spread to the bone resulting in osteomyelitis- also known as a bone infection. Bone infections are serious and are the primary cause of amputation of toes.

Before returning to running this runner (and her doctor) would have to be certain that the toes wasn't broken and the infection was well on its way to healing. Once that has been accomplished, it would be necessary to have a podiatrist who treats runners often evaluate the runner's shoes and determine the best way to offload the toe so that it could continue to heal with any irritation. She should then be able to get back to training for her marathon.

Dr. Christopher Segler is sports medicine podiatrist who practices in San Francisco. He is an active runner and triathlete who is competing in 1 marathon and 4 Ironman triathlons in 2012. His practice is limited to active runners and triathletes. You can learn more about running injuries at www.DocOnTheRun.com and www.AnkleCenter.com

Achilles Tendonitis in a Runner...from dropping out to 4th place.

We recently received this inspiring patient testimonial from a runner who had been suffering with chronic Achilles Tendinitis that was so bad it actually forced him to drop out of a race. Dr. Segler saw him and helped him heal the Achilles tendon with some simple treatments..and NO surgery. He didn't even need a PRP injection to heal the Achilles tendon. He went on to run a half marathon, full marathon and compete with his team to win 4th place at the PA/USATF 2011 Cross Country Grand Prix.

"I'm a runner who competes in the PA/USATF. I injured my achilles (tendinitis) last summer and needed to recover before the start of the cross country season (1st week of Sept).

This injury had been bothering me chronically for the last year and a half, impairing my training and in some occasions, forcing me to drop out during races. I called Dr Segler following a drop out from a local race last July. My achilles was very painful and I had difficulty walking. I'm generally a point-scorer for the team (top 5 runners) so my return to competition was much anticipated by my teammates.

Dr Segler came to my house and assessed my injury, explained what type of tendinitis I had and gave me a number of options and treatments (I think 12 in total). Most importantly for me, Dr Segler understood my need to not become totally out of shape before the XC season. Since he is a triathlete himself, he knows what competition means, the efforts you've put into your training, and the satisfaction of a good race. For my type of injury, most doctors would simply recommend to (heavily) use NSAIDs, rest and not run at all for a number of weeks.

Dr Segler gave me additional options to maintain a minimum level of fitness while my tendon was recovering. I followed his advice to the letter and got better in a few weeks, while maintaining some training. I returned to competition on Aug 27th, ran many of this year's XC races, and contributed to my team achieving 4th place at the PA/USATF 2011 XC Grand Prix. More recently I completed a half and full marathon part of the PA/USATF road racing Grand Prix and was part of the "A" scoring team. A great feeling ! I think we will take 3rd place in the Grand Prix this season, the best the club has done in years ... Thanks Doc !"

- Patrick M., San Francisco, CA

Dr. Christopher Segler is a runner, triathlete and 6-time Ironman finisher. His practice focuses on rapid recovery of running injuries. He offers a range of services to help runners get back to running as quickly possible. He provides PRP injections for Achilles tendonitis and ESWT therapy for heel pain in San Francisco, Marin and Palo Alto. He also frequently provides second opinions for runners through remote consultations via web conferencing for complicated injuries world-wide. The best treatment is fast treatment! If you have a question about running injuries, you can reach Dr. Segler directly at 415-308-0833.

San Francisco Podiatrist on Difference Between Heel Pain and a Heel Spur

Heel pain is the most common form of foot pain that causes people in San Francisco to make an appointment with a podiatry clinic. In fact, nationwide, about 40% of all visits to podiatrists are due to heel pain diagnosed as plantar fasciitis. As a podiatrist in San Francisco myself, the thing that I find interesting is that most people with plantar fascitis think they must have a heel spur to have heel pain. But that’s not always true.

So what is the difference between plantar fasciitis and a heel spur?

To begin with, let’s explain how to tell if you have plantar fasciitis. Anyone with plantar fasciits will have pain in the bottom of the heel or in the arch. In most cases this pain is worse when you get up and step out of bed in the morning. The heel may also hurt when you get up from your desk after working at a computer for a couple of hours.

As you start to walk, the first step is usually a sharp pain or sudden ache in the bottom of the heel. After a few steps, the heel pain starts to subside and feels better. In many cases, it may not even hurt at all while you are walking around or even running. But when you sit still and get back up again to start walking, that’s when the heel pain returns.

If you have this kind of morning heel pain and simply push on the bottom of the heel (and it hurts) you most likely have plantar fasciitis.

Many people in the San Francisco Bay Area seem to believe that heel pain is due to a sharp heel spur poking down and causing pain. But in fact about half of all people who have this kind of heel pain don’t have a heel spur at all. And about half of people with no heel pain, happen to have a heel spur that will show up on x-ray. So the two problems aren’t necessarily related.

The most common cause of heel pain is plantar fasciitis, which is simply inflammation of the plantar fascia. The plantar fascia is a big ligament attaching to the bottom of the heel and extending out to the toes. If you put too much stress on the plantar fascia, it can become inflamed where it attached to the heel bone.



With improper biomechanics, such as excessive pronation (flat feet that roll inward as the arch collapses) the plantar fascia ligament may tug away at the heel bone. With tension applied to the plantar fascia, the attachment may cause the heel spur to form.

The way this happens is that the ligament pulls the covering (called the periosteum) of the heel bone away. A small blood clot forms and then becomes calcified as it heals. If this happens again and again, the heel spur gradually grows. Because the heel spur is caused by the pulling on this big ligament, you can understand why a heel spur points out toward the toes and not down toward the ground.




Any podiatrist in San Francisco can simply take an x-ray of your heel to tell whether or not you have a heel spur. But the reality is, it doesn’t matter.

In the last 7 years, I have only surgically removed 2 heel spurs. Both of them were broken and wouldn’t heal. One was an young ironworker in San Francisco who fell off some scaffolding while working on the Golden Gate Bridge retrofit project. The other was a woman in her sixties who has some osteoporosis and broke the heel spur while doing high impact aerobics.

But most people with plantar fasciitis can get better on their own, even if they have a heel spur. In the vast majority of cases, spending a few minutes doing our San Francisco Podiatry Heel Pain Recovery Stretches will make the heel pain go away. The spur just simply doesn’t usually need to be removed in surgery.

Dr. Christopher Segler is a nationally recognized expert on conditions affecting the heel bone. In 2006 he was awarded 1st Place at the National Meeting of the American Podiatric Medical Association for his research on diagnosing heel bone infections with magnetic resonance imaging (MRI). He offers podiatry house calls in San Francisco for busy athletes and people who just think it is ridiculous to take half a day off work just to see a foot doctor. You can reach him through Doc On The Run: San Francisco Bay Area Podiatry House Calls.You can also learn more about the causes and available treatments for heel pain at AnkleCenter.com.

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