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Aim: In rheumatoid arthritis (RA), forefoot bursitis is prevalent, with limited studies comparing ultrasonography (US) and Magnetic Resonance Imaging (MRI). This study aims to evaluate these bursae, providing a comparative analysis of US and MRI, and explore associations with demographic, disease-related factors, pain, clinical examination, and baropodometryin RA patients., Material and Methods: Participants with RA were recruited from the day-hospital clinic. The forefeet were assessed clinically, and the selected foot was examined by US and MRI to evaluate intermetatarsal (IMB) and submetatarsal bursitis (SMB). Baropodometry assessed plantar pressures and contact surfaces., Results: Thirty-five RA patients were enrolled, 85.7% females, mean age 59.2 (11.3) years, mean body mass index (BMI) 26.5 (5.7) kg/m2, median disease duration of 36.0 (16.5-114.0) months, and 34.3% with painful forefoot. A total of 140 intermetatarsal and 175 submetatarsal spaces were evaluated. Agreement between US and MRI was high (PA=97.14%, k=0.801, p<0.001), and interobserver reliability for both modalities was excellent (US: PA=98.73%, k=0.888, p<0.001; MRI: PA=98.41%, k=0.900, p<0.001). IMB was negatively associated with disease duration (the only independent predictor) and linked to clinical signs like the opening toes sign and hammer toe deformity. SMB showed an association with BMI and erosions. Baropodometric analysis indicated no significant differences in plantar pressures for IMB, and larger contact surfaces in SMB regions., Conclusions: US and MRI are valuable tools for forefoot bursitis evaluation. IMB is associated with disease duration (negative association), the opening toes sign, and hammer toe deformity, while SMB correlates with BMI, erosions, and foot architectural deformity. Baropodometry revealed larger contact surfaces in regions with SMB.

Abstract: A 74-year-old man with poorly controlled seropositive rheumatoid arthritis was referred for 18F-FDG PET/CT for follow-up of lung cancer, which demonstrated intense FDG activity in atlantoaxial, sternoclavicular, glenohumeral, and hip joints consistent with active rheumatoid arthritis. There was also unexpected intense uptake at scapulothoracic, ischiogluteal, and trochanteric bursae signifying active bursitis., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

We experienced a case of bilateral shoulder bursitis with gas images in a rheumatoid arthritis (RA) patient. A 60-year-old man with RA had been treated with weekly methotrexate 10 mg and daily prednisolone (PSL) 10 mg for 7 months. Generalized pain, especially in the bilateral shoulder joints, developed and exacerbated daily with increased C-reactive protein (CRP) level. Despite the initiation of biweekly sarilumab 200 mg, joint symptoms and CRP level continued to worsen. Computed tomography (CT) scan to determine the cause of severe shoulder inflammation revealed low absorption areas with contrast effects at the margins around the bilateral shoulder joints, accompanied by internal gas images. In addition, magnetic resonance imaging demonstrated subacromial bursae and coracoid bursae and bursitis, leading to the suspicion of abscess formation depending on the presence of gas image. In spite of antimicrobial therapy, arthralgia did not improve, and a CT-guided arthrocentesis of the left shoulder joint resulted in negative findings of infection in culture and pathological examinations. Switching treatment to intensive anti-inflammatory therapy with high-dose steroids and etanercept finally improved symptoms and CRP levels associated with the reduction of low absorption areas and disappearance of gas images at bilateral shoulder joints. Our case indicated that bursitis with gas image in RA patients involves unusual pathophysiology and requires intensive anti-rheumatic treatment., (© Japan College of Rheumatology 2022. Published by Oxford University Press.)

Background: The forefoot is a preferential location for joint and tendon sheath inflammation in rheumatoid arthritis (RA). It also contains bursae, of which the intermetatarsal bursae have a synovial lining. Some small imaging studies suggested that intermetatarsal bursitis (IMB) and submetatarsal bursitis (SMB) are involved in RA, but their association has not been thoroughly explored. Healthy control studies suggested that lesion size might be relevant. We studied the relation between IMB and SMB in early RA, compared to other arthritides and healthy controls, and the relevance of lesion sizes., Methods: Six hundred and thirty-four participants were studied: 157 consecutive patients presenting with early RA, 284 other arthritides, and 193 healthy controls. All underwent unilateral contrast-enhanced MRI of the forefoot at presentation. Two readers independently scored IMB and SMB and measured transverse and dorsoplantar diameters, blinded to clinical data. Subsequently, consensus was reached. Intra-reader ICC was 0.89. Logistic regression models were used, and test characteristics were calculated., Results: IMB and SMB associated with RA independent of each other (P < 0.001) and independent of age, gender, BMI, RA-MRI inflammation, and anti-CCP-antibodies (P = 0.041). Sensitivity for RA of IMB was 69%, and for SMB 25%. Specificity for IMB was 70% compared to other arthritides, and 84% compared to healthy controls. For SMB, this was 94% and 97% respectively. Regarding lesion size, the groups had considerable overlap: no cut-off size for RA could be distinguished with high sensitivity and specificity., Conclusion: Intermetatarsal and submetatarsal bursitis associated with early rheumatoid arthritis, contributing to the emerging evidence that inflammation of juxta-articular soft tissues is an early feature of RA.

Rationale: Power Doppler ultrasonography (PDUS) in musculoskeletal ultrasound (MSUS) is a sensitive and reliable method for the assessment of rheumatoid arthritis (RA). The association between ultrasound-detectable forefoot bursae and the development of RA has gained attention. However, a few studies have evaluated the utility of PDUS for examining forefoot bursae in early RA. We report the case of an RA patient who developed reduced foot mobility and had detectable intermetatarsal bursitis with remarkable power Doppler (PD) signals in MSUS at the onset of RA., Patient Concerns: A 40-year-old Japanese woman diagnosed with palindromic rheumatism visited our department due to sustained forefoot pain and difficulty walking. The levels of both rheumatoid factor (RF) and anticitrullinated protein antibody (ACPA) were high. She had opening toes with swelling in metatarsophalangeal (MTP) joints. PDUS showed intermetatarsal bursitis with mild MTP synovitis., Diagnoses: We diagnosed RA by comprehensive judgment based on the 2010 American College of Rheumatology and European League Against Rheumatism classification criteria for RA., Interventions: We administered 6.0 mg/wk of methotrexate (MTX) and 2.0 mg/d of prednisolone (PSL) followed by an increase of MTX to 10 mg/wk., Outcomes: After those treatments, the patient's symptoms showed improvement. As of this writing, the patient's remission has been maintained for >2 months., Lessons: Her case suggests that PDUS is useful for the detection of forefoot bursitis, and the detection of forefoot bursitis by PDUS may provide the opportunity to make an early diagnosis of RA.

The bicipitoradial bursa lies at the insertion of the biceps tendon on the radial tuberosity. It is an unusual site for chronic bursitis and most often, results from repetitive mechanical trauma or overuse. Other causes include tuberculosis, immunological complications of the rheumatological disease, for example, psoriatic arthropathy, rheumatoid arthritis and synovial chondromatosis. Unlike ganglion cyst arising from the elbow joint, resection of the bursa through the elbow arthroscopy is not possible as the bursa is not communicated with the joint. We reported a patient with rheumatoid arthritis presenting with bicipitoradial bursitis extended around the radial neck which was successfully resected endoscopically.

We report on a 54-year-old woman with rheumatoid arthritis who had severe femoral nerve palsy affected by a distended synovium in the hip joint. Surgical exploration demonstrated a perforation of the iliopectineal bursa connecting with the hip joint. The patient fully recovered from femoral nerve palsy after surgery. It was considered that synovitis of the hip joint had developed following huge iliopectineal bursitis.

A 39-year-old man with rheumatoid arthritis developed femoral neuropathy secondary to iliopsoas bursitis. The adjacent hip joint was severely damaged. Magnetic resonance imaging showed enlargement and inflammation of the psoas muscle at the same side of iliopsoas bursitis. Iliopsoas bursitis and abnormal findings of the psoas muscle disappeared while the symptoms improved.

The shoulder is the site of multiple injuries and inflammatory conditions that lend themselves to diagnostic and therapeutic injection. Joint injection should be considered after other therapeutic interventions such as nonsteroidal anti-inflammatory drugs, physical therapy, and activity-modification have been tried. Indications for glenohumeral joint injection include osteoarthritis, adhesive capsulitis, and rheumatoid arthritis. For the acromioclavicular joint, injection may be used for diagnosis and treatment of osteoarthritis and distal clavicular osteolysis. Subacromial injections are useful for a range of conditions including adhesive capsulitis, subdeltoid bursitis, impingement syndrome, and rotator cuff tendinosis. Scapulothoracic injections are reserved for inflammation of the involved bursa. Persistent pain related to inflammatory conditions of the long head of the biceps responds well to injection in the region. The proper technique, choice and quantity of pharmaceuticals, and appropriate follow-up are essential for effective outcomes.

A 58-year-old woman with rheumatoid arthritis (RA) presented with persistent hip pain and an inguinal mass. Considerable liquid had collected inside the iliopsoas bursa, apparently not in communication with the hip joint, as shown by ultrasonography and computed tomography (CT). After one month of systemic steroidal therapy (25 mg/day prednisone), the palpable inguinal mass and pain had disappeared. Iliopsoas bursitis should be suspected in RA patients with a long history of disease presenting with an inguinal mass, persistent groin pain or unilateral leg swelling. The lack of communication between the hip joint cavity and bursa may be considered as a favourable prognostic index. Steroid treatment should be always attempted in order to avoid surgery.

A 65-year-old woman with rheumatoid arthritis (RA) developed symptomatic compression of the femoral nerve secondary to an iliopsoas bursitis. Her adjacent hip joint was not severely affected by arthritis. This entity should be included among the entrapment neuropathies complicating RA.

A 66-year-old woman with rheumatoid arthritis presented with unilateral leg edema attributable to an enlarged iliopsoas bursa with presumed impedance of lymphatic drainage. The adjacent hip joint was not severely involved by arthritis. Ultrasonography and computed tomography were used to delineate the bursal mass and demonstrate communication with the joint space.