The investigation of bursae in the forefoot of patients with rheumatoid arthritis using musculosketal ultra sound imaging performed by a podiatrist

Abstract

Patients with rheumatoid arthritis (RA) frequently present with pain under their feet. Forefoot bursae can give rise to such symptoms, but are rarely investigated. The aim of this thesis was to use musculoskeletal ultrasound (MSUS) performed by a podiatrist to evaluate the prevalence and natural history of bursae in the forefoot in RA patients.
Once reliability of technique was established, a longitudinal study design was used in which a sample of RA patients (N=149) and a comparator group (N=50) of healthy individuals were assessed at baseline. A Diasus MSUS system was used to image the forefeet of all participants to determine prevalence of bursae. 120 patients (98 female, 22 male) with RA (24 seronegative, 93 seropositive, 3 unknown) completed the study at twelve months: mean age 60.7 (SD 12.1) years and disease duration 12.99 (10.4) years.
Results confirmed a high prevalence of forefoot bursae (92.6% of patients; mean per individual =3.54, range 0-9) and that these were often missed by clinical examination. Findings that there could be an association between patient reported foot impact scales of impairment/footwear (LFISIF) and activity participation restriction/limitation (LFISAP) and presence of bursae (LFISIF ?=0.377, p=0.033; LFISAP ?=0.762, p=0.013) independent of disease activity were unique. On examination of prospective data after one year, 25.8% of participants had increases in bursae and 23.3% decreases. There was a significant correlation between changes in bursae with changes in LFISIF (PCC=0.216, p=0.018) and LFISAP (PCC=0.193, p=0.036) and a significant negative correlation with changes in duration of RA (PCC=-0.269, p=0.003).
The findings imply that MSUS detectable bursae in the forefeet are highly prevalent, clinically under-reported and change over time. The findings suggest that bursae within the foot in RA deserve increased clinical attention and that further work is required to confirm associations with patient reported foot impact outcome measures.

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Identifiers

ORCID for Catherine Jane Bowen: orcid.org/0000-0002-7252-9515

ORCID for Jane Burridge: orcid.org/0000-0003-3497-6725

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