Assessment of the Natural History of Forefoot Bursae Using Ultrasonography in Patients With Rheumatoid Arthritis: A Twelve-Month Investigation

Objective. To determine the natural history and clinical significance of forefoot bursae over a 12-month period in patients with rheumatoid arthritis (RA). Methods. Patients with RA (n = 149) attending rheumatology outpatient clinics were assessed at baseline. A total of 120 participants, mean +/- SD age 60.7 +/- 12.1 years and mean +/- SD disease duration 12.99 +/- 10.4 years, completed the 12-month followup (98 women, 22 men, 93 rheumatoid factor positive, 24 rheumatoid factor negative, and 3 unknown). Musculoskeletal ultrasound (US) was used to identify forefoot bursae in all of the participants. Clinical markers of disease activity (well-being visual analog scale [VAS], erythrocyte sedimentation rate [ESR], C-reactive protein [CRP] level, and Disease Activity Score in 28 joints [DAS28]) and foot symptoms on the Leeds Foot Impact Scale (LFIS) Questionnaire were recorded on both occasions. Results. Presence of US-detectable forefoot bursae was identified in 93.3% of returnee (n = 120) participants (individual mean 3.7, range 0-11) at baseline. Significant associations were identified between bursae presence and patient-reported foot impact for impairment/footwear (LFIS(IF); baseline: r = 0.226, P = 0.013 and 12 months: r = 0.236, P = 0.009) and activity limitation/participation restriction (LFIS(AP); baseline: r = 0.254, P = 0.005 and 12 months: r = 0.235, P = 0.010). After 12 months, 42.5% of participants had an increase in the number of US-detectable forefoot bursae and 45% of participants had a decrease. Changes in bursae number significantly correlated with changes in LFIS(IF) (r = 0.216, P = 0.018) and LFIS(AP) (r = 0.193, P = 0.036). No significant associations were identified between changes in bursae and changes in global well-being VAS, ESR, CRP level, or DAS28. Conclusion. The findings of this study suggest that forefoot bursae may regress or hypertrophy over time in patients with RA, and that these changes may be associated with self-reported foot impairment and activity restriction.