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Heel fat pad involvement in rheumatoid arthritis: a review and case series

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Abstract

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease affecting not only the synovial joints but also multiple extra-articular sites, including ankle and foot soft tissue. Hindfoot abnormalities usually follow those in the forefoot, with up to 4 out of 10 patients experiencing talalgia during their disease course. Enthesophytosis, retrocalcaneal bursitis, and plantar fasciitis are among the most common etiologies, while heel fat pad abnormalities like subcalcaneal bursitis are rare. Here, we report two cases of subcalcaneal bursitis, and the first case of heel fat pad and subcalcaneal bursa herniation in patients with established RA, along with a comprehensive literature review of subcalcaneal bursitis and other heel fat pad abnormalities in RA. Subcalcaneal bursitis, also referred to as panniculitis, inflammatory-edematous lesion, or adventitial (adventitious) bursitis has been reported in up to 10% of patients with RA. It appears as a compressible, heterogeneous, and hypoechoic subcalcaneal mass on ultrasound (US), with peripheral vascularization on Doppler US. Patients may present with heel discomfort. Ultrasonographic assessment is usually sufficient to confirm the presence of heel fat pad pathologies. Rest, analgesics, and mechanical aids with or without addition of disease-modifying antirheumatic drugs are usually employed, while intervention is rarely required.

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References

  1. Aletaha D, Smolen JS (2018) Diagnosis and management of rheumatoid arthritis: a review. JAMA 320(13):1360–1372

    Article  Google Scholar 

  2. Gerster JC, Vischer TL, Bennani A, Fallet GH (1977) The painful heel. Comparative study in rheumatoid arthritis, ankylosing spondylitis, Reiter’s syndrome, and generalized osteoarthrosis. Ann Rheum Dis 36(4):343–348

    Article  CAS  Google Scholar 

  3. Serban O et al (2020) Do ankle, hindfoot, and heel ultrasound findings predict the symptomatology and quality of life in rheumatoid arthritis patients? J Ultrason 20(81):e70–e82

    Article  Google Scholar 

  4. Wickman AM, Pinzur MS, Kadanoff R, Juknelis D (2004) Health-related quality of life for patients with rheumatoid arthritis foot involvement. Foot Ankle Int 25(1):19–26

    Article  Google Scholar 

  5. Bowen CJ, Hooper L, Culliford D, Dewbury K, Sampson M, Burridge J, Edwards CJ, Arden NK (2010) Assessment of the natural history of forefoot bursae using ultrasonography in patients with rheumatoid arthritis: a twelve-month investigation. Arthritis Care Res 62(12):1756–1762

    Article  Google Scholar 

  6. O’Brien TS, Hart TS, Gould JS (1997) Extraosseous manifestations of rheumatoid arthritis in the foot and ankle. Clin Orthop Relat Res 340:26–33

    Article  Google Scholar 

  7. Hammer HB, Kvien TK, Terslev L (2019) Intermetatarsal bursitis is frequent in patients with established rheumatoid arthritis and is associated with anti-cyclic citrullinated peptide and rheumatoid factor. RMD Open 5(2):e001076

    Article  Google Scholar 

  8. Ivanoski S, Nikodinovska VV (2019) Sonographic assessment of the anatomy and common pathologies of clinically important bursae. J Ultrason 19(78):212–221

    Article  Google Scholar 

  9. Suzuki T, Hidaka Y, Seri Y (2018) Retrocalcaneal bursitis precedes or accompanies achilles tendon enthesitis in the early phase of rheumatoid arthritis. Clin Med Insights Arthritis Musculoskelet Disord 11:1179544118781094

    Article  Google Scholar 

  10. Koski JM (1998) Ultrasound detection of plantar bursitis of the forefoot in patients with early rheumatoid arthritis. J Rheumatol 25(2):229–230

    CAS  PubMed  Google Scholar 

  11. Suzuki T, Shirai H (2020) Subcalcaneal bursitis as the initial manifestation of rheumatoid arthritis: ultrasonographic observation of two cases. Reumatismo 71(4):230–234

    Article  CAS  Google Scholar 

  12. Van Hul E et al (2011) Pseudotumoural soft tissue lesions of the foot and ankle: a pictorial review. Insights Imaging 2(4):439–452

    Article  Google Scholar 

  13. Falsetti P, Conticini E, Baldi C, Acciai C, D'Alessandro R, Bardelli M, Cantarini L, Frediani B (2020) Observations about subcalcaneal adventitial bursitis (heel fat pad inflammatory lesion) in rheumatoid arthritis. Comment on the article of Suzuki and Shirai. Reumatismo 72(3):182–183

    Article  CAS  Google Scholar 

  14. Falsetti P, Frediani B, Fioravanti A, Acciai C, Baldi F, Filippou G, Marcolongo R (2003) Sonographic study of calcaneal entheses in erosive osteoarthritis, nodal osteoarthritis, rheumatoid arthritis and psoriatic arthritis. Scand J Rheumatol 32(4):229–234

    Article  CAS  Google Scholar 

  15. Falsetti P, Frediani B, Acciai C, Baldi F, Filippou G, Marcolongo R (2004) Heel fat pad involvement in rheumatoid arthritis and in spondyloarthropathies: an ultrasonographic study. Scand J Rheumatol 33(5):327–331

    Article  CAS  Google Scholar 

  16. Falsetti P, Frediani B, Acciai C, Baldi F, Filippou G, Galeazzi M, Marcolongo R (2006) Ultrasonography and magnetic resonance imaging of heel fat pad inflammatory-oedematous lesions in rheumatoid arthritis. Scand J Rheumatol 35(6):454–458

    Article  CAS  Google Scholar 

  17. Serban O et al (2019) Reasons for discordances between ultrasonography and magnetic resonance imaging in the evaluation of the ankle, hindfoot and heel of the patients with rheumatoid arthritis. Med Ultrason 21(4):405–413

    Article  Google Scholar 

  18. Boutry N, Flipo RM, Cotten A (2005) MR imaging appearance of rheumatoid arthritis in the foot. Semin Musculoskelet Radiol 9(3):199–209

    Article  Google Scholar 

  19. Gibbon WW, Long G (1999) Ultrasound of the plantar aponeurosis (fascia). Skelet Radiol 28(1):21–26

    Article  CAS  Google Scholar 

  20. Yamakado K (2013) Subcalcaneal bursitis with plantar fasciitis treated by arthroscopy. Arthrosc Tech 2(2):e135–e139

    Article  Google Scholar 

  21. Lemont H, Ammirati KM, Usen N (2003) Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc 93(3):234–237

    Article  Google Scholar 

  22. Resnick RB, Hudgins LC, Buschmann WR, Kummer FJ, Jahss MH (1999) Analysis of the heel pad fat in rheumatoid arthritis. Foot Ankle Int 20(8):481–484

    Article  CAS  Google Scholar 

  23. Martins N, Polido-Pereira J, Caneira M, Fonseca JE (2019) Treatment of persistent cutaneous atrophy after corticosteroid injection with fat graft. Reumatol Clin 15(6):e122–e124

    Article  Google Scholar 

  24. Taneja AK, Santos DC (2014) Steroid-induced Kager’s fat pad atrophy. Skelet Radiol 43(8):1161–1164

    Article  Google Scholar 

  25. Basadonna PT, Rucco V, Gasparini D, Onorato A (1999) Plantar fat pad atrophy after corticosteroid injection for an interdigital neuroma: a case report. Am J Phys Med Rehabil 78(3):283–285

    Article  CAS  Google Scholar 

  26. Schlappner OL, Wood MG, Gerstein W, Gross PR (1972) Painful and nonpainful piezogenic pedal papules. Arch Dermatol 106(5):729–733

    Article  CAS  Google Scholar 

  27. Jiang ZX, Tan GZ, Li BY, Wang L, Li XQ (2019) Painful piezogenic pedal papules in a female babysitter: a case-based review. Am J Dermatopathol 41(6):463–464

    Article  Google Scholar 

  28. Rocha Bde O, Fernandes JD, Prates FV (2015) Piezogenic pedal papules. An Bras Dermatol 90(6):928–929

    Article  Google Scholar 

  29. Shelley WB, Rawnsley HM (1968) Painful feet due to herniation of fat. JAMA 205(5):308–309

    Article  CAS  Google Scholar 

  30. Kahana M, Levy A, Ronnen M, Cohen M, Schewach-Millet M (1985) Painful piezogenic pedal papules on a child with Ehlers-Danlos syndrome. Pediatr Dermatol 3(1):45–47

    Article  CAS  Google Scholar 

  31. Ronnen M, Suster S, Huszar M, Schewach-Millet M (1987) Solitary painful piezogenic pedal papule in a patient with rheumatoid arthritis. Int J Dermatol 26(4):240–241

    Article  CAS  Google Scholar 

  32. Wortsman X, Ferreira-Wortsman C (2020) Ultrasound in sports and occupational dermatology. J Ultrasound Med. https://doi.org/10.1002/jum.15550

  33. Turkmani MG (2018) Piezogenic pedal papules treated successfully with deoxycholic acid injection. JAAD Case Rep 4(6):582–583

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Internal Medicine, Boston University/Boston Medical Center, Boston, MA, USA

    Eleni Pilitsi

  2. Department of Rheumatology, Boston University/Boston Medical Center, 725 Albany Street, Boston, MA, 02118, USA

    Eugene Kissin

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  1. Eleni Pilitsi
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  2. Eugene Kissin
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Both authors reviewed the literature and wrote the manuscript.

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Correspondence to Eugene Kissin.

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Supplementary Information

Video Subcalcaneal bursa with heel fat pad herniation in a patient with RA (MP4 32770 kb)

Light pressure of the right heel fat pad leads to material shifting from the plantar surface to the medial side of the calcaneus with corresponding ultrasonographic assessment showing hypoechoic and non-compressible tissue with a small amount of internal hypoechoic fluid extending from the inferior to the medial aspect of the calcaneus (MP4 32770 kb)

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Pilitsi, E., Kissin, E. Heel fat pad involvement in rheumatoid arthritis: a review and case series. Clin Rheumatol 40, 4373–4377 (2021). https://doi.org/10.1007/s10067-021-05725-4

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  • DOI: https://doi.org/10.1007/s10067-021-05725-4

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