Rheumatology International

, Volume 39, Issue 12, pp 2129–2136 | Cite as

Intermetatarsal bursitis as first disease manifestation in different rheumatological disorders and related MR-imaging findings

  • Omar M. AlbtoushEmail author
  • Theodoros Xenitidis
  • Marius Horger


Metatarsalgia defined as pain at the plantar aspect of the forefoot. Intermetatarsal bursitis is considered one potential soft-tissue cause of metatarsalgia that is presumably under-estimated, under-investigated, and, consequently, often misdiagnosed. To assess the role of MRI in the elucidation of the cause of metatarsalgia in patients with different autoimmune disorders presenting primarily with this symptom and to present the accompanying clinical and radiological findings of intermetatarsal bursitis. Retrospective evaluation of the medical records of patients with different rheumatological conditions claiming primarily of pedal pains suggests metatarsalgia and who underwent, therefore, all magnetic resonance imaging between March 2010 and April 2018. Of them, six patients fulfilled these criteria and were diagnosed subsequently with intermetatarsal bursitis. Several underlying autoimmune conditions were diagnosed. All patients were clinically assessed by the squeeze test and radiologically investigated with MRI; three patients underwent additional sonography. All patients presented intermetatarsal bursitis as first disease manifestation. The number of involved bursae ranged from one to three on one side. The main MR findings were distension of the intermetatarsal bursa with increased signal intensity on T2-weighted and post-contrast fat saturation T1-weighted images. Most frequent locations were the second and third intermetatarsal spaces. The size of the intermetatarsal bursitis and its plantar extension were correlated in all patients. Intermetatarsal bursitis can potentially be the first manifestation of different rheumatological diseases. Awareness of this potential association as well as cognizance of its imaging findings can help for making a more accurate and prompt earlier diagnosis of the underlying disease changing also the therapeutic approach.


Intermetatarsal Bursitis Metatarsalgia Squeeze test Foot MRI 


Author contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by OMA, TX, and MH. The first draft of the manuscript was written by OMA, TX, and MH, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Koski JM (1998) Ultrasound detection of plantar bursitis of the forefoot in patients with early rheumatoid arthritis. J Rheumatol 25(2):229–230PubMedGoogle Scholar
  2. 2.
    Martel W, Stuck KJ, Dworin AM et al (1980) Errosive osteoarthritis and psoriatic arthritis: a radiological comparison in the hands, wrist and foot. AJR 134:125CrossRefGoogle Scholar
  3. 3.
    Șerban O, Bădărînză M, Fodor D (2019) The relevance of ultrasound examination of the foot and ankle in patients with rheumatoid arthritis—a review of the literature. Med Ultrason 21(2):175–182CrossRefGoogle Scholar
  4. 4.
    Endo Y, Koga T, Eguchi M et al (2018) Utility of power doppler ultrasonography for detecting forefoot bursae in early rheumatoid arthritis: a case report. Med (Baltimore) 97(51):e13295CrossRefGoogle Scholar
  5. 5.
    Resnick D (1974) Patterns of peripheral joint disease in ankylosing spondylitis. Radiology 110:523–532CrossRefGoogle Scholar
  6. 6.
    Mukherjee S, Cherry L, Zarroug J et al (2016) A pilot investigation of the prevalence of US-detectable forefoot joint pathology and reported foot-related disability in participants with systemic lupus erythematosus. J Foot Ankle Res 9:27CrossRefGoogle Scholar
  7. 7.
    Claustre J, Bonnel F, Constans JP et al (1983) The intercapital metatarsal space: anatomical and pathological aspects. Rev Rhum Mal Osteoartic 50:435–440PubMedGoogle Scholar
  8. 8.
    Blocka KLN, Basset LW, Furst DE et al (1981) The arthropathy of advanced progressive systemic sclerosis: a radiographic survey. Arthritis Rheum 24:874CrossRefGoogle Scholar
  9. 9.
    Awerbuch MS, Shephard E, Vernon-Roberts B (1982) Morton’s metatarsalgia due to intermetatarsophalangeal bursitis as an early manifestation of rheumatoid arthritis. Clin Orthop 167:214–221Google Scholar
  10. 10.
    Ganguly A, Warner J, Aniq H (2018) Central metatarsalgia and walking on pebbles: beyond morton neuroma. AJR Am J Roentgenol 210(4):821–833CrossRefGoogle Scholar
  11. 11.
    Bowen CJ, Hooper L, Culliford D et al (2010) Assessment of the natural history of forefoot bursae using ultrasonography in patients with rheumatoid arthritis: a twelve-month investigation. Arthritis Care Res (Hoboken). 62(12):1756–1762CrossRefGoogle Scholar
  12. 12.
    Aletaha D, Neogi T, Silman AJ et al (2010) Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis 69(9):1580–1588CrossRefGoogle Scholar
  13. 13.
    Wiesinger T, Smolen JS, Aletaha D et al (2013) Compression test (Gaenslen’s squeeze test) positivity, joint tenderness, and disease activity in patients with rheumatoid arthritis. Arthritis Care Res (Hoboken). 65(4):653–657CrossRefGoogle Scholar
  14. 14.
    Boutry N, Larde A, Lapegue F et al (2003) Magnetic resonance imaging appearance of the hands and feet in patients with early rheumatoid arthritis. J Rheumatol 30:671–67915PubMedGoogle Scholar
  15. 15.
    Cherry L, King L, Thomas M et al (2014) The reliability of a novel magnetic resonance imaging-based tool for the evaluation of forefoot bursae in patients with rheumatoid arthritis: the FFB score. Rheumatol (Oxford) 53(11):2014–2017CrossRefGoogle Scholar
  16. 16.
    Bossley CJ, Cairney PC (1980) The intermetatarsophalangeal bursa: its significance in Morton’s metatarsalgia. J Bone Joint Surg Br 62-B:184–187CrossRefGoogle Scholar
  17. 17.
    Theumann NH, Pfirrmann CW, Chung CB et al (2001) Intermetatarsal spaces: analysis with MR bursography, anatomic correlation, and histopathology in cadavers. Radiology 221(2):478–484CrossRefGoogle Scholar
  18. 18.
    Chauveaux D, Le Huec JC, Midy D (1987) The supra-transverse intermetatarsocapital bursa: a description and its relation to painful syndromes of the forefoot. Surg Radiol Anat 9:13–18CrossRefGoogle Scholar
  19. 19.
    Zanetti M, Strehle JK, Zollinger H et al (1997) Morton neuroma and fluid in the intermetatarsal bursae on MR images of 70 asymptomatic volunteers. Radiology 203:516–520CrossRefGoogle Scholar
  20. 20.
    Hartmann D (1981) The tendon sheaths and synovial bursae of the foot: by Gustav Schwalbe, 1896—translated by Hartmann. Foot Ankle 1:246–269CrossRefGoogle Scholar
  21. 21.
    Zanetti M, Strehle JK, Kundert HP et al (1999) Morton neuroma: effect of MR imaging findings on diagnostic thinking and therapeutic decisions. Radiology 213:583–588CrossRefGoogle Scholar
  22. 22.
    Ashman CJ, Klecker RJ, Yu JS (2001) Forefoot pain involving the metatarsal region: differential diagnosis with MR imaging. Radiographics 21(6):1425–1440CrossRefGoogle Scholar
  23. 23.
    Iagnocco A, Coari G, Palombi G et al (2001) Sonography in the study of metatarsalgia. J Rheumatol 28(6):1338–1340PubMedGoogle Scholar
  24. 24.
    Cohen SL, Miller TT, Ellis SJ et al (2016) Sonography of morton neuromas: what are we really looking at? J Ultrasound Med 35(10):2191–2195CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of RadiologyEberhard Karls University TuebingenTuebingenGermany
  2. 2.Department of Diagnostic and Interventional RadiologyUniversity of JordanAmmanJordan
  3. 3.Department of Internal Medicine IIEberhard Karls University TuebingenTuebingenGermany

Personalised recommendations