USS or MRI for L1st MTPJ bursa?

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Dear all,

I recently assessed a 19 year old male whom appears to have a very large bursa to the plantar surface of his left first metatarsophalangeal joint. This began approximately six to seven months ago when he noticed a large swelling to plantar aspect here. He is on his feet a lot with work wearing safety shoes as a car mechanic. He notes that the pain is made worse by weight bearing activities. He denies any trauma to the foot and no obvious history for occurrence. He is generally fit and well. Previous orthoses, RICE, NSAIDS and footwear adaptions have not helped.

On examination there was a large palpable soft tissue mass akin to a bursal sac at the plantar surface of the left first metatarsophalangeal joint. This covered the joint in its entirety. There was no associated swelling or signs of infection.

I am planning on organising a scan of the foot but unsure whether to organise and USS or MRI. Usually for confirmation of bursae I would choose an USS. However, I am not 100% this is a bursa and am considering an orthopaedic opinion. I am wondering also about the possiblity that it may commmunicate with the first MTPJ. Would an MRI be more helpful for both these queries?

Thanks for any advice and feedback.

 

US would be a good 1st line intervention. It might show you a communication, you can determine if their is inflammatory changes, whether it is cystic or solid, respects tissue planes and has a vascular supply, all valuable tools for the orthopaedic surgeon. US is quick, non-invasive, cheap and portable, so he might have to travel less than the nearest hospital with MRI.

 

Thanks Peter. Would there be any merit in organsing an MRI or would the USS be comprehensive enough? Would there be a time in this situation where an MRI may be preferable? Would the USS show the potential communication or would an MRI be more useful for this?

 

MRI would be obviously more accurate and definitive than US. US MAY show the communication, dependant upon the "tail" and barriers to sound eg bone. Us would give you a working diagnosis to start treatment from, and to rule out some basic nasties. Would an MRI change your Rx plan, might be the question. I tend to use MRI when I cannot find anything relative on US, or in cases of global symptoms eg peri-articular swelling/post trauma.

 

Thanks again, Peter.