Intermetatarsal bursitis (IMB) is a condition characterized by inflammation of the bursae—small, fluid-filled sacs located between the metatarsal bones in the forefoot. These bursae cushion and reduce friction between the bones, tendons, and soft tissues during walking. When they become inflamed, pain and swelling develop in the ball of the foot, often mistaken for other conditions such as Morton’s neuroma.
How Common It Is and Who Gets It? (Epidemiology)
IMB can affect anyone but is more common in adults who spend long hours on their feet or wear tight or narrow shoes. It is also frequently seen in individuals with rheumatoid arthritis (RA) or other autoimmune conditions, where inflammation extends to the small joints and bursae of the foot. Both men and women can develop IMB, though women are slightly more prone due to footwear choices that place pressure on the forefoot.
Why It Happens – Causes (Etiology and Pathophysiology)
IMB develops when the bursae between the metatarsal heads become irritated and inflamed. Causes include:
- Mechanical stress: Repetitive pressure from walking, running, or ill-fitting shoes.
- Structural abnormalities: Flatfoot, high arches, or misalignment of the metatarsals increase friction between bones.
- Inflammatory diseases: Rheumatoid arthritis, lupus, and other autoimmune conditions that attack the synovial lining of bursae.
- Injury or trauma: Direct impact to the forefoot.
In rheumatoid arthritis, IMB is often an early indicator of disease activity and may occur alongside synovitis (joint lining inflammation) and tenosynovitis (tendon sheath inflammation).
How the Body Part Normally Works? (Relevant Anatomy)
The metatarsal bones are the five long bones in the forefoot that connect the toes to the midfoot. Between these bones lie the intermetatarsal bursae, which act as natural cushions. When healthy, they minimize friction during walking and balance the load across the foot. When inflamed, these bursae swell and compress nearby nerves, resulting in forefoot pain, numbness, or tingling sensations.
What You Might Feel – Symptoms (Clinical Presentation)
Symptoms of IMB include:
- Sharp, burning pain in the ball of the foot, especially between the second and third toes.
- Pain that worsens with walking or tight shoes and improves with rest.
- Swelling or tenderness between the metatarsal heads.
- Numbness or tingling in adjacent toes.
- In RA patients, associated stiffness, joint swelling, and deformities.
Because symptoms mimic those of Morton’s neuroma, accurate diagnosis is essential.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis begins with a physical exam to identify the site of pain and swelling.
- Ultrasound (US): Detects fluid-filled bursae and inflammation.
- MRI: Offers high-resolution imaging to confirm bursitis and rule out Morton’s neuroma or stress fractures. Contrast-enhanced MRI highlights inflamed bursae in detail.
- Clinical Correlation: For patients with autoimmune disease, lab tests such as rheumatoid factor (RF) and anti-CCP antibodies may confirm systemic inflammation.
Classification
IMB can be categorized as:
- Mechanical IMB: Caused by repetitive pressure or poor biomechanics.
- Inflammatory IMB: Associated with rheumatoid arthritis or autoimmune diseases.
- Post-Traumatic IMB: Following direct injury or surgery to the foot.
Other Problems That Can Feel Similar (Differential Diagnosis)
- Morton’s neuroma
- Metatarsalgia (general forefoot pain)
- Plantar plate tear
- Stress fracture
- Gout or pseudogout
Treatment Options
Non-Surgical Care
Initial management focuses on reducing inflammation and relieving pressure.
- Rest and Ice: Reduce swelling and pain.
- NSAIDs: Nonsteroidal anti-inflammatory drugs help control inflammation.
- Footwear Modification: Wearing wide, cushioned shoes to decrease forefoot compression.
- Orthotic Devices: Custom inserts redistribute pressure away from the inflamed area.
- Corticosteroid Injections: Reduce local inflammation when pain is persistent.
- Physical Therapy: Includes gentle stretching and gait correction exercises.
- RA Management: If caused by rheumatoid arthritis, DMARDs (disease-modifying antirheumatic drugs) such as methotrexate or biologics are used to control systemic inflammation.
Surgical Care
Surgery is reserved for chronic or severe cases unresponsive to conservative care.
- Bursa Excision (CPT 28090): The inflamed bursa is surgically removed to relieve pressure and eliminate pain.
- Procedure Details:
- Performed under local anesthesia.
- A small incision is made between the affected metatarsal heads.
- The bursa is excised, and the area is carefully closed with sutures.
- A sterile dressing and postoperative shoe protect the foot during healing.
Recovery and What to Expect After Treatment
Most patients can walk with protective footwear shortly after surgery.
- Initial Recovery: 2–3 weeks with limited activity and elevation.
- Full Recovery: 6–8 weeks, depending on healing and activity level.
- Physical Therapy: Encouraged after healing to restore mobility and strength.
Pain relief is typically immediate after recovery, and recurrence is rare if underlying causes are addressed.
Possible Risks or Side Effects (Complications)
- Infection or delayed wound healing
- Nerve irritation or numbness between toes
- Recurrence of bursitis if pressure persists
- Rarely, stiffness or scar sensitivity
Long-Term Outlook (Prognosis)
The long-term outlook after bursa excision is excellent. Most patients achieve lasting pain relief and return to normal walking without limitations. For rheumatoid arthritis patients, continued medical management is key to preventing recurrence or spread of inflammation to other joints.
Out-of-Pocket Cost
Medicare
CPT Code 28090 – Excision of Intermetatarsal Bursitis: $106.42
Medicare Part B covers 80% of the approved cost for this procedure once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield usually cover that remaining 20%, greatly reducing or eliminating out-of-pocket expenses for Medicare-approved procedures. These supplemental plans coordinate with Medicare to fill the coverage gap and provide financial protection.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it will act as a secondary payer. These plans often cover any remaining coinsurance or small deductibles, which typically range between $100 and $300, depending on your specific plan and provider network.
Workers’ Compensation
If your intermetatarsal bursitis developed due to a work-related condition or repetitive strain injury, Workers’ Compensation will cover all medical expenses, including surgery, rehabilitation, and postoperative care. You will not have any out-of-pocket costs, as your employer’s insurance carrier directly covers all approved treatments.
No-Fault Insurance
If your bursitis or related foot pain is due to an automobile accident, No-Fault Insurance will typically cover the entire cost of treatment, including excision and follow-up visits. The only potential out-of-pocket expense may be a small deductible or co-payment depending on your insurance policy.
Example
Laura Bennett had chronic pain and swelling between her metatarsal bones due to intermetatarsal bursitis. She underwent excision of the inflamed bursa (CPT 28090) with an estimated Medicare out-of-pocket cost of $106.42. Since Laura had supplemental insurance through AARP Medigap, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is Intermetatarsal Bursitis (IMB)?
A. Intermetatarsal Bursitis (IMB) is the inflammation of the bursae located between the metatarsal bones in the foot, leading to pain, swelling, and discomfort, especially in the forefoot.
Q. What causes Intermetatarsal Bursitis?
A. IMB can be caused by mechanical pressure on the foot, misalignment of bones, high-impact activities, or systemic inflammatory conditions like rheumatoid arthritis (RA), which may lead to inflammation in the bursa.
Q. How is Intermetatarsal Bursitis diagnosed?
A. Diagnosis is made through a physical examination and imaging techniques such as MRI or ultrasound to assess the extent of the bursitis and rule out other conditions like Morton’s neuroma.
Q. What are the treatment options for Intermetatarsal Bursitis?
A. Initial treatment includes anti-inflammatory medications, custom orthotics, and physical therapy. If conservative methods fail, excision of the inflamed bursa may be considered.
Q. What is the excision procedure for Intermetatarsal Bursitis?
A. The excision procedure involves making a small incision over the affected area, removing the inflamed bursa, and then closing the incision with sutures. It is typically performed under local anesthesia.
Q. What is the recovery time after excision of Intermetatarsal Bursitis?
A. Recovery typically takes 6 to 8 weeks, with patients advised to rest and use special footwear to avoid pressure on the foot during healing.
Q. Are there risks associated with the excision of Intermetatarsal Bursitis?
A. Risks include infection, nerve damage, and recurrence of bursitis. However, these risks are rare, and the procedure is generally safe and effective for relieving pain.
Q. What is the long-term outlook after excision of Intermetatarsal Bursitis?
A. The long-term prognosis is generally good, with most patients experiencing pain relief and improved mobility, although recurrence may happen, particularly if the underlying cause is not addressed.
Q. Will I be able to walk immediately after excision of Intermetatarsal Bursitis?
A. You will need to avoid putting weight on the foot for a short period after surgery. A special shoe or walking boot will typically be worn for several weeks to protect the foot while it heals.
Q. Is physical therapy required after excision of Intermetatarsal Bursitis?
A. Physical therapy is often recommended to help restore strength, flexibility, and mobility in the foot and to prevent complications such as stiffness or muscle weakness.
Q. Can excision of Intermetatarsal Bursitis be performed as an outpatient procedure?
A. Yes, excision of Intermetatarsal Bursitis is typically performed as an outpatient procedure, meaning you can go home the same day after the surgery.
Q. How long does the excision procedure for Intermetatarsal Bursitis take?
A. The procedure typically takes about 30 to 45 minutes, depending on the complexity of the condition and the patient’s individual needs.
Q. Is there a risk of recurrence after excision of Intermetatarsal Bursitis?
A. While recurrence is uncommon, it can happen, especially if the underlying cause, such as abnormal foot mechanics or continuous pressure on the area, is not addressed.
Q. Can I return to sports after excision of Intermetatarsal Bursitis?
A. Most patients can return to low-impact activities within 6 to 8 weeks, but high-impact activities should be avoided until the foot has fully healed and strength is restored.
Q. Will the excision of Intermetatarsal Bursitis affect my foot’s appearance?
A. The procedure generally does not significantly affect the foot’s appearance, as it only involves removing the inflamed bursa and not altering the overall structure of the foot.
Q. What is Intermetatarsal Bursitis?
A. IMB is inflammation of the fluid-filled sacs between the metatarsal bones, causing forefoot pain and swelling.
Q. Can IMB be confused with Morton’s neuroma?
A. Yes. Both conditions cause pain between the toes, but MRI or ultrasound can distinguish them.
Q. Is surgery always required?
A. No. Most patients improve with non-surgical care such as anti-inflammatories, orthotics, and proper footwear. Surgery is reserved for severe, persistent cases.
Q. How long does recovery take after bursa excision?
A. Typically 6–8 weeks, with light activity resuming earlier under doctor supervision.
Q. Is the procedure painful?
A. The surgery is minimally invasive and performed under local anesthesia; postoperative discomfort is mild and manageable.
Q. Can IMB recur?
A. Recurrence is rare, especially if underlying issues such as rheumatoid arthritis or foot mechanics are properly managed.
Summary and Takeaway
Intermetatarsal bursitis causes pain and inflammation in the ball of the foot due to irritation of the bursae between metatarsal bones. It can result from mechanical stress or inflammatory diseases like rheumatoid arthritis. Conservative treatments—including anti-inflammatories, orthotics, and physical therapy—are usually effective. For persistent cases, surgical removal of the inflamed bursa provides lasting relief and restores mobility.
Clinical Insight & Recent Findings
A recent study published in the International Journal of Surgery Case Reports highlighted how intermetatarsal bursitis (IMB) can serve as an early manifestation of rheumatoid arthritis (RA) and the importance of recognizing it early for effective treatment.
The case involved a 50-year-old woman who presented with chronic foot pain and swelling that was initially mistaken for Morton’s neuroma. MRI imaging revealed synovial proliferation and inflammation around the metatarsal joints, confirming IMB linked to RA. Surgical synovectomy provided significant pain relief and improved joint motion, and subsequent methotrexate therapy helped control ongoing inflammation.
The report emphasized that IMB is common in RA but often under-recognized by general orthopedic surgeons; identifying it early through MRI and laboratory testing can prevent joint destruction and deformity. (“Study on early rheumatoid arthritis presenting as intermetatarsal bursitis – see PubMed.”)
Who Performs This Treatment? (Specialists and Team Involved)
Excision of intermetatarsal bursitis is performed by an orthopedic foot and ankle surgeon or podiatric surgeon. The care team may include a rheumatologist (for autoimmune cases), anesthesiologist, and physical therapist to coordinate recovery and rehabilitation.
When to See a Specialist?
Consult a specialist if you have persistent pain in the ball of your foot that does not improve with rest, shoe changes, or medications. Early evaluation prevents chronic pain and disability.
When to Go to the Emergency Room?
Seek urgent care if you experience severe swelling, redness, warmth, or inability to walk, which may signal infection or a fracture.
What Recovery Really Looks Like?
Expect mild swelling and limited activity for a few weeks. Gradual return to walking is typical within 6–8 weeks, and most patients regain full mobility. Consistent follow-up ensures optimal healing.
What Happens If You Ignore It?
Untreated IMB can lead to chronic pain, altered walking mechanics, and nerve irritation. In rheumatoid arthritis patients, it may worsen joint deformities and compromise mobility.
How to Prevent It?
- Wear well-fitted, supportive shoes with wide toe boxes.
- Use orthotics to offload pressure on the forefoot.
- Maintain healthy body weight.
- Treat systemic inflammatory diseases early.
Nutrition and Bone or Joint Health
A balanced diet with omega-3 fatty acids, calcium, vitamin D, and protein supports tissue repair and reduces inflammation. Avoid smoking, which delays healing and worsens vascular supply.
Activity and Lifestyle Modifications
After recovery, engage in low-impact activities such as swimming, cycling, or yoga. Maintain proper foot support and flexibility exercises to prevent recurrence and maintain long-term foot health.
Dr. Mo Athar
