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I have a 14 year old male patient who we have recently discovered has a condition called Bone Marrow Oedema sydnrome. This was diagnosed using MRI. He initially presented to the joint physio/pod clinic with a history of achilles tendon pain, a noticable bursitis around the achilles insertion. He was limping heavily and had a very protective gait pattern. We initially thought the pain was related to the bursitis and possibly Severs. Bursitis was confirmed on MRI, but also bone marrow oedema was shown in the posterior aspect of the calc and in a number of other bones in the ankle/subtalar complex. I have never heard of this condition and couldn't find any colleague/physios who had either - does anyone have any experience of this?:confused: A quick Google search should some limited info only - apparently it's usually in the feet. Was I not listening in that lecture?!

Thanks, Ella

PS - note to self - must stop seeing weird and wonderful paeds conditions with a certain physio!!!:bang:

 

You probably found little as little is known about it. As a diagnosis, it only recently been recognised due to MRI.

See this post on bone marrow oedema in some cases of plantar fasciitis. There was also this thread on decompression drilling for heel pain, which could be speculated as help bone marrow oedema.

 

Also see bone marrow oedema in medial tibial stress syndrome, so no big surprises to find it in the calc. in association with Severs.

 

Bone marrow edema is also the hallmark in "stress reactions" in metatarsals, previously known as "pre-stress fractures of metatarsals". The MRI scan is opening up a whole new world of possibilities in the early detection and treatment of mechanically-induced bone pathology previously invisible to plain-film radiographs. MRI is now being used in collegiate and professional athletes to detect bone marrow edema and stress reaction before stress fracture occurs.

Check out this paper.....the future is here!
Role of MRI in Prevention of Metatarsal Stress Fractures in Collegiate Basketball Players

 

Thanks for all your replies, and to Kevin for the paper. I'm glad it's not just me that finds this relatively new! Very interesting though

 

Bone Marrow Edema Patterns in the Ankle and Hindfoot: Distinguishing MRI Features.
Rios AM, Rosenberg ZS, Bencardino JT, Rodrigo SP, Theran SG.
AJR Am J Roentgenol. 2011 Oct;197(4):W720-W729.

 

Does diagnosis change treatment regime ? i.e should I M.R.I all suspected severs?
Tim

 

I would not think so Tim on both counts

 

I really would like a copy of this anyone help me please

 

Couldn't manage to PM it, so ...

 

As an update (as this thread was originally started 3 1/2 years ago), the patient in question went on to be diagnosed with Juvenille Idiopathic Arthritis after we referred him on.

 

The N.H.S is awash with flow charts and guidelines, at what point in say a non -resolving severs would you press for MRI investigation?It is not uncommon for paed pods to have no access to M.R.I
Tim

 

Pictorial essay: Evaluating bone marrow oedema patterns in musculoskeletal injury
Michael Gregory Kozoriz, Julia Grebenyuk, Gordon Andrews, Bruce B Forster
Br J Sports Med doi:10.1136/bjsports-2011-090661

 

BONE MARROW OEDEMA SYNDROME OF THE FOOT AND ANKLE – IS IT REALLY TRANSIENT
A. Guha, A. Abbassian, S. Zaidi, A. Goldberg, and D. Singh
J Bone Joint Surg Br 2012 94-B:(SUPP XLIII) 61

 

Bisphosphonates or prostacyclin in the treatment of bone-marrow oedema syndrome of the knee and foot.
Baier C, Schaumburger J, Götz J, Heers G, Schmidt T, Grifka J, Beckmann J.
Rheumatol Int. 2012 Nov 10.

 

Effects of intravenous iloprost therapy in patients with bone marrow oedema of the foot and ankle.
Röhner E, Zippelius T, Steindl D, Fussi J, Perka C.
Eur J Orthop Surg Traumatol. 2013 Sep 19.

 

Bone Marrow Edema Lesions in the Professional Runner.
Kornaat PR1, Van de Velde SK.
Am J Sports Med. 2014 Feb 20.

 

Bone Marrow Edema Lesions in the Professional Runner
Peter R. Kornaat, MD, PhD and Samuel K. Van de Velde, MD, MPH
Am J Sports Med May 2014 vol. 42 no. 5 1242-1246

 

Word of advice to researchers and clinicians when seeing bone marrow edema in the feet and ankles in competitive distance runners: don't call physiologic bone marrow edema that occurs due to the increased bone stress of distance running "Bone Marrow Edema Syndrome"!!

Just call it asymptomatic bone marrow edema!

 

Kevin, Can you expand on that, what if it is symptomatic does that mean it is BME syndrome?

Attached is an MRI report - would you consider this BME syndrome - this is a 53 year old non athletic female with pain in the cuneiforms and along 1st Ray that has been reduced with orthotic therapy but still persistently painful, which is why we went for MRI investigation.



Regards Dave

 

Dave:

My point in making that comment was that just because someone has bone marrow edema on MRI, doesn't also make it "Bone Marrow Edema Syndrome". Bone marrow edema within the feet is nearly always caused by excessive magnitudes of mechanical stress within the bones that, in turn, causes microfractures within the injured bone. We have known of the histological correlation between microfractures in bone and bone edema on MRI now for over 17 years.

http://informahealthcare.com/doi/pdf/10.3109/17453679809000933

Here's an interesting study on hip osteoarthritis which compared radiographic findings, MRI findings and histopathological findings along with the following quote in the conclusion:

The microfractures that cause bone edema are not always symptomatic. An MRI scan can't tell us if the bone edema is symptomatic or asymptomatic, it only tells us that the bone edema is present and it specifically tells us where the bone edema is anatomically located. Before MRI technology came along, we didn't even know "bone edema" existed.

As the radiologist noted, your patient has stress reactions (i.e. probable microfractures) within certain bones of the foot likely related to the abnormal magnitude of stress within this 53 year old female patient's bones. My educated guess is that either this woman is overweight or has relatively low bone density (i.e. osteopenia or osteoporosis). It is likely that, simply, her bones are not dense (i.e. strong) enough to support her body weight without causing microfracture damage within the points of highest compression stress within her foot skeleton. In addition, I expect that her midfoot bone edema may also be caused by a lack of sufficient first ray dorsiflexion stiffness due to her hallux valgus deformity which, in turn, is causing a transfer of ground reaction force to her 2nd and 3rd metatarsal heads and excessive magnitudes of dorsiflexion moments on the 2nd and 3rd rays.

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.362.7815&rep=rep1&type=pdf

Hope this helps.:drinks

 

Treatment of Bone Marrow Edema of the Talus with Pulsed Electromagnetic Fields.
Nicolò Martinelli, Alberto Bianchi, Elena Sartorelli, Alessandra Dondi, Carlo Bonifacini, and Francesco Malerba
Journal of the American Podiatric Medical Association: January 2015, Vol. 105, No. 1, pp. 27-32.

 

Bone Marrow Edema Syndrome of the Foot and Ankle
Mid- to Long-Term Follow-up in 18 Patients
Dishan Singh et al
Foot Ankle Spec October 12, 2015

 

Extracorporeal shock wave therapy in the treatment of primary bone marrow edema syndrome of the knee: a prospective randomised controlled study
Fuqiang Gao et al
BMC Musculoskeletal Disorders 2015, 16:379 doi:10.1186/s12891-015-0837-2

 

In a vast majority of reports RM, outside the outside part of the skeleton, all usually put bone marrow edema. Therefore, you have to frame it as a symptom and not a disease.

 

Patent:
Treatment of bone marrow edema (oedema) with polysulfated polysaccharides

 

Bone Marrow Edema Syndrome in the Foot and Ankle
Seyed Alireza Mirghasemi et al
Foot & Ankle International September 1, 2016

 

High Prevalence of Vitamin D Deficiency in Patients With Bone Marrow Edema Syndrome of the Foot and Ankle
Konstantin Horas, MD, Lukas Fraissler, MD, Gerrit Maier, MD, Franz Jakob, MD, Lothar Seefried, MD, Christian Konrads, MD, Maximilian Rudert, MD, Matthias Walcher, MD
Foot & Ankle International March 24, 2017

 

Bone Marrow Oedema Syndrome of the Foot and Ankle: Our clinical experience using a single dose of intravenous Zolendronic acid (UK)
Madhu Mahindrakar, Christopher Otu, Kiran Putchakayala, Muditha Samaranayaka, Simon Barnes, Sankalp Tripathi, Rheumatology, Mid Cheshire Hospitals NHS Trust, Crewe, UNITED KINGDOM.
British Society for Rheumatology Conference April 27, 2017, 10:30 - 11:30 AM

 

Treatment of Bone Marrow Edema of the Foot and Ankle With the Prostacyclin Analog Iloprost.
Hörterer H et al
Foot Ankle Int. 2018 Jun 1

 

Identification of vitamin D and other bone metabolism parameters as risk factors for primary bone marrow oedema syndrome.
Oehler N et al
BMC Musculoskelet Disord. 2018 Dec 22;19(1):451. doi: 10.1186/s12891-018-2379-x.

 

Juvenile Transient Bone Marrow Oedema of the foot associated with vitamin D deficiency: a case study and an overview of pathogenesis and treatment
AngelosKaspirisaOlga D.SavvidoubEfstathiosChrronopouloscEliasVasiliadisd
The Foot; 4 January 2019

 

Prevalence of bone marrow edema in a study population with foot and/or ankle pain
DavidGonzález-MartínaMarioHerrera-PérezabcPabloMartín-VélezaDiegoRendón-Díazac
The Foot; 17 April 2019

 

Traumatic bone marrow edema of the calcaneus: Evaluation of color-coded virtual non-calcium dual-energy CT in a multi-reader diagnostic accuracy study.
Booz C et al
Eur J Radiol. 2019 Sep;118:207-214

 

Bone Marrow Foot Oedema in Adolescents: The Role of Vitamin D.
Pieropan S et al
J Bone Metab. 2019 Nov;26(4):241-246

 

Traumatic and non-traumatic bone marrow edema in ankle MRI: a pictorial essay
Pawel Szaro et al
Insights Imaging. 2020 Aug 17;11(1):97

 

Bone marrow oedema syndrome of
the foot and ankle in a paediatric population: a retrospective
case series with serial MRI evaluation.
De Houwer H, Van Beek N, Prinsen S, Van Riet
A, De Roeck J, Verfaillie S.
J Child Orthop 2020;14.

 

Bone Marrow Edema Syndrome of the Foot Treated with Extracorporeal Shock Wave Therapy: A Retrospective Case Study
Jin Cao et al
October 06, 2020

 

Bone marrow oedema syndrome of the foot and ankle in a paediatric population: a retrospective case series with serial MRI evaluation
Hannah De Houwer et al
J Child Orthop. 2020 Oct 1;14(5):440-450

 

Bone Marrow Edema Syndrome of the Foot Treated with Extracorporeal Shock Wave Therapy: A Retrospective Case Series
Jin Cao et al
J Foot Ankle Surg. 2020 Oct 7;S1067-2516(20)30391-4