Reviewing Bone Marrow Edema in Athletes: A Difficult Diagnostic and Clinical Approach

Bone marrow edema (BME) is defined as an area of low signal intensity on T1-weighted (T1W) MRI images and associated with intermediate or high signal intensity findings on T2-weighted (T2W) MRI images. BME represents a typical imaging finding that characterizes common stress-related bone injuries of professional and amateur athletes. The etiology of stress-related injuries is influenced by numerous factors, including the initiation of a new sports activity or changes in an existing training protocol. The clinical significance of BME remains unclear. However, a correlation between the imaging pattern of BME, the clinical history of the patient and the type of sports activity practiced is essential for correct diagnosis and adequate therapeutic treatment. It is also important to clarify whether there is a specific threshold beyond which exercise can adversely affect the bone remodeling process, as the clinical picture may degenerate into the presence of BME, pain and, in the most severe cases, bone loss. In our review, we summarize the current knowledge on the etiopathogenesis and treatment options for BME and highlight the main aspects that make it difficult to formulate a correct diagnosis and establish an adequate therapeutic treatment.

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Subchondral insufficiency fracture of the knee: review of current concepts and radiological differential diagnoses

Japanese Journal of Radiology ◽

10.1007/s11604-021-01224-3 ◽

2021 ◽

Author(s):

Junko Ochi ◽

Taiki Nozaki ◽

Akimoto Nimura ◽

Takehiko Yamaguchi ◽

Nobuto Kitamura

Keyword(s):

Bone Marrow ◽

Signal Intensity ◽

Bone Marrow Edema ◽

Insufficiency Fracture ◽

Differential Diagnoses ◽

Osteochondral Lesions ◽

Imaging Features ◽

Subchondral Insufficiency Fracture ◽

Increased Risk ◽

Marrow Edema

AbstractSubchondral insufficiency fracture of the knee (SIFK) is a common cause of knee joint pain in older adults. SIFK is a type of stress fracture that occurs when repetitive and excessive stress is applied to the subchondral bone. If the fracture does not heal, the lesion develops into osteonecrosis and results in osteochondral collapse, requiring surgical management. Because of these clinical features, SIFK was initially termed “spontaneous osteonecrosis of the knee (SONK)” in the pre-MRI era. SONK is now categorized as an advanced SIFK lesion in the spectrum of this disease, and some authors believe the term “SONK” is a misnomer. MRI plays a significant role in the early diagnosis of SIFK. A subchondral T2 hypointense line of the affected condyle with extended bone marrow edema-like signal intensity are characteristic findings on MRI. The large lesion size and the presence of osteochondral collapse on imaging are associated with an increased risk of osteoarthritis. However, bone marrow edema-like signal intensity and osteochondral collapse alone are not specific to SIFK, and other osteochondral lesions, including avascular necrosis, osteochondral dissecans, and osteoarthritis should be considered. Chondral lesions and meniscal abnormalities, including posterior root tears, are also found in many patients with SIFK, and they are considered to be related to the development of SIFK. We review the clinical and imaging findings, including the anatomy and terminology history of SIFK, as well as its differential diagnoses. Radiologists should be familiar with these imaging features and clinical presentations for appropriate management.

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Short tau inversion recovery (STIR) after intravenous contrast agent administration obscures bone marrow edema-like signal on forefoot MRI

Skeletal Radiology ◽

10.1007/s00256-021-03852-2 ◽

2021 ◽

Author(s):

Tim Fischer ◽

Yassir El Baz ◽

Stephan Waelti ◽

Simon Wildermuth ◽

Sebastian Leschka ◽

...

Keyword(s):

Bone Marrow ◽

Contrast Agent ◽

Signal Intensity ◽

Bone Marrow Edema ◽

Healthy Tissue ◽

Intravenous Contrast ◽

Signal Change ◽

Contrast Agent Administration ◽

Intravenous Contrast Agent ◽

Marrow Edema

Abstract Objective Short tau or short TI inversion recovery (STIR) MRI sequences are considered a robust fat suppression technique. However, STIR also suppresses signals from other tissues with similar T1 relaxation times. This study investigates the in vivo effect of intravenous gadolinium-based T1-shortening contrast agent on STIR signal. Materials and methods Institutional board approval and informed consent was obtained. MRI examinations (1.5-T or 3-T) of 31 prospectively included patients were analyzed by two readers. Signal intensity of degenerative bone marrow edema-like signal at the Lisfranc joint on precontrast STIR images and on STIR images acquired after intravenous contrast agent administration (gadoteric acid, gadolinium: 0.5 mmol/ml, 15 ml) was measured. The medial cuneiform bone without observable bone marrow edema-like signal was considered a healthy tissue and served as a reference. Relative changes in signal intensity between precontrast and postcontrast images were calculated for the two tissues. Wilcoxon signed-rank test served for statistical analyses. Results In bone marrow edema-like signal, both readers observed a median signal change of -35% (interquartile range (IQR) 24) and -34% (IQR 21), respectively, on postcontrast STIR images compared to precontrast STIR. In healthy tissue, the signal remained constant on postcontrast STIR images (median change -2%, IQR 15, and 0%, IQR 17) respectively. For both readers, postcontrast signal change in bone marrow edema-like signal differed from that in healthy tissue (p < 0.001). Conclusion Intravenous gadolinium-based contrast agent causes a significant reduction of signal intensity in bone marrow edema-like signal on routine STIR images. Thus, pathological MRI findings may be obscured.

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Bone Marrow Lesion: Image, Clinical Presentation, and Treatment

Magnetic Resonance Insights ◽

10.1177/1178623x17703382 ◽

2017 ◽

Vol 10 ◽

pp. 1178623X1770338 ◽

Cited By ~ 6

Author(s):

Marcelo Batista Bonadio ◽

Alipio Gomes Ormond Filho ◽

Camilo Partezani Helito ◽

Xavier MGRG Stump ◽

Marco Kawamura Demange

Keyword(s):

Bone Marrow ◽

Bone Marrow Edema ◽

Clinical Presentation ◽

High Signal Intensity ◽

High Signal ◽

Imaging Characteristics ◽

Generic Term ◽

Osteoarthritis Progression ◽

Initial Results ◽

Marrow Edema

In this article, the cause, histology, imaging characteristics, clinical presentation, and treatment of these lesions are thoroughly discussed. Bone marrow edema is the generic term classically used to describe the high-signal-intensity alterations detected on magnetic resonance fluid-sensitive sequences. The significance of bone marrow edema for the patient’s clinical condition and the prognosis of the affected joint is being increasingly investigated and discussed, and situations characterized by subchondral insufficiency are receiving increasing attention. More recent studies found some important correlations between bone marrow lesions and patient’s pain and osteoarthritis progression. Conservative treatment is based on anti-inflammatory and analgesic uses according to the patient’s pain, combined with reduced load on the affected limb. Regarding surgical treatment, subchondroplasty is an option still in development, albeit with promising initial results.

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Bone Marrow Edema Syndrome in the Foot and Ankle

Foot & Ankle International ◽

10.1177/1071100716664783 ◽

2016 ◽

Vol 37 (12) ◽

pp. 1364-1373 ◽

Cited By ~ 20

Author(s):

Seyed Alireza Mirghasemi ◽

Elly Trepman ◽

Mohammad Saleh Sadeghi ◽

Narges Rahimi ◽

Shervin Rashidinia

Keyword(s):

Bone Marrow ◽

Bone Marrow Edema ◽

Treatment Options ◽

Correct Diagnosis ◽

Symptomatic Treatment ◽

Unknown Etiology ◽

Foot And Ankle ◽

Level Of Evidence ◽

Bone Marrow Edema Syndrome ◽

Marrow Edema

Bone marrow edema syndrome (BMES) is an uncommon and self-limited syndrome characterized by extremity pain of unknown etiology. Symptoms may include sudden or gradual onset of swelling and pain at rest or during activity, usually at night. This syndrome mostly affects middle-aged men and younger women who have pain in the lower extremities. The most common sites involved with BMES, in decreasing order of frequency, are the bones about the hip, knee, ankle, and foot. The diagnosis of BMES is confirmed with magnetic resonance imaging to exclude other causes of bone marrow edema. The correct diagnosis in the foot and ankle often is delayed because of the low prevalence and nonspecific signs. This delay may intensify bone pain and impair patient function and quality of life. The goal of BMES treatment is to relieve pain and shorten disease duration. Treatment options are limited and may include symptomatic treatment, pharmacologic treatment, and surgery. Level of Evidence: Level V, expert opinion.

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Dental implants: a potential cause of bone marrow edema in the jaw—preliminary report

International Journal of Implant Dentistry ◽

10.1186/s40729-021-00306-1 ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Hirotaka Muraoka ◽

Naohisa Hirahara ◽

Kotaro Ito ◽

Takumi Kondo ◽

Shungo Ichiki ◽

...

Keyword(s):

Bone Marrow ◽

Magnetic Resonance ◽

Dental Implants ◽

Signal Intensity ◽

Bone Marrow Edema ◽

Magnetic Resonance Images ◽

Short Axis ◽

Bone Marrow Signal ◽

Marrow Signal ◽

Marrow Edema

Abstract Background Different magnetic resonance imaging (MRI) sequences are frequently used to examine bone marrow in the jaw, including short tau inversion recovery (STIR). MRI is a sensitive method for detecting bone marrow lesions. Currently, pantomography and computed tomography (CT) are used frequently for preoperative dental implant treatment. However, no study has evaluated bone marrow edema around dental implants using MRI. This study aimed to assess bone marrow edema in the jaw around dental implants using brain magnetic resonance images. Methods This retrospective cohort study was approved by our university ethics committee (EC19-011). A total of 17 patients (170 sites) who underwent brain MRI between April 2010 and March 2016 were analyzed. All subjects underwent scanning more than 3 years after implant placement. This study investigated two bone marrow signals (with implant site and without implant site). These two groups were then compared using Fisher’s exact test. The Mann–Whitney U test was used to analyze bone marrow signal intensity as the dependent variable and the long and short-axis diameters of the implant as the independent variables. Results The were 22/31 sites (71%) and 38/139 sites (27%) of bone marrow edema in the dental implants and without dental implants groups, respectively (p < 0.001). Furthermore, there was a significant correlation between bone marrow signal intensity and the short-axis diameter of the implant (p < 0.001). Conclusion The signal intensity in the bone marrow sites in the jaw with dental implants was significantly higher than that in the sites without dental implants. The present study findings suggest that dental implants are a potential cause of bone marrow edema in the jaw.

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MRI Bone Marrow Edema Signal Intensity

Spine ◽

10.1097/brs.0000000000003277 ◽

2019 ◽

Vol 45 (18) ◽

pp. E1166-E1171

Author(s):

Kevin Sims ◽

Alex Kountouris ◽

James R. Stegeman ◽

Andrew H. Rotstein ◽

David Beakley ◽

...

Keyword(s):

Bone Marrow ◽

Signal Intensity ◽

Bone Marrow Edema ◽

Marrow Edema

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MRI features of and factors related to ankle injuries in asymptomatic amateur marathon runners

Skeletal Radiology ◽

10.1007/s00256-020-03530-9 ◽

2020 ◽

Vol 50 (1) ◽

pp. 87-95

Author(s):

Wanzhen Yao ◽

Yanjing Zhang ◽

Li Zhang ◽

Jing Zhou ◽

Yi Zhang ◽

...

Keyword(s):

Risk Factors ◽

Bone Marrow ◽

Signal Intensity ◽

Bone Marrow Edema ◽

Lateral Collateral Ligament ◽

Ankle Injuries ◽

Ligament Injury ◽

Marathon Runners ◽

Mri Features ◽

Marrow Edema

Abstract Objective To analyze the MRI manifestations of and factors related to ankle injuries in asymptomatic amateur marathon runners. Materials and methods A total of 113 amateur marathon runners without any ankle joint symptoms were recruited. Each participant was asked to complete a questionnaire at the beginning of the study and underwent MRI of the ankle. The MRI manifestations of ankle injuries were summarized, and binary logistic regression analysis was applied to analyze the factors related to ankle injuries. Results The main MRI features were bone marrow edema-like signal intensity, peritendinous effusion, and partial lateral collateral ligament injury. Others included Achilles tendinopathy, cyst-like lesions, osteochondral lesions, and subcutaneous soft tissue edema. The risk factor for bone marrow edema-like signal intensity in amateur marathon runners was a rearfoot strike pattern (p = 0.028, OR = 1.172); the risk factors for peritendinous effusion were a higher weekly running distance (p = 0.013, OR = 1.685) and increased running years (p = 0.039, OR = 1.113), whereas a rearfoot strike pattern (p = 0.005, OR = 0.831) was a protective factor for peritendinous effusion; the risk factor for Achilles tendinopathy was increased age (p = 0.008, OR = 1.412); the risk factors for anterior talofibular ligament injury were a rearfoot strike pattern (p = 0.017, OR = 1.346) and higher weekly running distance (p = 0.022, OR = 1.171); and the factors for calcaneofibular ligament injury were a higher weekly running distance (p = 0.029, OR = 1.570) and rearfoot strike pattern (p = 0.035, OR = 1.463). Conclusion The main MRI features of asymptomatic amateur marathon runners are bone marrow edema-like signal intensity, peritendinous effusion, and partial lateral collateral ligament injury. In addition, increased age, increased running years, higher weekly running distance, and different foot strike patterns are risk factors for ankle injuries.

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