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Bony Oedema. I think this is very interesting.

I had a MVA pt who had "Diffuse bony oedema of calcaneus, cuboid and cuneiform." (seen by MRI imaging)

What is interesting is the fact that alot of MRIs of knees that identify ACL ruptures also identify bony oedema of femur and tibia (not sure about fibula).

What I am saying, ..............if this is the case that a knee injury may cause this bony oedema could it be that some pain we could not identify clinically or by normal imaging could be related to bony oedema picked up by MRI?

Yes it is hypothetical however what springs to my mind first is the pt's that are classified as having arthritic pain with near perfect joint space in plain film x-rays.

A very long shot......but interesting.

Any experiences with this?

Cheers,
Con

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Plain film changes of DJD always lag several years behind the actual pathology. Its like looking in the rear view mirror.

MRI is just much more sensitive to the inflammatory component of degenerative joint disease...much less altered weight-bearing dynamics that can often cause striking bone marrow oedema.

I can't wait for the day that in-house, cheap MRI extremity scanning is a reality in every podiatry practice...

LL

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Remember, it's just a foot.

Con:

Bone edema (e.g. bone marrow edema) is a finding that is specific to MRI scanning and has become a terminology and objective finding specifically due to the technological development of MRI scanning....it can't be seen with any other test. This has led not only to the ability to detect bone injuries that we could not have identified before but can also be used to detect the development of disease processes from their subclinical initiation to their full-blown disabling presentations.

Many of the disease processes we treat now with great confidence are evidenced primarily by the MRI finding of bone edema: medial tibial stress syndrome, metatarsal stress reaction (i.e. pre-stress fracture), bone bruising from contusion (e.g. proximal plantar fasciitis will sometimes show plantar calcaneal bone edema) and bone bruising from joint motions (e.g. subchondral edema in talus/tibia with inversion ankle sprains). In my opinion, it has totally changed our ability to diagnose pathology, but has also given us a much better handle on the progression of stress-related injuries in the foot and lower extremity.

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Sincerely,

Kevin

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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
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Voice: (916) 925-8111 Fax: (916) 925-8136
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Con,

I agree with Kevin that MRI examination is extremely useful in detecting this hitherto non-specific clinical pain. Had a patient recently who had an episode of pain in the 1st metatarsal, cuboid and navicular several years ago which took 4-5 months to resolve. In February this year this pain returned - same foot but in the calcaneum, cuboid and 3rd netatarsal. X-ray and MRI examination diagnosed osteopenia and bone oedema. Published research suggests this usually resolves within 6-9 months however further episodes can occur and in different sites. Rx with ice, immobilisation and NSAIDs seem to work best.

Mark

1. Treatment of bone-marrow oedema of the talus with the prostacyclin analogue iloprost. N. Aigner, G. Petje, G. Steinboeck, W. Schneider,
C. Krasny, F. Landsiedl- From the Orthopaedic Hospital Vienna-Speising, Vienna, Austria

http://www.jbjs.org.uk/cgi/reprint/83-B/6/855.pdf

2. Clinical Outcome of Edema-like Bone Marrow Abnormalities of the Foot
Marco Zanetti, MD, Christian Luzius Steiner, Burkhardt Seifert, PhD and Juerg Hodler, MD

http://radiology.rsnajnls.org/cgi/co...l/2221010316v1

3. Bone marrow edema in the foot—MRI findings after conservative therapy
Foot and Ankle Surgery, Volume 11, Issue 2, Pages 87-91
N.Aigner, C.Radda, R.Meizer, G.Petje, S.Kotsaris, C.Krasny, F.Landsiedl, G.Steinboeck


Abstract
Bone marrow edema (BME) is a rare cause of pain in the foot. We reviewed 23 patients with unilateral idiopathic bone marrow edema located in the foot. The patients' mean age was 59.1 years (32–73). Bone marrow edema was located 12 times in the talus, four times in the cuneiform bones, four times in the metatarsal bones, two times in the calcaneus, and once in the navicular bone. Edema secondary to an activated osteoarthritis, to mechanic stress, to a chronic regional pain syndrome or to trauma were excluded. The size of BME was categorized large in nine cases (50–100% of the bone involved), in nine cases medium (25–50%) and in five cases small (<25%).

Conservative therapy consisted of infusions with the vasoactive substance iloprost and limited weight-bearing for a period of three weeks. After 3 months, in 15 patients BME showed total regression on MRI scan. In three there was subtotal regression and in three no change in the size of the BME (p<0.0001).

No correlation between the primary size of BME and outcome was seen (p=0.453). No progression to AVN occurred in our patients. In two patients BME appeared to migrate to neighbouring bones and in one patient to a femoral head.

Conclusions. Bone marrow edema syndrome is rarely seen in the foot. Progress to avascular necrosis is unlikely. Conservative therapy can be recommended.

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www.mark-russell.net

"citing an indisposition due to special circumstances"

My location

Mark, what was the symptomatic response?

Cheers

Fred

Dear All

The MRI works by producing an electromagmentic field that targets the hydrogen atom. In this field all the protons line up in one plane.

Hydrogen is in water, fat and any tissue that contains blood.

The MRI can have its power cut rapidly or slowly (basically). This rate of power decay allows the protons in different materials to emit energy as they move back to their normal spin pattern.

proton's in fluids eg. blood (read serum/plasma), lose their energy quickly while fat loses it's energy slowly.
This by manipulating the power one can let the fluid section of the body show up white (lots of proton energy this is a type 2 MRI scan) while using a slower deacy one can let the fat and other tissues show up. Called a type 1 MRI.
Thus the saying: Type 1 shows anatomy (pictures are made quickly and thus one does not move much - breathing)
while type 2 take much longer and thus sharp images are not obtainable (the main bug bear of MRI).

So by manipulating the signals, one can produce what are called fat supression images (thus the bone marrow will not show up as well as the surrounding tissues. All will appear dark)

When these fat supressed images are focused into the bones the only thing that will show up is the water and this water is called bony oedema.

Most MRI machines are rated between 1 and 1.5 Tesla in power.

The reason why one cannot see early cartlige damage is because cartilage has almost no blood supply and thus no water present, so early changes cannot be seen.

In march 09 a 3.0 strength Tesla MRI was able to use the sodium atom instead of hydrogen atom for their studies.
As cartilage has a great deal of sodium present, they now can detect early OA changes in knee catilage.

So far only large joints can be viewed by as all medical things, they soon will be able to look at smaller joints.

Hope that helps you understand this great tool.
Unfortunatley the MRI will stay fixed. The one I use has a 7 tonne magnet and the magnet lives in 5.5 tonnes of liquid helium!
20 years ago a 1.0 Tesla had a 25 tonne magnet and 20 tonnes of liquid helium to keep it cool and convert the magnet into a superconducting magnet.

Regards from sunny sydney 21 C today...silly for the middle of winter.
musmed

Fred,

The patient describes the pain as being localised, intense and unremitting, sudden onset - she was woken by it early one morning - with the primary centre moving from site to site in different days. The pain during the first week was not alleviated by rest or NSAIDs (she described it as similar to an acute toothache), however ice footbaths provided some relief by week 2. I would accept Kevin's trauma/injury can precipitate an episode, however it can also appear to be idiopathic (unless osteopenia has a bearing in this case).

Mark

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"citing an indisposition due to special circumstances"

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