SLR - March 2019 - Candice Cooper

Technologies in the Treatment of Bone Marrow Edema Syndrome

Reference: Ghasemi RA, Sadeghi S, Rahimee N, Tahmasebi M. Technologies in the Treatment of Bone Marrow Edema Syndrome. Orthop Clin N Am. Jan 50(2019):131–8.

Scientific Literature Review

Reviewed by: Candice Cooper, DPM
Residency Program: Hennepin Healthcare

Podiatric Relevance: Bone marrow edema syndrome (BMES) is defined as increased interstitial fluid within the bone marrow causing intractable bone pain with no discernable cause. The bones of the foot and ankle are some of the most commonly involved sites of BMES. The etiology and pathophysiology of BMES remain relatively unclear, and there are a wide variety of suggested treatments in the literature. This article aims to review the current treatment options for BMES of the foot an ankle.

Methods: This article reviewed the various treatment options presented in the literature for BMES. Treatment options reviewed included symptomatic treatment with offloading and pharmacologic agents for pain control, the use of iloprost, bisphosphonates (alendronate, ibandronate, denosumab, and zoledronic acid), vitamin D, pulsed electromagnetic fields, polysulfated polysaccharides, core decompression and subchondroplasty.

Results: Symptomatic treatment consisting of offloading and pain control generally requires six to 12 months for complete recovery. Iloprost, when given over five consecutive days, has shown to immediately decrease pain within days of treatment. Follow-up MRI scans at one year showed reduction of bone marrow edema in a majority of the patients assessed. Of the bisphosphonates assessed, ibandronate had the most rapid resolution of pain in days to weeks with the others requiring months. When considering bisphosphonates, it is important to consider the possible side effects, with denosumab and zoledronic acid having the least risk of adverse effects. One study revealed that inadequate vitamin D levels were found in 84 percent of patients with BMES. As a result, it is highly recommended to check vitamin D levels and supplement as necessary. Five out of six patients who underwent pulsed electromagnetic fields were found to have resolution of pain after one month of treatment. It has been shown that patients receiving polysulfated polysaccharides for bone marrow edema can improve clinical symptoms and can decrease the amount of edema present; however, little research is available on this treatment method. Core decompression and subchondroplasty have been found to provide rapid relief of symptoms when conservative management has failed.

Conclusions: The authors conclude that the conservative treatments described for BMES provide satisfactory results and surgical treatments should only be considered once conservative management has failed. Simply treating with offloading and pain control may be a viable option, but highly active patients, such as athletes, may be interested in options that provide them the opportunity to return to activity faster. While the literature provided seemed to show current treatments yield good results, the authors made no comment on the quality of the studies assessed. Additionally, based on the literature, it seems rational to check vitamin D levels and supplement as necessary.

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