introduction

Bone marrow edema syndrome ( BMÖS ) or transient osteoporosis is a temporary disease of the bones, in most cases the hip. However, knee and upper ankle joints may also be affected, albeit less frequently. Spontaneous pain in the hip is the classic hallmark of this disease. Men are statistically more affected than women. In both sexes, the disease usually occurs in middle age, ie between the 3rd and 5th decade of life. A diagnosis can be made on the basis of the symptoms and by MRI very safe.

causes

The causes of the primary bone marrow edema syndrome are not yet clarified, which is referred to in the jargon as " idiopathic ".

Secondarily, however, it can occur as a result of other diseases.
Traumatic injuries such as bruising, in particular, play a direct role in this, or they can indirectly lead to tissue wasting due to circulatory disorders and ultimately to a BME.

Even in the last trimester of pregnancy, in rare cases, due to compression fractures of the lumbar spine, it can come to the KMÖS.

diagnosis

X-ray examinations are usually inconspicuous in the case of primary bone marrow edema syndrome, since a reduction in bone density becomes visible only after a loss of 40% of the usual bone substance. Only sometimes, but usually only one to two months after onset of symptoms, a focal ( focal ) density decrease can be seen. The secondary CMEs, on the other hand, can show characteristic changes in the underlying disease in X-rays. The inflammatory and rheumatic values ​​remain negative in blood tests in both forms.

The best and almost 100% certainty is to diagnose bone marrow edema by MRI and differentiate it from other diseases. In this show significant bone marrow edema, ie the increased accumulation of tissue fluid, especially in femoral head and femoral neck. This may also be the case in lower regions of the thigh bone and may represent a blurred area. This picture is typical of a KMÖS. Scintigraphy may also be useful in the diagnosis. The use of radioactive markers reveals a characteristically increased blood flow to the hips and an increased activity of the bone-forming cells.

The most important differential diagnosis is osteonecrosis. This is the death of bone due to an infarct (the occlusion of a vessel ). However, with the above-mentioned examination findings, the osteonecrosis can be distinguished very well from a CMOS.

symptoms

The clinical picture of bone marrow edema syndrome is characterized by acute groin pain and limping gait as a result of this. The intensity of the pain usually increases over time, but in any case they will not completely regress. Rest and night pain usually do not occur. Also typical are movement restrictions in the area of ​​the hip joints. Above all, the spreading, the bending in the hip and the rotation of the thigh around its own axis are more difficult.

therapy

The aim of treating a bone marrow edema is to achieve a partial or complete relief of the hip, as well as freedom from pain. This can be achieved by the administration of drugs such as ibuprofen or diclofenac (belonging to the group of NSAIDs) and sometimes also with weak opioids, such as tramadol. With the aid of physiotherapy, micro fractures and compression fractures of the bone, which has a low load capacity, can be prevented. Furthermore, the intake of Aminobisphosphaten promote bone formation. These essentially exert two effects on the bone. On the one hand, they are taken up by bone-degrading cells, the osteoclasts, and inhibit their activity; on the other hand, they can attach themselves to the surface of bones, contributing directly to mineralization. In contrast, the use of calcitonin (an endogenous hormone to build the bone) and cortisone has not been proven. Prostacyclin and structurally similar drugs can be partially used in off-label use, without clinically proven proof of efficacy, and achieve a positive effect. Drilling edema, such as is often done with osteonecrosis, can result in an immediate and significant improvement in discomfort by relieving pressure on the bone and subsequently improving blood circulation. In any case, however, a drug and physiotherapy therapy is of the highest priority.

prophylaxis

As with other musculoskeletal disorders, sport is an excellent means of preventing bone marrow edema. Musculoskeletal construction provides good joint stability, significantly reducing the risk of bone injury and the likelihood of falls. Also, the stress on the bone promotes its metabolism and thus the structure of the bone substance.

After localization

Bone marrow edema at the knee

The knee of a human does not consist of a single bone, but is to be regarded as a joint. It consists of three bones that are stabilized by ligaments and muscles. Its bony parts include in the exact thigh, tibia and kneecap.

If fluid accumulates in one or more bones of the knee joint, this is called bone marrow edema of the knee.

  • Reason:
    The cause of the accumulation of fluid in the small cavities of the bone can range from an accident to a metabolic disease and must be clarified by a doctor.
  • symptoms:
    Symptomatic feel Affected pain in the area of ​​the knee, which can be explained by the increased pressure on the bone structures.
    The fluid fills the small interstices of the bone and exerts an unfamiliar force on the inside. The pressure increases just when the burden of the affected joint, if your own body weight and gravity stress the joint additionally.
    Movement-dependent pain peaks are typical for a bone marrow edema in the knee with an otherwise inconspicuous appearance of the joint.
    The fluid in the bone is in fact not visible to the naked eye from the outside. So optically it can correspond to a healthy knee.
  • Therapy:
    The therapy is always based on the cause of the bone marrow edema, but usually includes an initial protection of the affected joint. A relief with forearm crutches is sufficient and maintains the mobility of the joint. With the protection one allows the body to get the inflammatory reaction under control.
    Movement would only mean further irritation of all structures and reactively lead to even more fluid retention.
    Supportive lymph drainage can drain the fluid even faster.

How long the relief of the knee joint should take depends on the healing process. From experience, however, it should take about six weeks and be replaced in the course of a gradual reloading.

Bone marrow edema is very tedious because the metabolism of the bone becomes progressively slower with age.
Repair processes therefore require more and more time as they age. It will often take about one year for a bone marrow edema to completely heal.

For athletes, this means gradually increasing their performance and not running a competitive sport for at least three months.
Afflicted too fast the joint, the bone threatens to lose stability and elasticity.
The more pressure that is pressed onto the bone by accumulated fluid, the more its small blood vessels and nerves are compressed. The result is a deficiency of the bone tissue, which shows in the worst case in a sinking of the bone. Broken bones could be the result.

In order to avoid a too fast load, painkillers should be used sufficiently however metered. Only in the extreme case, operational measures such as a relief well should be considered. They often involve unnecessary risks and do not shorten the course of the disease.

Bone marrow edema at the hip

By a bone marrow edema of the hip is meant a fluid accumulation in the small cavities of the hip bone.
The liquid preferably accumulates in the femoral head.

  • Symptoms: To better understand the symptoms, it is important to know the structure of the hip joint. It consists of the thigh and the pelvis. For these two bones to form a joint, the thigh has a femoral head and the pelvis has a socket. Only with a perfect fit, together with ligaments and muscles, will they create an optimal joint.
    If fluid is lodged in the femoral head, the fluid presses on the mesh of its bony structures. The result is a painful inflammatory reaction in the bone itself. If the leg or hip is not moved, it does not hurt because there is no friction point between the hip bones in a quiet position.
    However, if the affected person is straining the leg, it causes pain. The articular surfaces meet and the nerves in the femoral head are compressed and irritated by the pressure of the fluid and the body's weight.
    The pain radiation often extends to the groin and often leads to a limp.
  • Causes: The cause of a bone marrow edema in the hip must always be found in individual cases.
    Often, age-related osteoarthritis in the hip is the trigger for fluid retention.

    Bone marrow edema on the shoulder

    Bone marrow edema of the shoulder is often due to accidents or age-related bone wear.

    • Causes:

    Both causes cause irritation of the bone and reactively lead to an inflammatory fluid accumulation in its interstices, and especially in its marrow. The fluid helps the body heal the inflammation better.
    The blood vessels become more permeable at the inflamed site during wound healing and allow cells and valuable substances to migrate into the tissue so that they can take over their defense and repair function.

    The fluid in the form of a bone marrow edema is therefore accumulated by the body itself. The bone is a very firm tissue that can not stretch as well as the skin. If too much fluid accumulates in its cavities, it presses on both its solid structures and its blood vessels and nerves. The effect is the sensation of pain. The pain will only dissipate when the fluid in the bone is reduced.

    • Therapy:

    A protection of the shoulder is therefore essential for the therapy. The discharge minimizes the inflammatory stimulus and allows the fluid to be transported away via lymphatic and blood vessels.
    If the affected person would put additional strain on his shoulder, the pressure on the bones would additionally irritate the nerves and the body would try to bring even more fluid with defense cells into the inflamed area.

    The carrying and lifting of loads and sports must therefore be avoided for at least three weeks (in some cases up to six weeks).

    Depending on the sensitivity to pain, a partial load follows, which must be increased in increments to full load.
    At the shoulder it is very difficult to estimate when a complete healing can be achieved.
    In order to maintain the mobility of the joint in all degrees of freedom, it must be moved regularly. Of course, the movement always causes irritation of the joint and delays the healing process. Nevertheless, it is necessary to retain no restrictions later.

    Physiotherapy is recommended for adequate exercise. It can take up to a year to complete healing.

    Bone marrow edema on the ankle

    A bone marrow edema of the ankle is a collection of fluid in one or more bones of the ankle.

    • Causes:
      Often the cause is a trauma that happens quite often during sports.
      The irritation of bone structures can be done either suddenly by a Fehlbelastung or permanently by an overload. So, when someone kinks, they can develop bone marrow edema just as well as over-stretching their bones through days of running.
      But also metabolic diseases, drugs or a disturbed blood circulation in the ankle area can cause bone marrow edema in the ankle joint.
    • symptoms:
      The symptoms are always comparable and are mainly due to ankle pain. The ankle may initially be swollen by the trauma, with swelling not being a characteristic sign of bone marrow edema.
      Much more typical is that sufferers feel pain without a cause is recognizable from the outside. The pain occurs especially during exercise and increase in intensity.
      Depending on the location of the bone marrow edema, the pain can additionally drag into the foot or the tibia.
    • Therapy:
      Normally, the immobilization of the ankle is sufficient to heal the bone marrow edema. Patients often receive initial forearm crutches for complete relief and, subsequently, a splint or unrolling aid for partial loading.
      The downer is that this treatment can take up to a year. However, it is also the safest and complication poorest, since it is not associated with any surgery.
      Surgery is rarely needed for bone marrow edema. If the pressure from the fluid on the bone is too strong and threatens to break the bone, a relief hole can be made. The fluid can drain through the drilled hole and the pain subsides.
      Nevertheless, after such an operation, the ankle must be relieved and the disease is not shortened.
      It only protects against bone destruction in an emergency. The procedure itself does not take long if no other structures such as muscles or ligaments have to be corrected by a trauma in the same procedure.

    Bone marrow edema at the lumbar spine

    The diagnosis of a bone marrow edema of the lumbar spine is a collection of fluid in the bone marrow of one or more vertebral bodies.

    Normally there is no free fluid in the small interstices of the bone, so that edema is always abnormal.

    • Causes:
      The cause can be many. Often it is traumas that lead to a bruise of the spine. Metabolic diseases such as those of the rheumatic type or age-related signs of wear can also lead to bone marrow edema of the lumbar spine.
    • diagnosis:
      It is important to find out how many vertebrae are affected by edema and whether the stability of the spine is given.
      Not infrequently, bone marrow edema occurs as a result of displacements or malpositions of the vertebral bodies.
      Imaging in the form of a magnetic resonance imaging of the lumbar spine provides information on the extent and severity.
      The treating physician then splits the bone marrow lesions into different types using imaging.
      The common classification by Modic distinguishes three types.
      Type I stands for bone marrow edema. Sometimes it is also given as a modic character. In Type II, the hematopoietic bone marrow is replaced by fatty marrow and Type III stands for a hardened bone marrow.
    • Therapy:
      Depending on the cause and alteration of the bone marrow edema, the treatment also depends. Basically, however, there is always an adequate pain therapy, which should be accompanied by a protection of the spine. The lifting and carrying of heavy objects and also sports should be avoided as a result.
      Depending on the severity, surgery may even be required to restore stability to the spine. If, in addition to back pain or loss of sensitivity on, this suggests an entrapment of nerves, which must be resolved as soon as possible by a procedure.

    Bone marrow edema at the cervical spine

    In cervical spine bone marrow edema, the vertebral bodies contain fluid in their solid bone network that can exert pressure on surrounding structures.

    • symptoms:

    If nerves or blood vessels are squeezed, this leads to the formation of the characteristic symptoms. Affected feel a bone marrow edema of the cervical spine, especially by pain in the neck area, which can even radiate into the shoulder.
    But headaches can also occur if the muscles harden as a result.
    Sensitivity failures such as a tingling sensation, this indicates an entrapment of nerves.

    • causes

    There are many causes that can lead to bone marrow edema. It always has to be found individually the trigger.
    But quite often it is trauma or rheumatic diseases that lead to bone marrow edema.

    • diagnostics

    To confirm the suspected diagnosis, a doctor will request imaging of the spine. The images of magnetic resonance imaging of the cervical spine then make it possible to objectify the severity and the number of vertebrae affected.

    In this context, the findings according to Modic are also collected.
    The classification according to Modic divides bone marrow changes in the field of vertebral bodies into three types.
    Type I stands for a bone marrow edema and can also be called a Modic sign.
    Type II has a fatty stain instead of the hematopoietic bone marrow.
    And in type III, the bone marrow is hardened.

    • Therapy:

    Depending on the cause and extent of the bone marrow edema, the therapy will also take place. If the stability of the spine is given, a conservative treatment is possible.
    So pain is relieved by medication and relieves the spine as much as possible. For those affected, this means carrying or lifting as little as possible and not doing sports. If the pain subsides, the strain can slowly be increased again.

    Often, however, it takes about a year until a bone marrow edema is completely healed. After six weeks of consistent protection, however, an improvement should already be felt.

    forecast

    Despite extensive medical therapy and physiotherapy, patience is needed when it comes to the healing of bone marrow edema. Symptoms persist for at least 4 weeks, often up to 6 months. Although even longer disease courses of 12 or 18 months are possible, a chronification of the complaints is still not known. Whether and to what extent bone marrow edema syndrome is a precursor to osteonecrosis is controversial.


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