From the Guidelines
The treatment for moderate bone marrow edema at the pubic symphysis, suggestive of a stress response, should start with NSAIDs/COXIBs in maximum tolerated and approved dosage for 2−4 weeks, as recommended by the expert consensus 1. The goal of this approach is to reduce inflammation and manage pain, allowing the bone to heal naturally.
- The initial treatment may include NSAIDs such as naproxen 375−1100 mg/day in two doses, diclofenac starting at 150 mg/day in divided doses, or ibuprofen 1800 mg/day in divided doses, as outlined in the expert consensus recommendations 1.
- If the first NSAID/COXIB does not provide benefit or is not tolerated, a trial of another NSAID/COXIB may be considered.
- Treatment response should be evaluated at 2−4 weeks after initiation, and if sufficient response is achieved, treatment can be continued or switched to on-demand treatment or dose tapering can be considered with sustained sufficient response at 12 weeks 1.
- In cases of insufficient response, second-line treatments such as intravenous bisphosphonates (IVBP) or tumor necrosis factor-α inhibitors (TNFi) may be considered, depending on patient characteristics.
- It is essential to note that the evidence for the optimal treatment choice and duration in adult chronic non-bacterial osteitis (CNO) is limited, and the recommendations are based on expert consensus and observational evidence 1.
From the Research
Treatment for Moderate Bone Marrow Edema
The treatment for moderate bone marrow edema at the pubic symphysis, suggestive of a stress response, can be approached through various methods.
- Nonoperative management and rehabilitation have been shown to be effective in managing osteitis pubis/pubic bone stress in professional soccer players 2.
- A multimodal conservative treatment approach, including pharmacological interventions, physical therapies, and modification of activities to avoid exacerbating the condition, may be beneficial 3.
- The use of neridronate, calcium, and vitamin D supplementation, along with biophysical therapies such as magnetotherapy and extracorporeal shockwave therapy, has been reported to lead to significant improvement in symptoms and regression of edema 3.
- Rehabilitation programs focusing on improving range of motion, strengthening, and stability, as well as gradual return to activity, can help in managing the condition and preventing recurrences 2.
Considerations for Treatment
When considering treatment options, it is essential to:
- Assess the extent and severity of the bone marrow edema through imaging studies such as MRI 4, 5.
- Evaluate the patient's overall health, activity level, and goals to determine the most appropriate treatment approach.
- Monitor the patient's progress and adjust the treatment plan as needed to ensure optimal outcomes.
Clinical Significance and Treatment Options
Bone marrow edema is a known prognostic factor associated with pain, dysfunction, and progressive cartilage damage 6.
- Treatment options may include novel biologic surgical options, although the current evidence is limited 6.
- A comprehensive treatment plan should address the underlying causes of the bone marrow edema, as well as provide symptomatic relief and support for recovery.