What is the management approach for bone marrow oedema?

Management of Bone Marrow Oedema

The management of bone marrow oedema depends critically on identifying the underlying cause, as treatment varies dramatically between inflammatory, traumatic, ischemic, and mechanical etiologies—but when the diagnosis is uncertain or the condition is idiopathic, conservative management with protected weight-bearing combined with iloprost infusion provides the most rapid symptom relief and accelerated resolution.

Diagnostic Evaluation First

Before initiating treatment, you must determine the underlying cause because bone marrow oedema is a non-specific finding that occurs in multiple conditions 1:

• MRI with T2-weighted and STIR sequences is the preferred imaging modality to demonstrate bone marrow oedema and assess for associated findings 1
• Correlate imaging patterns with clinical context: Look for deep oedema extending >1 cm from the articular surface (suggests inflammatory arthritis), associated fracture lines (traumatic), or geographic patterns with surrounding reactive oedema (osteonecrosis) 2, 1
• Rule out subchondral insufficiency fracture early, as MRI identifies these before radiographs become abnormal, and untreated cases can progress to articular collapse requiring arthroplasty 3
• Consider inflammatory arthritis when bone marrow oedema is combined with synovitis/effusion, as this requires disease-modifying therapy rather than symptomatic treatment 3

Treatment Based on Etiology

For Idiopathic/Ischemic Bone Marrow Oedema Syndrome

Iloprost infusion is the most effective treatment for rapid symptom resolution:

• Administer 50 μg iloprost intravenously over 6 hours daily for 5 consecutive days 4, 5
• This vasoactive prostacyclin analogue provides complete pain relief during the infusion period and normalizes MRI findings within 3 months 4, 5
• In foot and ankle bone marrow oedema, 56% of patients experience significant pain reduction and 83% show decreased oedema on MRI at 3 months 6
• Allow protected weight-bearing as tolerated during and after treatment 5
• Minor complications during infusion are common (reported in 12/70 patients) but self-limited 6

Alternative Medical Therapies

When iloprost is unavailable or contraindicated, consider 7, 8:

• Bisphosphonates for cases with underlying metabolic bone disease or osteonecrosis risk
• Vitamin D supplementation if deficiency is present
• Extracorporeal shock wave therapy (ESWT) or pulsed electromagnetic fields as adjunctive treatments
• Hyperbaric oxygen therapy for ischemic etiologies

For Traumatic/Mechanical Causes

• Protected weight-bearing with immobilization using total contact casting or non-removable knee-high devices for 6-12 weeks 9
• Custom footwear with specialized insoles after acute phase to prevent recurrence 9
• Traumatic bone marrow oedema typically resolves within 1-3 months without specific intervention 1

For Inflammatory Causes (Axial Spondyloarthritis, Chronic Non-Bacterial Osteitis)

• Disease-modifying anti-rheumatic drugs (DMARDs) or biologic therapy targeting the underlying inflammatory condition 2, 1
• Bone marrow oedema serves as a biomarker of disease activity rather than a primary treatment target 2

Surgical Intervention

Core decompression is reserved for:

• Cases failing 3-6 months of conservative management 4, 8
• Progressive osteonecrosis with impending subchondral collapse 1
• ARCO stage II-III lesions with persistent symptoms 6

However, surgical intervention requires several weeks for recovery, making it less desirable than iloprost therapy for idiopathic cases 4.

Critical Pitfalls to Avoid

• Do not assume all bone marrow oedema is benign: New or increasing oedema correlates with pain progression and can lead to joint destruction if the underlying cause is not addressed 3
• Do not delay diagnosis: In diabetic patients with Charcot arthropathy, bone marrow oedema can be difficult to distinguish from superimposed osteomyelitis, but delayed multidisciplinary referral leads to significant clinical deterioration 2, 9, 1
• Do not ignore the clinical context: Bone marrow oedema in healthy athletes or postpartum patients may be physiologic and require only observation, whereas the same finding in an elderly patient with acute pain suggests insufficiency fracture 2
• Monitor for progression: Subchondral insufficiency fractures can progress to articular fragmentation and collapse, particularly in the medial femoral condyle of middle-aged to elderly females 3

Expected Outcomes

• With iloprost therapy: Complete symptom relief during infusion, normalized MRI within 3 months, and functional scores improving from 44 to 95 points (AOFAS) within 3 months 4
• Without specific treatment: Natural resolution occurs over 3-18 months for idiopathic bone marrow oedema syndrome 8
• Long-term function: Patient-reported outcomes at 2 years show moderate residual impairment (FFI improving from 59 to 30, VAS FA 68/100) regardless of etiology or ARCO stage 6