Assume that you schedule an office assessment for knee pain, altered function and a slight limp. I complete the examination and review the radiograph only to find it “normal”. The examination excludes referral from the low back and hip so the next step is an MRI. 48 hours later I am able to diagnose a Bone Marrow Lesion (BML) as the cause of the problem. The Bone Marrow Lesion is an abnormal area of defect inside the bone. Also called Bone Marrow Edema (BME), they are defects typically found below or adjacent to a joint. They appear a hazy white area on the MRI against the background of darker, unaffected bone and bone marrow. Pathologists have shown that the BML represents a healing response as a result of a bone injury that doesn’t heal properly. In other cases, the MRI finding may be consistent with a stress reaction that forms from overuse or poor joint mechanics.

Obesity and poor diet are thought to increase the likelihood of developing BML. They are more commonly found in middle-aged patients rather than younger patients. Patients with poor joint alignment (bow legs or knock knees) are more likely to develop BML. Adults who quickly increase activity may develop Bone Marrow Lesions or Edema.

As in most initial diagnoses, a course of conservative treatment should be instituted so as to allow the body to heal itself. If the lesion doesn’t heal with medications, braces, non-weight bearing, injections and physical therapy, then an intraosseous injection into the lesion is indicated. Left untreated, the problem may result in the loss of joint support and the development of osteoarthritis.

I treat the symptomatic, non-responsive BML with an intraossous, intralesional procedure called a subchondroplasty whereby Bone Marrow Concentrate rich in stem cells and growth factors is injected into the non-healing insufficiency fracture. Fluoroscopy is used (intraoperative X-ray) to guide the placement of a special drillable cannula into the bone defect.  At times, should the BML be of sufficient size as to cause me to be concerned about a possible fracture, I will use a Calcium Phosphate preparation in addition to the Bone Marrow Concentrate. The engineered Calcium Phosphate readily fills the subchondral defect and mimics the properties of cancellous bone eventually being resorbed and replaced with new bone.

Most Orthopedic Surgeons believe that Chronic Bone Marrow Lesions will not heal without intervention. Additionally, the pain generator in osteoarthritis diagnosed by narrowing of a joint space may in fact be secondary to a BML. Bone Marrow Edema and lesions were among the topics I reviewed during my Instructional Programs in St Petersburg, Russia, two weeks ago. To learn about chronic joint pain with a “normal “or even abnormal X-ray, call for a consultation and evaluation.

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