10 I Winter 2019 www.anjc.info TEC OUR When an athlete presents with MRI findings of “bone marrow edema,” what should be our plan of care? Bone marrow edema is best defined as a generic term that describes the hyperintensity seen on MRI fluid-sen- sitive sequences such as T2. It is most commonly associated with trauma or repetitive stress to a region. These find- ings often lead to a treatment plan of rest, booting or splinting and NSAIDs. This treatment plan is effective for the athlete initially, but what frequently happens is that the athlete experiences an exacerbation of the same bone marrow edema or a slightly different location of bone marrow edema after return to play. Understandably, this is more than frustrating to the athlete. What we need to consider in our evaluation of bone marrow edema is, WHY did this occur? This is the most important question and determines the successful outcome and prevention of this injury. The cause of this injury could be one or several factors, such as bad technique, diet, footwear, caloric deprivation, and the list goes on and on. Taking the time to fully evaluate the condition and question the athlete about the training schedule, diet, changes in footwear or training regime will help prevent a reoccurrence. A helpful tool is to video tape the athlete or watch old video of the athlete in sport. This may uncover some questions as to the origin of the condition. A good example is recent case of a basketball player who came to the office after one year of low back pain and right hip (femoral neck) bone marrow edema (pre-stress fracture). She had completed physical therapy and then returned to sport. However, shortly after her return she developed right sacral bone marrow edema. With the beginning of the next season upon her, she was more than disappointed with her yearlong quest for recovery. Her evaluation consisted of lumbar exam, hip exam, gait exam, running evaluation, diet review, training regime review and history of past injuries. Evaluation found significant limitation in right hip external rotation, lumbar extension restriction, glute weakness and left adductor weakness. In consideration of her sport and what movements are needed, hip internal rotation bilaterally was imperative. So, without hip internal rotation, what could potentially develop a stress related injury? The femoral neck is a good option since the body is trying to rotate around a limited joint, or the sacrum, which is now doing the work that the hip is not. In re-gaining hip mobility in internal rotation, she was fairly quickly able to return to sport. Treatment focuses on strengthening the left adductor to help the right hip exter- nally rotate, hip mobilization, stretching of the hip and entire lower extremity including hip extension, strengthening of glutes, as well as lumbar treatment and chiropractic manipulation. Important points in treatment of bone marrow edema-related injuries are to look to where the stress could be coming from. The area of injury is not always the cause of the injury. Take the time to thoroughly evaluate the condition and all the factors that could be important to better understand the source of the injury. Inquire about NSAID use since the use of NSAIDS arrests osteoblasts in growth. This will singlehandedly delay healing of the region. Diet and vitamin D are also important factors in the care plan. Lastly, teach the athlete how to take control of the injury, what exercises are critical to maintain when treatment is completed, and how to notice the early warning signs of reinjury. Christine Foss, DC, MSEd, ATC, DACBSP, ICCSP, is past president of the NJCCSIR and an ANJC member. She and her husband, Dr. Glenn Foss, own Advanced Sports Medicine and Physical Therapy practice in Riverdale. By Dr. Christine Foss Bone Marrow Edema in the Athlete