Intravenous bisphosphonates and vitamin D in the treatment of bone marrow oedema in professional athletes

Abstract

Introduction

The goal of this retrospective study was to evaluate the safety and efficacy of ibandronate for bone marrow oedema (BMO) syndrome and stress fracture cases, and to demonstrate an additional field of therapeutic importance—the high-performance athlete.

Patients and methods

This retrospective study included twenty-five high-performance athletes. Sixty per cent of the athletes were European soccer players and 40.0% other high-class international athletes (3 women and 22 men with an average age of 25.0 ± 4.2), with BMO of the lower trunk or extremity diagnosed by magnetic resonance imaging (MRI). The treatment regimen consisted of high-dose vitamin D supplementation and intravenous ibandronate therapy.

Results

The time between the onset of pain and proper diagnosis of BMO was 106.3 ± 104.1 days. Excellent pain reduction (pain at rest and under strain) and improved mobility was reported within the first two weeks after the first ibandronate administration by sixteen patients (64%). The time from first treatment until return to competition (RTC) was on average 102.6 ± 65.2 days in total. If the time from onset of pain until diagnosis was within 40 days, the RTC was significantly reduced (p ≤ 0.05) to almost 50% (63.8 ± 48.1 days) when compared to the athletes with later diagnosis (124.4 ± 63.2 days).

Conclusions

The here-applied therapy regimen of intravenous BPs application and vitamin D supplementation in BMO syndrome has a beneficial effect for high-performance athletes. An early diagnosis and rapid treatment start can reduce the RTC significantly. An optimal bone metabolism with sufficient daily calcium and vitamin D intake is crucial and should not only be strived for the professional but also for the recreational athlete.

Introduction

Bone marrow oedema (BMO) is defined as an increase of interstitial fluid in an affected bone.¹ Among athletes and military recruits, BMO and stress fractures are a very common problem and diagnosis.2, 3, 4 It can cause pain and disable the person to move and particularly in athletes to participate in sports practices or competitions.5, 6 It can be diagnosed on MR-images in patients with joint and bone pain. Predominantly, the lower extremity joints are affected and its occurrence is often in young and middle-aged patients.5, 7, 8, 9, 10, 11 The initially taken radiograph appears normal or rather non-diagnostic in the early phase, but is essential to exclude fractures, osteoarthritis or other degenerative changes. The earliest changes can be detected with MR-images, but this diagnostic step is often postponed, due to unspecific symptoms, which are compromising the quality of life, and furthermore because the BMO syndrome is not commonly known. But with advanced imaging technology and greater magnetic resonance imaging (MRI)-widespread an early diagnosis is achievable. Though with BMO syndrome being often a transient and self-limiting disorder an early diagnosis is important, in particular for high-performance athletes. However, development of an osteonecrosis on a basis of a BMO is possible, but there is not yet a good consensus on this topic.12, 13 Though histological analyses of 80 cases demonstrated a correlation between these two disorders.¹⁴ The treatment options range from conservative regimens with weight-bearing, analgesic medication, pharmacologic therapy, physiotherapy to surgical interventions.5, 7, 8, 9, 10, 12, 15, 16 However, looking at the current patient collective of high-performance athletes a quick return to full exercise and competition fitness, and halt of the progression to osteonecrosis is wanted.

BMO can occur at different sites, mostly in the hip and lower extremity, and has been described under several synonyms, e.g. transient (bone) marrow oedema, transient osteoporosis or avascular osteonecrosis.5, 10, 17, 18 According to Meizer et al., the knee was most BMO affected region (48.1%) followed by the talus (18.3%), femur (17.3%) and other locations (16.3%), respectively.⁵ BMO is an unspecific finding in the MRI, which can eventually progress to osteonecrosis as seen in 50% of symptomatic hip cases where a focal necrosis was identified and surrounded by BMO.¹³ The complex aetiology of osteonecrosis (ON) is at present unclear.¹⁹ The deterioration stages of the affected bone and cartilage are defined by radiographs and/or MR-images.¹¹

BMO syndrome shows an increased bone turnover as previously described.¹⁵ This is often due to the fact that BMO are additionally accompanied by stress fractures.¹⁷ Stress fractures are very common in athletes and military recruits, 2.9% in Finnish military recruits and 5.9% in female Navy recruits within the first 8 weeks of service.20, 21, 22, 23 This is often due to intensive exercises, abrupt increase in intensity, and too little and too short regeneration times.²⁴ Additionally, other studies have shown with therapeutic regimens and images that BMO syndrome and stress fractures differ from avascular osteonecrosis.5, 7, 9, 14 This is important for treatment strategies, often surgical with e.g. core decompression in avascular ON or a conservative management for BMO and stress fracture cases. Therefore, antiresorptive drugs like bisphosphonates (BPs) are useful pharmacological agents in increased bone turnover as detected in BMO and stress fracture cases.6, 18, 25

BPs have shown since many decades a positive effect on bone metabolism. They inhibit osteoclasts and herewith reduce bone resorption.26, 27 BPs have been effectively used to treat local bone metabolism disorders as seen in ON or localised transient osteoporosis,11, 15, 28 furthermore their positive influence in treatment of BMO and stress fractures has been demonstrated.6, 10, 11, 18, 29 This was recently demonstrated by Bartl et al. where 93% of patients receiving ibandronate had returned after 3 months to normal daily activities compared to only 20% of the control group, the rest was still on strong pain medication and using walking aids.¹¹

Here, a special group of high-performance athletes showing symptomatic clinical patterns and radiographical signs of BMO and their non-operative treatment regimens and outcomes is presented. All of the athletes were refrained from sports performance due to the symptomatic BMO. The goal of this retrospective study was to evaluate the safety and efficacy of ibandronate for BMO syndrome and stress fracture cases, and to demonstrate an additional field of therapeutic importance—the high-performance athlete.