Original Article Spotty Bone Marrow: A Frequent MRI Finding in

the Feet of Ballet Dancers

J Dance Med Sci
ePub date: March 15, 2022
https://doi.org/10.12678/1089-313X.061522e
Natalia Gorelik,1 Bethany U. Casagranda,2 Philip G. Colucci,3
Copyright © 2022 J. Michael Ryan Publishing, Inc. Julie L. Green,4 Johannes B. Roedl,5 William B. Morrison,5 and
All rights reserved.
Adam C. Zoga5
To cite this article:
Gorelik N, Casagranda BU, Colucci PG, Green JL, Roedl JB,
Morrison WB, Zoga AC. Spotty bone marrow: a frequent
MRI finding in the feet of ballet dancers. J Dance Med Sci.
2022;26(2):125-33

Abstract
Introduction: Bone marrow signal abnormalities on magnetic resonance imaging (MRI) are common
in athletes. However, few studies evaluate the MRI appearance of bone marrow in the feet of ballet
dancers. Our study aims to describe the “spotty bone marrow” (SBM) pattern in the tarsal bones of a
cohort of ballet dancers, establishing its prevalence, distribution, potential associations, and evolution.
Methods: Eighty-six MRIs of 68 ankles in 56 ballet dancers were retrospectively reviewed for mar-
row signal alterations, which were classified as focal or SBM (defined as patchy fluid-sensitive signal
hyperintensity spanning more than one location or tarsal bone). When SBM involved the talus, its
anatomic distribution in the bone and morphologic pattern were recorded. Additional osseous and soft
tissue findings were documented. For subjects with more than one MRI of the same ankle, the SBM’s
evolution was monitored.
Results: Spotty bone marrow was identified in 44 ankles (65%). Spotty bone marrow was isolated
to the talus (44%), present in all tarsal bones (25%), or distributed between the talus and one to
three other tarsal bones (31%). In the talus, The SBM involved the entire bone (65%), the neck and
body (31%), or the head and neck (4%). The SBM most commonly showed a random morphologic
pattern (87%) but occasionally showed a peripheral predominance (13%). There was no statistically
significant difference in the prevalence of other pathologies in ankles with and without SBM. In eight
ankles with a follow-up MRI, the SBM worsened in one, remained stable in two, and improved in
five ankles. None progressed to a stress fracture.
Conclusion: Spotty bone marrow is an MRI finding frequently encountered in ballet dancers. It is
usually self-limiting and should not be misinterpreted as a more aggressive pathology.

Key Points
• The “spotty bone marrow” (SMB) pattern is a common finding in the feet of ballet dancers
on MRI.
1. McGill University Health Center, Montreal, • The talus is the tarsal bone most frequently affected by SBM.
Quebec, Canada.
• SBM is usually a self-limiting imaging finding, therefore, it should not be misinterpreted
2. Allegheny Health Network, Pittsburgh, for a more aggressive pathology.
Pennsylvania, USA.
3. Hospital for Special Surgery, New York, New Introduction
York, USA. During our routine clinical work, when interpreting magnetic resonance imag-
4. Philadelphia Ballet, Philadelphia, Pensylvania, ing (MRI) of the midfoot and hindfoot of ballet dancers, we observed a frequent
USA. pattern of patchy, speckled bone marrow signal hyperintensity on fluid-sensitive
5. Thomas Jefferson University Hospital, Sidney fat-suppressed MRI sequences. Based on the imaging appearance, we called this
Kimmel Medical College at Thomas Jefferson finding “spotty bone marrow” (SBM). Bone marrow edema-like signal is a common
University, Philadelphia, Pennsylvania, USA.
finding in MRI for athletic injury. Magnetic resonance imaging signal alterations in
Correspondence: the bone marrow of weightbearing extremities of physically active individuals, such
Natalia Gorelik
natalia.gorelik@mail.mcgill.ca as athletes and military recruits, may reflect osseous stress and altered biomechan-
ics.1-6 A variety of other etiologies may result in bone marrow edema-like lesions,
Funding Statement: The authors report no conflicts
of interest in regard to the information presented in including traumatic, inflammatory, infectious, vascular, neoplastic, metabolic,
this work. Dr. Natalia Gorelik receives salary support developmental, and iatrogenic processes.7-22
by an AUR GE Radiology Research Academic While a myriad of foot and ankle injuries in dancers are well-documented,23-27
Fellowship Award.
bone marrow signal variations and patterns in dancers are incompletely described7,28;

The Journal of Dance Medicine & Science is the official publication of the International Association for Dance Medicine & Science | www.iadms.org 125
 Journal of Dance Medicine & Science • Volume 26, Number 2, 2022 126

Peace et al.28 noted generalized patchy edema in the hindfoot MRI examinations were complete and of satisfactory quality,
of 40% of 23 ballet dancers with posterior ankle impingement therefore, no patients were excluded. All subjects underwent a
syndrome. In a study by Elias et al.,7 patchy bone marrow edema clinical non-contrast MRI for various ankle- or hindfoot-related
in the talus was seen in 75% of 11 professional ballet dancers signs and symptoms. The MRI examinations were performed to
and was reported to be associated with pain. To the best of our assess the ankle following an injury (9%); to evaluate symptoms
knowledge, patterns of bone marrow signal abnormalities on of pain (69%), swelling (2%), and instability (1%); to assess
MRI in the tarsal bones of ballet dancers have not been in- for clinically suspected tendinopathy (19%), ligament sprain
vestigated further; therefore, we decided to study SBM in our (9%), impingement (6%), and plantar fasciitis (2%); and to
ballet dancer patients. For professionals who treat ballet dancers, exclude a fracture (10%), an osteochondral lesion (5%), a loose
awareness of the expected bone marrow imaging appearances in body (1%), and osteoarthritis (1%). The clinical information
the feet of ballet dancers is important because failure to recog- was not available in 6% of the MRI examinations.
nize the SBM pattern as a common MRI finding may lead to
it being overcalled as a stress fracture, resulting in unwarranted Imaging Technique
alterations in training regimens, or as a more worrisome process, Given the retrospective nature and long imaging period
engendering unnecessary additional testing. of the study, slight variations in the imaging technique and
The study aims to describe the SBM pattern in the midfeet protocol existed. Seventy-four examinations were carried on a
and hindfeet of ballet dancers, establishing its prevalence, dis- 1.5 Tesla MRI unit, 10 examinations were performed on a 1.0
tribution, potential associations, and evolution. Tesla MRI unit, and two examinations were performed on a
3.0 Tesla MRI unit. The examinations were acquired either on
Methods a large bore MRI with a dedicated quadrature extremity coil
This retrospective study was approved by our institutional with the ankle positioned in plantar flexion or using a dedicated
review board. The need for informed consent was waved. extremity MRI. The institutional standard imaging protocol
included sagittal T1-weighted spin echo (TR 400 to 700 ms,
Subject Population TE 10 to 20 ms, slice thickness 4 mm, inter-slice gap 1 mm,
Ballet dancers who underwent an ankle or hindfoot MRI field of view 16 to 18 cm, matrix 256 x 256, echo train length
between October 2005 and February 2017 at our institution 3, signal average 2), sagittal fast short tau inversion recovery (TR
were identified by an automated search of our radiology report 1,900 to 5,000 ms, TE 30 to 90 ms, TI 150 ms, slice thickness
database and through a registry of dancers provided by the 4 mm, inter-slice gap 1 mm, field of view 16 to 18 cm, matrix
team physician of a local professional ballet company. Fifty-six of 256 x 192, echo train length 8, signal average 2), axial and
active ballet dancers (41 females, 15 males; 38 professionals, coronal T2-weighted fat-suppressed fast spin echo (TR 2,400
18 pre-professionals; mean age: 23.0 years; range: 11.6 to 37.7 to 7,500 ms, TE 55 to 90 ms, slice thickness 4 mm, inter-slice
years) were included in the study, with a total of 86 MRI exam- gap 1 mm, field of view 12 to 18 cm, matrix 256 x 192, echo
inations in 68 ankles. Exclusion criteria included incomplete train length 8, signal average 2 to 3), and axial proton densi-
or technically inadequate MRI examinations; however, all the ty-weighted fat-saturated fast spin echo (TR 2,500 to 4,000

Figure 1 Focal bone marrow changes versus spotty bone marrow. A, Sagittal STIR MRI ankle in a 19-year-old ballerina demonstrating
focal bone marrow signal hyperintensity related to an osteochondral defect at the posterior talar dome (arrow). B, Sagittal STIR MRI
ankle in a 32-year-old male ballet dancer showing randomly distributed patchy bone marrow signal hyperintensity (arrows) throughout
the talus, compatible with spotty bone marrow.
 Journal of Dance Medicine & Science • Volume 26, Number 2, 2022 127

ms, TE 30 to 40 ms, slice thickness 4 mm, inter-slice gap 1 The SBM pattern was defined as multifocal patchy areas
mm, field of view 14 to 16 cm, matrix of 512 x 256, echo train of increased signal intensity on fat-suppressed, fluid-sensitive
length 4, signal average 2) sequences. MRI sequences spanning more than one location within a
bone or more than one bone in the midfoot and hindfoot not
Magnetic Resonance Image Analysis attributable to a recognized cause of focal bone marrow reactive
Magnetic resonance images were retrospectively reviewed changes. The areas of bone marrow signal abnormality may be
by two radiologists in consensus (reviewer 1: musculoskeletal ill-defined or sharply demarcated. They are usually not cystic,
radiology fellow, reviewer 2: musculoskeletal radiologist with tubular, or linear, and are thereby distinguishable from cystic
15 years’ experience). The MRIs were reviewed for the pres- bone lesions, prominent vascular channels, or fracture lines.
ence and distribution of hyperintense bone marrow signal on The prevalence of SBM in bilateral and in skeletally immature
fluid-sensitive, fat suppressed sequences within the bones of ankles was assessed. The presence of SBM in skeletally mature
the hindfoot and midfoot. The pattern of bone marrow signal versus immature ankles was compared. The prevalence of SBM
alterations in each tarsal bone was classified as focal or SBM in each tarsal bone was tabulated.
(Fig. 1). Focal bone marrow signal abnormalities and SBM were In each tarsal bone, the SBM was graded according to a
not mutually exclusive. three-point scale. Grade 1 SBM signifies ill-defined patchy
Focal bone marrow signal abnormalities were limited to a areas of mildly increased signal intensity on fat-suppressed
subcortical, subchondral, or subenthesial location or along a fluid-sensitive sequences relative to normal bone marrow, with
fracture and could be attributed to a recognized cause of bone no perceptible decrease in T1 signal intensity (Fig. 2A). Grade
marrow reactive changes, such as arthropathy, impingement, 2 SBM shows patchy areas of moderately to markedly increased
osteochondral injury, contusion, fracture, avulsion injury at a fluid-sensitive signal intensity relative to normal marrow, some-
tendon or ligament insertion, articulation with ossicles, tarsal times accompanied by decreased T1 signal intensity (Fig. 2B).
coalition, and traction at sinus tarsi ligaments.7,9,10,13,16-18 The In grade 3 SBM, most of the bone marrow exhibits patchy high
causes of focal bone marrow changes were recorded. signal intensity on fluid-sensitive sequences relative to normal

Figure 2 Grades of SBM. A, Sagittal STIR MRI

ankle in a 24-year-old ballerina demonstrating
grade 1 spotty bone marrow with a random
distribution in the talus. B, Sagittal STIR MRI
ankle in a 19-year-old ballerina showing grade 2
spotty bone marrow, with a random distribution
in the talus. C, Sagittal STIR MRI ankle and D,
Sagittal T1-weighted MRI ankle in a 32-year-old
ballerina showing grade 3 spotty bone marrow
in the hindfoot with a random distribution in
the talus. Arrows indicate some of the areas of
marrow signal abnormality.
 Journal of Dance Medicine & Science • Volume 26, Number 2, 2022 128

Figure 3 Spotty bone marrow morphology within the talus. Sagittal (A) and axial (B) STIR MRI ankle in a 23-year-old ballerina
demonstrating spotty bone marrow in the talus with a random distribution. Sagittal (C) and coronal (D) STIR MRI ankle in a 20-year-
old male ballet dancer demonstrating spotty bone marrow in the talus with a peripheral distribution. Arrows indicate some of the areas
of marrow signal abnormality.

marrow with an associated decreased T1 signal intensity (Fig. tered predominantly within the cancellous bone rather than in
2C and D). subcortical or subchondral locations (Fig. 3A and B). Peripheral
When SBM was present in the talus, its anatomic distri- SBM shows diffuse increased signal intensity involving mostly
bution (head, neck, or body) and morphology (random or the subcortical or subchondral bone marrow (Fig. 3C and D).
peripheral) within the bone were recorded. A random SBM The presence of additional osseous or soft tissue abnormal-
morphology implies multiple patches of signal abnormality cen- ities, including ankle tendon or ligament pathologies, plantar
 Journal of Dance Medicine & Science • Volume 26, Number 2, 2022 129

fasciitis, posterior impingement, tibiotalar or subtalar effusion, teochondral injury (eight ankles), avulsion injury at a ligament
and presence of a ganglion cyst about the ankle, was recorded. or tendon attachment site (seven ankles), nonspecific changes
If follow-up examinations were available, the overall evo- about the tarsal sinus (four ankles), osteoarthritis (three ankles),
lution of the SBM was assessed as to whether the extent of fracture (one ankle, nutcracker fracture of the cuboid), articu-
involvement within a single bone and among all tarsal bones lation with an ossicle (one ankle), and coalition (one ankle).
as well as degree of severity of marrow abnormalities were im-
proved, stable, or worsened. Prevalence of SBM in Bilateral Ankles
Four patients had imaging of bilateral ankles within less than
Statistical Analysis 1 year apart (mean: 3.4 months; range: 0 to 8.5 months). One
The demographic characteristics of the groups of ankles with patient had bilateral SBM while the three other patients did
and without SBM were compared using the Mann-Whitney U not have SBM in either ankle.
test for the age and the chi-squared test for the sex. The pres-
ence of SBM in skeletally mature versus immature ankles was Prevalence of SBM in Skeletally Immature Dancers
assessed using the chi-squared test. Associations between the Eleven ankles demonstrated an immature skeleton with
presence of SBM and the occurrence of other osseous or soft unfused distal tibial or fibular physes (mean patient age: 14.4
tissue pathologies were also evaluated using the chi-squared test. years; range: 11.6 to 16.7 years). Spotty bone marrow was seen
in eight of these 11 ankles (73%), (Fig. 4), which is slightly
Results higher than in the 57 skeletally mature ankles of which 36 had
Prevalence of SBM SBM (63%) but not statistically significantly (p = 0.79). None
Prevalence of SBM and Focal Marrow Signal of the skeletally immature patients had simultaneous imaging
Hyperintensity of bilateral ankles.
Spotty bone marrow was identified in 44 (65%) of the 68
imaged ankles. Twenty ankles had only SBM while 24 ankles Distribution of SBM
had SBM and focal bone marrow signal hyperintensity. Seven- Distribution of SBM Between Tarsal Bones
teen ankles had only focal bone marrow signal hyperintensity The talus was involved with SBM in all 52 MRI examinations
and seven ankles had no bone marrow signal abnormality. in the 44 ankles with SBM. Spotty bone marrow was isolated
Among the 41 ankles that demonstrated focal bone marrow to the talus in 23 (44%) cases. In 13 (25%) cases, the SBM
changes, these were predominantly seen in the talus (34 ankles), was present in all the tarsal bones. Other distributions of SBM
followed by the calcaneus (six ankles), cuboid (five ankles), included the talus and calcaneus (15%); the talus and navicular
lateral cuneiform (five ankles), navicular (four ankles), medial (6%); the talus, calcaneus, and navicular (4%); the talus, cal-
cuneiform (four ankles), and middle cuneiform (one ankle). caneus, and cuboid (4%); and the talus, calcaneus, navicular,
Causes of focal bone marrow signal abnormalities included and cuboid (2%). The SBM grades among the tarsal bones are
posterior impingement (20 ankles), contusion (10 ankles), os- detailed in Table 1.

Figure 4 Age distribution of patients with ankles demonstrating an immature skeleton, with or without spotty bone marrow (SBM).
Follow-up MRIs were available for three ankles with SBM.
 Journal of Dance Medicine & Science • Volume 26, Number 2, 2022 130

Table 1 Spotty Bone Marrow Grades in the Bones of the Midfoot and Hindfoot in the 52 Ankle Magnetic Resonance
Images
Lateral Middle Medial
Talus Calcaneus Navicular Cuboid Cuneiform Cuneiform Cuneiform Total
Grade 1 17 (33%) 14 (54%) 6 (30%) 5 (31%) 5 (38%) 5 (38%) 5 (38%) 57 (37%)
Grade 2 31 (60%) 11 (42%) 12 (60%) 11 (69%) 8 (62%) 7 (54%) 7 (54%) 87 (57%)
Grade 3 4 (8%) 1 (4%) 2 (10%) 0 0 1 (8%) 1 (8%) 9 (6%)
Total 52 26 20 16 13 13 13 153

Table 2 Comparison of the Demographic Characteristics and Prevalence of Additional Osseous and Soft Tissue
Abnormalities in the Group of Ankles With and Without Spotty Bone Marrow
Ankles With Spotty Bone Marrow Ankles Without Spotty Bone Marrow
Demographic Characteristics (n = 44) (n = 24) P-value
No. MRI examinations 51* 29
No. patients 39 22
Male: Female 12: 27 3: 19 0.59
Age at time of MRI, range (years) 22.0, 11.6-33.9 24.7, 14.0-37.7 0.3
Ankle Pathologies n n
Focal marrow abnormalities 22 (50%) 17 (71%) 0.14
Lateral tendons abnormalities† 8 (18%) 5 (21%) 0.12
Medial tendons abnormalities† 26 (59%) 13 (54%) 0.29
Achilles tendon abnormalities‡ 9 (20%) 7 (29%) 0.42
Plantar fasciitis 6 (14%) 0 (0%) 0.06
Ligamentous injuries§ 26 (59%) 16 (67%) 0.67
Posterior impingement 11 (25%) 10 (42%) 0.08
Tibiotalar or subtalar effusion 25 (57%) 12 (50%) 0.59
Ganglion cyst about the ankle 12 (27%) 5 (21%) 0.44
*For the ankles with SBM that were imaged by MRI more than once, six MRI examinations were excluded as SBM was not present on those MRI examinations.
†Lateral and medial tendons abnormalities include tendinosis, tear, and tenosynovitis. ‡Achilles tendon abnormalities include tendinosis, tear, paratenonitis, and
retro-calcaneal or retro-Achilles bursitis. §Ligamentous injuries include sprains, tears, and scarring of the anterior talofibular, calcaneofibular, posterior talofibular,
deltoid, anterior tibiofibular, and posterior tibiofibular ligaments.

Distribution of SBM within the Talus to 104.2 months). The SBM pattern showed interval improve-
The anatomic distribution of SBM within the talus included ment or resolution in five ankles, stability in two ankles, and
the head, neck, and body seen in 34 cases (65%); the neck and worsening in one ankle. None of the follow-up examinations
body seen in 16 cases (31%); and the head and neck seen in showed progression to a complete stress fracture. In two ankles
two cases (4%). Talar SBM was most commonly randomly without SBM on initial MRI, a subsequent follow-up MRI
distributed (87%) but occasionally demonstrated a peripheral showed the appearance of new SBM at 6.4 months and 12.6
predominance (13%). months.

Associations of SBM with Demographics and Other Discussion

Pathologies Spotty bone marrow, a reproducible pattern of patchy,
The demographic characteristics and the frequencies of speckled T2 hyperintense bone marrow on fat-suppressed, flu-
additional abnormalities in the groups with and without SBM id-sensitive MRI sequences, was seen at a high frequency (65%)
are detailed in Table 2. There was no statistically significant in the tarsal bones of our cohort of ballet dancers. This finding
difference in the prevalence of other pathologies in the ankles is within the range of the previously documented prevalence of
with and without SBM. bone marrow signal abnormalities in the midfoot and hindfoot
of ballet dancers (40% to 75%).7,28 It is also concordant with the
Evolution of SBM reported frequent occurrence of bone marrow signal alterations
Follow-up examinations were available in eight ankles with in physically active individuals, such as athletes and military
SBM (mean duration of follow-up: 44.2 months; range: 3.4 recruits.1-5
 Journal of Dance Medicine & Science • Volume 26, Number 2, 2022 131

“Bone marrow edema” has often been used in reference to frequently seen at the talar dome, suggesting that this part
regions of bone marrow generating a hyperintense signal on of the ankle is subject to significant stress in ballet dancers.26
fluid-sensitive MRI sequences.3,6,8,10,19,20,24,29 There is, however, In a study by Elias et al.,7 bone marrow signal hyperintensity
a paucity of studies correlating this MRI appearance to his- in the ankles of professional ballet dancers was seen only in
tological findings,6 as a biopsy is usually not indicated. In a the talus. Isolated stress injuries of the navicular, cuboid, and
study by Zanetti et al.,29 areas of bone marrow edema on MRI cuneiform bones are considered rare.2,34 Our cohort predomi-
in osteoarthritic knees were found to differ significantly from nately included overuse type symptoms that are very common
regions of marrow with normal signal characteristics for the in ballet dancers. Only a single patient in our series had a tarsal
presence of abnormal trabeculae, bone marrow necrosis, and bone fracture, and this was a typical “nutcracker fracture” of
fibrosis but not in the prevalence of marrow edema on histolog- the cuboid.
ical examination. Since areas of marrow abnormality on MRI In ankles with follow-up MRIs, the SBM signal abnor-
may represent replacement by any material richer in water, like malities showed various permutations, with resolution of
edema, necrosis, abnormal trabeculae, fibrosis, or bleeding, some of the patches and appearance of new patches. None
their designation by the alternative term “edema-like lesions” of our patients with SBM progressed to a true stress fracture.
has been proposed in the recent literature.8 In our work, we use These observations suggest that SBM is generally a reversible,
the term “spotty bone marrow” to describe the MR finding of a self-limiting condition. A similar waxing and waning nature
generalized patchy pattern of varying signal intensities, without of bone marrow lesions has been reported in professional
implying a histological diagnosis. runners.1 The clinical significance of bone marrow edema-like
As SBM is not a frequent finding in our overall ankle MRI lesions, their prognosis, and their appropriate treatment and
patient population, we postulate that SBM is a manifestation follow-up remain an issue for discussion.1,5,17,18,24 The present
of osseous stress and microtrabecular injury without cortical observational study does not allow for a complete understand-
disruption, commonly occurring in response to the repetitive ing of the significance of SBM. However, it is plausible that
rigors of intensive ballet dancing.7,27,28 Ballet training requires SBM represents a finding along the stress injury continuum,
countless hours of weightbearing practice activities to achieve which ranges from normal physiologic response to a complete
the precise motor control through extremes of joint range of stress fracture.3,6,8,13 Conceivably, asymptomatic grade 1 SBM
motion necessary for the proper execution of dance move- may be an incidental finding of no clinical significance and
ments.25-27,30,31 The classical ballet maneuvers, such as en pointe should not necessarily lead to an altered training program.
or demi-pointe positions, alter the normal biomechanics at the Symptomatic grade 3 SBM, on the other hand, may indicate
foot and ankle and predispose dancers to stress injuries.7,25,28,30,31 a pathological overuse injury and portend a risk of progression
Ballet is often practiced on hard surfaces in footwear lacking a to a true stress fracture. In such cases, it may be reasonably
shock-absorbing sole, rending the foot and ankle further vul- advisable to reduce the training intensity in order to minimize
nerable to trauma.30,32 In addition, the relative energy deficiency potential short- and long-term complications.
in sport (RED-S), previously known as the female athlete triad, Other conditions can cause diffuse or extensive bone marrow
which is prevalent among dancers,23,25,31,33,34 acts as a synergistic heterogeneity on MRI and thus mimic SBM. They include,
factor predisposing to a combination of fatigue and insufficiency among others, hematopoietic bone marrow, immobilization,
stress injuries.23,24,30,33 Stress injuries in the foot and ankle of bone marrow edema syndrome, infection, neoplasm, neuro-
ballet dancers are thus very common.7,23-27,30 pathic arthropathy, and osteonecrosis.8,9,13-16,20 Bone marrow
Bone is dynamic, ceaselessly remodelling itself in reaction to heterogeneity has been described as a normal asymptomatic
applied forces.6 Excessive repetitive stresses without adequate finding in the pediatric population, particularly up to the age
recovery time overload the normal bone metabolism and of 15 years.10,11,13,21 It is thought to represent islands of hemato-
disrupt the physiologic balance between the osteoclastic and poietic marrow interspersed in regions of predominantly yellow
osteoblastic activity.2,24 As bone formation is slower than bone marrow.21 Pathognomonic findings of foci of hematopoietic
resorption, the uncoupling of these processes leads to transient marrow include the “bull’s-eye” sign (referring to an island of red
bone weakening and, with continued stresses, to trabecular marrow with a central focus of yellow marrow) or metaphyseal
microfractures.24 It is plausible, therefore, that in SBM, areas “flame-shaped” areas (typically seen in the femur or humerus
of high fluid sensitive signal intensity on MRI may correspond abutting the physes and extending into the metaphysis).8,16 In
to foci of subclinical osseous injury, high turnover trabecular the foot and ankle, high signal T2 changes are usually in an
reorganization, and increased vascularity in areas chronically endosteal location and most frequently found in the calcane-
undergoing a disproportionate amount of stress.7 us.11 In our study, the imaging finding of diffuse marrow signal
The talus was the tarsal bone that most frequently demon- abnormality in skeletally immature patients was nonspecific,
strated SBM in our cohort and was the only bone affected in but given that these patients all had a strong clinical history of
isolation. The frequent involvement of the talus likely reflects overuse stress injury, SBM was favored.
the biomechanics of stresses specific to ballet.7 The key location Diffuse signal hyperintensity has been described in patients
of the talus between the leg and the rest of the foot may render after immobilization and occurs in a peripheral distribution.9
the talus particularly susceptible to injury due the uniquely Similarly, SBM can have a peripheral predominance, as seen in
high loads placed on it during ballet maneuvers.7,10 In a scin- 13% of the taluses in our sample, suggesting that osteopenia
tigraphic study of ballet stress injuries, increased uptake was may play a role. However, a clinical history of recent immobili-
 Journal of Dance Medicine & Science • Volume 26, Number 2, 2022 132

zation is key in differentiating SBM from marrow hyperintensity design, and small sample size. Although all patients underwent
related to immobilization. ankle imaging for ankle-related symptoms, it remains unclear
Bone marrow edema syndrome, which is considered a diag- whether their clinical symptoms were caused by SBM or by
nosis of exclusion, has been described as a painful self-limiting other pathologies. Indications for the MRI examinations in our
entity that occurs in the absence of a discernible traumatic epi- patient population ranged from acute injuries to longstanding
sode and can affect the foot and ankle.8,15,17,18,22,35,36 In contrast, symptoms lasting months or years. Information on post-imag-
complex regional pain syndrome (CRPS) occurs following an ing treatment was not available. Previously documented talar
inciting event, such as a fracture, blunt trauma, or surgery, and diffuse bone marrow changes in ballet dancers were associat-
manifests itself with sympathetic dysfunction as well as, in later ed with pain.7 Yet, asymptomatic bone marrow MRI signal
stages, with loss of function and muscle contractures.8,14,15,18,22 alterations are also reported.1,3-6,12,24,27 Asymptomatic foci of
Its MRI appearance includes patchy and subcortical marrow increased tracer uptake in the lower extremities of ballet dancers
hyperintensity along with extraosseous findings such as skin have also been noted on scintigraphy.26 Therefore, it remains to
thickening, periarticular soft-tissue edema, muscle atrophy, be determined whether SBM is correlated to clinical symptoms.
joint effusion, and, in chronic stages, periarticular soft-tissue The small sample size limits our ability to assess for associations
atrophy.8,18,35 between SBM and other pathologies. Moreover, only a few
Infection and neoplasm are often aggressive processes.15 patients had imaging of bilateral ankles and follow-up MRIs,
Their imaging features can include a periosteal reaction, cor- which precludes definite conclusions on the bilateral involve-
tical expansion, cortical destruction, and extension into the ment and evolution of SBM, respectively.
soft tissues.8,16 With infection, cutaneous ulceration, cellulitis, As a future study, a controlled prospective study including a
abscess, sequestrum, and sinus tract can sometimes be identi- large sample of symptomatic and asymptomatic ballet dancers
fied.13,16 While SBM may show striking bone marrow signal with correlation to symptoms and training regimen as well as
abnormalities, particularly in grade 3, there are no associated imaging of bilateral ankles along with follow-up imaging would
aggressive imaging features. Neuropathic arthropathies are most be helpful to assess the clinical significance and prognosis of
often centered about the Lisfranc and Chopart joints and are SBM.
characterized by destructive chronic changes.13
Osteonecrosis can occur secondary to many causes, such as Conclusion
steroids, trauma, sickle cell anemia, systemic lupus erythema- In conclusion, SBM is a frequently encountered MRI finding
tosus, alcoholism, pregnancy, pancreatitis, and idiopathic.16,18,37 in the tarsal bones of ballet dancers, and it is likely stress-related
Osteonecrosis differs from SBM because it demonstrates the and self-limiting. Health care professionals involved in the care
classic MRI “double-line” sign or serpentine geographic distri- of ballet dancers should be familiar with the patchy, speckled
bution and progresses to sclerosis and bone collapse as seen on MRI pattern of SBM to avoid incorrectly reporting more ag-
radiographs.8,10,13,15,16,20,35,37 gressive lesions, such as infection or neoplasm, and to prevent
Since diffuse bone marrow signal abnormalities may rep- unnecessarily invasive diagnostic and treatment plans.
resent the manifestation of a broad range of conditions with
nonspecific overlapping MRI findings, correlation of the MRI Acknowledgments
findings with findings on other imaging modalities such as ra-
Dr. Natalia Gorelik is grateful for the salary support from an
diographs, clinical evaluation, laboratory results, and sometimes
AUR GE Radiology Research Academic Fellowship Award.
tissue analysis may be necessary to establish the diagnosis.8,10,14-16
Albeit the distinction between SBM and focal marrow abnor- References
malities is easier than the differentiation among the etiologies 1. Kornaat PR, Van de Velde SK. Bone marrow edema lesions in the
of diffuse marrow signal abnormalities, its clinical implications professional runner. Am J Sports Med. 2014;42(5):1242-6.
remain important. In our cohort, focal marrow signal abnor- 2. Niva MH, Sormaala MJ, Kiuru MJ, et al. Bone stress injuries
malities were frequently related to posterior impingement of the ankle and foot: an 86-month magnetic resonance imag-
and traumatic injuries. In posterior impingement, additional ing-based study of physically active young adults. Am J Sports Med.
2007;35(4):643-9.
findings such as soft tissue reactive changes and anatomic pre- 3. Lazzarini KM, Troiano RN, Smith RC. Can running cause the
disposition (e.g., os trigonum, Stieda’s process, and prominent appearance of marrow edema on MR images of the foot and ankle?
posterior process of the calcaneus) can often be seen.25,28 In Radiology. 1997;202(2):540-2.
traumatic lesions, the pattern and location of marrow signal 4. Lohman M, Kivisaari A, Vehmas T, et al. MRI abnormalities of foot
changes are predictable from the mechanism of injury.9,13,17 and ankle in asymptomatic, physically active individuals. Skeletal
Radiol. 2001;30(2):61-6.
These patterns are distinct from the patchy, speckled pattern of 5. Trappeniers L, De Maeseneer M, De Ridder F, et al. Can bone
osseous structures in SBM. As treatments for some particular marrow edema be seen on STIR images of the ankle and foot after
focal marrow signal abnormalities are available (e.g., curative 1 week of running? Eur J Radiol. 2003;47(1):25-8.
arthroscopic resection of the os trigonum or Stieda’s process 6. Schweitzer ME, White LM. Does altered biomechanics cause marrow
for posterior impingement25), it is important for physicians to edema? Radiology. 1996;198(3):851-3.
7. Elias I, Zoga AC, Raikin SM, et al. Bone stress injury of the ankle
discern between SBM and focal marrow changes. in professional ballet dancers seen on MRI. BMC Musculoskelet
Limitations of our study include the lack of clinical and Disord. 2008;9:39.
histological correlation, the retrospective observational study 8. Chan BY, Gill KG, Rebsamen SL, Nguyen JC. MR Imaging of
 Journal of Dance Medicine & Science • Volume 26, Number 2, 2022 133

Pediatric Bone Marrow. Radiographics. 2016;36(6):1911-30. 53.

9. Elias I, Zoga AC, Schweitzer ME, et al. A specific bone marrow edema 23. Kadel NJ, Teitz CC, Kronmal RA. Stress fractures in ballet dancers.
around the foot and ankle following trauma and immobilization Am J Sports Med. 1992;20(4):445-9.
therapy: pattern description and potential clinical relevance. Foot 24. Navas A, Kassarjian A. Bone marrow changes in stress injuries. Semin
Ankle Int. Apr 2007;28(4):463-71. Musculoskelet Radiol. 2011;15(3):183-97.
10. Rios AM, Rosenberg ZS, Bencardino JT, et al. Bone marrow edema 25. Rehmani R, Endo Y, Bauman P, et al. Lower extremity injury patterns
patterns in the ankle and hindfoot: distinguishing MRI features. AJR in elite ballet dancers: ultrasound/MRI imaging features and an in-
Am J Roentgenol. 2011;197(4):W720-9. stitutional overview of therapeutic ultrasound guided percutaneous
11. Shabshin N, Schweitzer ME, Morrison WB, et al. High-signal T2 interventions. HSS J. 2015;11(3):258-77.
changes of the bone marrow of the foot and ankle in children: red 26. Nussbaum AR, Treves ST, Micheli L. Bone stress lesions in bal-
marrow or traumatic changes? Pediatr Radiol. 2006;36(7):670-6. let dancers: scintigraphic assessment. AJR Am J Roentgenol.
12. Zubler V, Mengiardi B, Pfirrmann CW, et al. Bone marrow changes 1988;150(4):851-5.
on STIR MR images of asymptomatic feet and ankles. Eur Radiol. 27. Hillier JC, Peace K, Hulme A, Healy JC. Pictorial review: MRI
2007;17(12):3066-72. features of foot and ankle injuries in ballet dancers. Br J Radiol.
13. Weishaupt D, Schweitzer ME. MR imaging of the foot and an- 2004;77(918):532-7.
kle: patterns of bone marrow signal abnormalities. Eur Radiol. 28. Peace KA, Hillier JC, Hulme A, Healy JC. MRI features of posterior
2002;12(2):416-26. ankle impingement syndrome in ballet dancers: a review of 25 cases.
14. Hayes CW, Conway WF, Daniel WW. MR imaging of bone marrow Clin Radiol. 2004;59(11):1025-33.
edema pattern: transient osteoporosis, transient bone marrow edema 29. Zanetti M, Bruder E, Romero J, Hodler J. Bone marrow edema
syndrome, or osteonecrosis. Radiographics. 1993;13(5):1001-11; pattern in osteoarthritic knees: correlation between MR imaging
discussion 1012. and histologic findings. Radiology. 2000;215(3):835-40.
15. Korompilias AV, Karantanas AH, Lykissas MG, Beris AE. Bone 30. Kadel NJ. Foot and ankle injuries in dance. Phys Med Rehabil Clin
marrow edema syndrome. Skeletal Radiol. 2009;38(5):425-36. N Am. 2006;17(4):813-26, vii.
16. Kung JW, Yablon CM, Eisenberg RL. Bone marrow signal alteration 31. Kadel N. Foot and ankle problems in dancers. Phys Med Rehabil
in the extremities. AJR Am J Roentgenol. 2011;196(5):W492-510. Clin N Am. 2014;25(4):829-44.
17. Vanhoenacker FM, Snoeckx A. Bone marrow edema in sports: general 32. Milan KR. Injury in ballet: a review of relevant topics for the physical
concepts. Eur J Radiol. 2007;62(1):6-15. therapist. J Orthop Sports Phys Ther. 1994;19(2):121-9.
18. Starr AM, Wessely MA, Albastaki U, et al. Bone marrow edema: 33. Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consen-
pathophysiology, differential diagnosis, and imaging. Acta Radiol. sus statement: beyond the Female Athlete Triad—Relative Energy
2008;49(7):771-86. Deficiency in Sport (RED-S). Br J Sports Med. 2014;48(7):491-7.
19. O’Hare A, Shortt C, Napier N, Eustace SJ. Bone marrow edema: 34. Carsen S, Quinn BJ, Beck E, et al. “Nutcracker fracture” in a
patterns and clinical implications. Semin Musculoskelet Radiol. ballet dancer performing in The Nutcracker. J Dance Med Sci.
2006;10(4):249-57. 2015;19(3):124-7.
20. Gil HC, Levine SM, Zoga AC. MRI findings in the subchondral 35. Gigena LM, Chung CB, Lektrakul N, et al. Transient bone marrow
bone marrow: a discussion of conditions including transient oste- edema of the talus: MR imaging findings in five patients. Skeletal
oporosis, transient bone marrow edema syndrome, SONK, and Radiol. 2002;31(4):202-7.
shifting bone marrow edema of the knee. Semin Musculoskelet 36. Mirghasemi SA, Trepman E, Sadeghi MS, et al. Bone marrow edema
Radiol. 2006;10(3):177-86. syndrome in the foot and ankle. Foot Ankle Int. 2016;37(12):1364-
21. Pal CR, Tasker AD, Ostlere SJ, Watson MS. Heterogeneous signal in 73.
bone marrow on MRI of children’s feet: a normal finding? Skeletal 37. Pearce DH, Mongiardi CN, Fornasier VL, Daniels TR. Avascular
Radiol. 1999;28(5):274-8. necrosis of the talus: a pictorial essay. Radiographics. 2005;25(2):399-
22. Orr JD, Sabesan V, Major N, Nunley J. Painful bone marrow edema 410.
syndrome of the foot and ankle. Foot Ankle Int. 2010;31(11):949-