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<v ->I'll show simple cases,

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but very interesting cases, lives

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that you see in almost every week

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to try to show examples

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about what you just talk for us, okay?

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The first case is a 30-years-old female who presented

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with pain,

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in posterior medial part of the ankle.

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I'll show you some images

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in T1 and that you can take a look

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in the images and try to find any anything here.

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We usually place cutaneous marker

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in the topography of the pain referred by the patient

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which in this case, corresponded posterior medial aspect

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of the ankle.

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Let me put different sequences here

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in T2 or DP fat suppression,

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you can see this finding.

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In a sensitive fluid sequence,

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we observe a diffuse bone edema

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in the entire distal third of the tibia.

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I don't know.

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Usually, when we see this pattern of edema,

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we begin to look to see where's the fracture.

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Let me zoom in the image.

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Where is the fracture here?

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We didn't see.

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This line is the (indistinct) line

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which should not be confused

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with a fracture, especially

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when we have a lot of edema.

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It's more evident, this line.

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But, we cannot see, even

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with this history of pain after running,

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it's very, very difficult to see any kind of fracture

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on these images.

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Well, another thing is the joint effusion.

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We can see the synovitis,

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it's like a joint effusion with reactive synovitis.

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It's very typical.

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This association, when we have this pattern of edema

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in synovitis or joint effusion in the joint near the area.

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The most important for me in this case,

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that the MRI makes the diagnosis of the disease.

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This is the most important,

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'cause clinically, it's very difficult to think about that.

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Usually, we can think about stress reactions,

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stress fractures, but when we see this kind of edema,

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we should think about the bone marrow edema syndrome.

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There's a lot of different names for this.

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Usually, it's a bone marrow transient, bone marrow edema

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or something like that.

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In view of this MRI, it was recommended

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for the patient to partially remove the load

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from this left lower link with use of a crutch.

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She also starting to use bisphosphonates as a treatment.

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But, about 35 days after this MRI,

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the patient presented a similar pain, now in the right side.

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And, the orthopedist request an MRI

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that I show right now.

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This is the image of the right side 35 days

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after the first examination.

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When we see this kind,

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of edema, it looked like the same that we saw

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in the contralateral side.

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It's a hyper signal on T2.

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It's a slight hyper signal on T1 without clear fracture.

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We can look for the fracture, we cannot see.

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The images in this case is very beautiful

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as if it were a paint in a frame.

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Really, it's diagnostic.

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Once again,

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my idea is related by mechanical overload

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or something like that, a stress reaction,

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was the the initial problem in this case.

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We had images

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after, two months, exactly two months,

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we see the control of the images.

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Let me put here in the...

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This is the right side, okay, right side.

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Let me in the top, I put the images

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from the 28th August in here.

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I put images from September, only to compare the images.

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Now, we can see the difference

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between the edema in the talus.

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It's only one month or less than one month

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to show the difference between the reduction.

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We can see the reduction of the edema

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and this patient is still in treatment using a crutch,

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using a bisphosphonate, rest and physiotherapy.

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And, after two months she did another MRI.

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She did another MRI, bilateral MRI.

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And, at this time, let's go

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and see the first MRI

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that I show you.

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This is the left side.

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Let me show you the left side.

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Left side here and left side here.

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We have the previous and the current examination.

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You can take a look and see,

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where is the bone edema?

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It's exactly two months

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and difference between the first and the control

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that we can see.

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We cannot see any more edema in this area.

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We look for to see any line of fracture

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that could be healing, it's easier to see,

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but it's impossible.

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We couldn't see any kind of fracture.

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The only thing that patient had,

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still have a little bit of pain

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in the posterior medial aspect,

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where we have an residual edema in this area.

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We can see the marker here.

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And, she had only this.

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But, when you take a look,

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let me divide this case in few,

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'cause this case is a very interesting case.

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Let me show you the images, the initial images.

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Let me put only the T2 images.

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It's easier to see the evolution of the case.

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Let me do here.

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This is the first.

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It's hard work with this.

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This is the first one, this is the second one.

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And, let me put the third one.

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Okay, I put images with after gadolinium

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to show you how is the enhancement.

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'Cause the enhancement changed a lot.

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Let's go, I try too many images, okay?

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Let me see, where is it?

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Okay, this is the first examination T2,

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after gadolinium, this is the second examination, T2,

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after gadolinium, we can see the difference

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between enhancement, it's high enhancement.

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And here, it's mild enhancement.

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In this time we are looking for how can this pattern

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of edema have so many enhancement like this?

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Should we have another different things in this case?

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This is one question.

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And when we see the last images,

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in the same aspect,

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we can look at the difference

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between the last one and the first one, was two months.

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And, the patient at this time, she didn't have symptoms,

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a little bit of symptoms.

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How can we have all this kind

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of enhancement after gadolinium?

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Do you have any comment about this kind of...

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Should we have any metabolic

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or any inflammatory process different

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that we see in the talus, that we see in the femoral head?

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It's a little bit different that we see in the other parts.

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Do you have any answer about?

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<v ->Yeah, I don't have an answer,

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but I agree with you

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that you know, it raises the possibility

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there's some sort of inflammatory component.

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One of the things that I love

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about this case I have to say, is, you know

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with all the theory that all

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of these transient painful marrow edema

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are insufficiency fractures,

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here, you have beautiful imaging

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that you have followed this case.

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And, not only is it

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in the talus, it's migrated and you never proved

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that there was an insufficiency fracture.

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And, it again, goes along with the idea

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that it's the marrow edema first

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and in some weight-bearing areas,

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an insufficiency fracture may develop.

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It doesn't have to develop, but it may develop.

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And, in this case, it seems like it never did.

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To me, I love that

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because it goes along with that theory.

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<v ->And, this is the migratory form, that's it.