Bone Marrow Edema in Sacroiliac Joints of Young Athletes Is Common and Shows Most Frequently in the Posterior Lower Ilium

Ulrich Weber¹, Anne Grethe Jurik², Anna Zejden³, Ejnar Larsen⁴, Steen Hylgaard Jørgensen⁵, Kaspar Rufibach⁶, Christian Schioldan⁷ and Søren Schmidt-Olsen⁵, ¹Department of Research, King Christian 10th Hospital for Rheumatic Diseases, Graasten, Denmark, ²Dept. of Radiology, Aarhus University Hospital, Aarhus, Denmark, ³Radiology, Aarhus University Hospital, Aarhus, Denmark, ⁴Radiology, North Denmark Regional Hospital, Hjørring, Denmark, ⁵Rheumatology and Sports Medicine, North Denmark Regional Hospital, Hjørring, Denmark, ⁶Biostatistics, F. Hoffmann-La Roche, Basel, Switzerland, Basel, Switzerland, ⁷Physiotherapy, Clinic Benefit, Frederikshavn, Denmark

Meeting: 2017 ACR/ARHP Annual Meeting

Date of first publication: September 18, 2017

Keywords: magnetic resonance imaging (MRI) and spondylarthritis

Session Information

Date: Monday, November 6, 2017

Session Title: Spondyloarthropathies and Psoriatic Arthritis – Clinical Aspects and Treatment II

Session Type: ACR Concurrent Abstract Session

Session Time: 2:30PM-4:00PM

Background/Purpose: Low grade bone marrow edema (BME) was reported in the sacroiliac joints (SIJ) of up to 25% of healthy individuals and mechanical back pain patients, challenging the imaging discrimination from early spondyloarthritis (SpA) [1]. Potential explanations range from mechanical stress lesions to vascular signals and anatomical SIJ variants. There is little evidence as to whether physical strain, e.g. sports, heavy labour work, or multiparity may trigger SIJ BME. The goal of this study was to determine BME frequency and anatomical distribution in 8 SIJ regions in hobby and professional athletes.

Methods: The sample consisted of 2 cohorts of 20 healthy hobby runners (HR) before and after running and 22 professional ice hockey players (IP) from the Danish premier league: HR/IP 40%/100% men; mean age (SD) 27.2 (5.4)/25.9 (4.6) years; mean BMI (SD) 22.6 (1.5)/25.7 (1.6) kg/m2. Semicoronal MRI scans of the SIJ with T1SE and STIR sequences were obtained in HR before and 24 hours after a running competition over 6.2 km (mean duration 35.4 minutes, mean speed 10.4 km/h), and in IP at the end of the competitive season. The scans were assessed for BME independently by 3 blinded readers (AGJ, AZ, UW) according to the quadrant based MORPHO module (www.carearthritis.com). Paired images of HR were read blinded to timepoint. 7 MRI scans (2 paired images) of SpA patients under TNF treatment served to mask readers. A pre-test reader calibration used MRI scans from 11 patients with active sacroiliitis and 9 healthy volunteers. Reader agreement was assessed by ICC (3, 1). Descriptive analysis comprised mean frequency of SIJ quadrants with BME and their distribution in 8 anatomical SIJ regions: upper/lower ilium and sacrum, subdivided in anterior and posterior slices, as concordantly recorded by the majority (≥2/3) of readers.

Results: Agreement among 3 readers for SIJ BME was excellent in calibration (ICC 0.93) and moderate in athletes (ICC 0.59) due to low frequency of BME. The mean number (SD) of SIJ quadrants showing BME was 3.1 (4.2)/3.1 (4.5) in HR before/after running, and 3.6 (3.0) in IP. The posterior lower ilium was the single most affected region, followed by the anterior upper sacrum, consistently across 2 cohorts of athletes.

Table 1. Frequency and anatomical distribution of SIJ quadrants with BME in 2 cohorts of athletes. Abbreviations. n (%) with ≥1/2/3/4 SIJ Q: number of subjects (%) with ≥1/2/3/4 SIJ quadrants with BME as reported by ≥2/3 readers.

Cohort	SIJ quadrants	Upper Ilium		Lower Ilium		Upper Sacrum		Lower Sacrum		All subjects
		Anterior	Posterior	Anterior	Posterior	Anterior	Posterior	Anterior	Posterior
HR before	Mean SIJ Q (SD)	0.1 (0.4)	0.1 (0.3)	0.2 (0.7)	1.4 (1.9)	0.5 (0.9)	0.1 (0.4)	0.3 (0.6)	0.5 (1.6)	3.1 (4.2)
	n (%) with ≥1 SIJ Q	3 (15.0)	0	1 (5.0)	8 (40.0)	4 (20.0)	2 (10.0)	3 (15.0)	1 (5.0)	15 (75.0)
	n (%) with ≥2 SIJ Q	0	0	1 (5.0)	6 (30.0)	3 (15.0)	0	0	1 (5.0)	14 (70.0)
	n (%) with ≥3 SIJ Q	0	0	1 (5.0)	2 (10.0)	1 (5.0)	0	0	1 (5.0)	5 (25.0)
	n (%) with ≥4 SIJ Q	0	0	0	1 (5.0)	0	0	0	1 (5.0)	3 (15.0)
HR after	Mean SIJ Q (SD)	0.2 (0.4)	0 (0.1)	0.3 (0.8)	1.2 (1.7)	0.5 (1.0)	0.2 (0.7)	0.3 (0.7)	0.5 (1.6)	3.1 (4.5)
	n (%) with ≥1 SIJ Q	2 (10.0)	0	2 (10.0)	9 (45.0)	3 (15.0)	2 (10.0)	3 (15.0)	1 (5.0)	16 (80.0)
	n (%) with ≥2 SIJ Q	0	0	1 (5.0)	6 (30.0)	2 (10.0)	1 (5.0)	0	1 (5.0)	14 (70.0)
	n (%) with ≥3 SIJ Q	0	0	1 (5.0)	3 (15.0)	2 (10.0)	0	0	1 (5.0)	8 (40.0)
	n (%) with ≥4 SIJ Q	0	0	1 (5.0)	1 (5.0)	0	0	0	1 (5.0)	5 (25.0)
IP	Mean SIJ Q (SD)	0.1 (0.4)	0.1 (0.3)	0.5 (0.8)	1.9 (1.9)	0.6 (1.1)	0.1 (0.4)	0.2 (0.6)	0.1 (0.6)	3.6 (3.0)
	n (%) with ≥1 SIJ Q	0	1 (4.5)	7 (31.8)	13 (59.1)	3 (13.6)	0	3 (13.6)	0	20 (90.9)
	n (%) with ≥2 SIJ Q	0	0	4 (18.2)	11 (50.0)	2 (9.1)	0	1 (4.5)	0	15 (68.2)
	n (%) with ≥3 SIJ Q	0	0	0	6 (27.3)	2 (9.1)	0	0	0	12 (54.5)
	n (%) with ≥4 SIJ Q	0	0	0	3 (13.6)	1 (4.5)	0	0	0	11 (50.0)

Conclusion:

In hobby and professional athletes, BME showed on average in 3-4 SIJ quadrants. The posterior lower ilium was the single most affected SIJ region, followed by the anterior upper sacrum. These findings in healthy controls help refine thresholds for a positive SIJ MRI in early SpA.

References. [1] Weber U et al. Curr Rheumatol Rep 2016;18:58.

Disclosure: U. Weber, None; A. G. Jurik, None; A. Zejden, None; E. Larsen, None; S. H. Jørgensen, None; K. Rufibach, None; C. Schioldan, None; S. Schmidt-Olsen, None.

To cite this abstract in AMA style:

Weber U, Jurik AG, Zejden A, Larsen E, Jørgensen SH, Rufibach K, Schioldan C, Schmidt-Olsen S. Bone Marrow Edema in Sacroiliac Joints of Young Athletes Is Common and Shows Most Frequently in the Posterior Lower Ilium [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/bone-marrow-edema-in-sacroiliac-joints-of-young-athletes-is-common-and-shows-most-frequently-in-the-posterior-lower-ilium/. Accessed September 24, 2021.

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