Longitudinal Progression of Traumatic Bone Marrow Lesions Following Anterior Cruciate Ligament Injury: Associations With Knee Pain and Concomitant Injuries

Traumatic bone marrow lesions (BMLs) occur in ~80% of anterior cruciate ligament (ACL) injuries, typically in the lateral femoral condyle (LFC) and lateral tibial plateau (LTP). Associated with microfractures, vascular proliferation, inflammation, and bone density changes, BMLs may contribute to posttraumatic osteoarthritis. However, their relationship with knee pain is unclear. This study examined the prevalence, characteristics, and progression of BMLs after ACL injury, focusing on associations with pain, meniscal and ligament injuries, and fractures. Participants (N = 100, aged 14-55) with MRI-confirmed ACL tears were scanned within 6 weeks post-injury (mean = 30.0, SD = 9.6 days). BML volumes were quantified using a validated machine learning method, and pain assessed via the Knee Injury and Osteoarthritis Outcome Score (KOOS). Analyses included t-tests, Mann-Whitney U, chi-square, and Spearman correlations with false discovery rate correction. BMLs were present in 95% of participants, primarily in the LFC and LTP. Males had 33% greater volumes than females (p < 0.05), even after adjusting for BMI. Volumes were higher in cases with depression fractures (p = 0.022) and negatively associated with baseline KOOS Symptoms. At 1 year, 92.68% of lesions (based on lesion counts) resolved in Nonsurgical participants, with a 96.13% volume reduction (p < 0.001). KOOS outcomes were similar between groups, except for slightly better Pain scores in the Nonsurgical group. Baseline Pain and Sport scores predicted follow-up outcomes. BMLs are common post-ACL injury, vary by sex and fracture status, and modestly relate to early symptoms. Most resolve within a year, with limited long-term differences by surgical status.