MRI in Ribbing disease—a case report

Abstract

A 35-year-old woman presented in September 2008 with pain in the right tibia for 2 years. The pain had worsened in the last 3 months. As she worked as an athletic trainer in a gymnasium, a stress fracture was suspected. Radiographs of the right tibia showed cortical thickening and endosteal sclerosis in the mid-diaphysis (Figure 1). A tentative diagnosis of sclerosing osteomyelitis was made. Figure 1. The right tibia showing endosteal sclerosis (arrows) obliterating the endosteal canal of the mid-diaphysis. A lesser degree of endosteal sclerosis can be seen in the upper diaphysis (arrowheads). A 99mTc-MDP bone scan demonstrated intense uptake in the right tibia and also involvement of the left tibia (Figure 2). Conventional radiographic evaluation of the left tibia was normal. The patient had no pain in the left tibia. Figure 2. Scintigraphy showed intense uptake in the diaphysis of the right tibia. Moreover, it revealed a focus of pathological uptake in the diaphysis of the left tibia (arrow). Biochemical evaluations showed normal erythrocyte sedimentation rate, and no serum rheumatoid factor, anti-DNA antibodies, or antinuclear antibodies. Serum alkaline phosphatase, parathyroid hormone, ionized calcium, phosphorus, and 1,25- and 25-vitamin D were normal. MRI examination of both tibias confirmed the presence of sclerosis and bone marrow edema in the right tibia as well as bone marrow edema in the diaphysis of the left tibia (Figures 3 and ​and4).4). Biopsy of the right tibia showed an unspecific reactive cortical thickening with fibrosis. Attempts at culture failed to grow any organism. Figure 3. A 5-mm-thick axial T1-weighted image through the mid-tibia confirming massive endosteal sclerosis that caused obliteration of the canal of the right tibia. Figure 4. A 5-mm-thick coronal STIR image revealing endosteal sclerosis (arrowhead) with associated hyperintense edema (black arrows) in the endosteal canal of the right tibia. Moreover, slight hyperintensity in the endosteal canal of the left tibia (white arrow) ... On the basis of the medical history, radiographic images, and MRI images, the diagnosis of Ribbing disease was made. The patient was treated with oral non-steroidal analgesics for 2 months, with modest pain relief. 3 months after discontinuation of therapy, the pain abated further.