⁠Pain Exposure Physical Therapy (PEPT) as a conservative treatment for Bone Marrow Edema Syndrome (BMES) of the foot and ankle in an athlete: a case report

ABSTRACT Study Design: this is a single case report describing the clinical course of an athlete with Bone Marrow Edema Syndrome (BMES) of the foot and ankle who was treated with Pain Exposure Physical Therapy (PEPT). Background: Bone Marrow Edema Syndrome (BMES) is a self-limiting condition characterized by localized bone pain and reversible bone marrow lesions, most frequently affecting the lower limbs. Pain Exposure Physical Therapy (PEPT), originally developed for Complex Regional Pain Syndrome (CRPS), promotes gradual mechanical loading and desensitization through controlled exposure to movement and discomfort. However, its application to BMES, particularly in athletic populations, has not yet been documented. Objective: the purpose of this study was to explore whether the PEPT approach could represent a safe and effective rehabilitation option for an athlete with BMES after the failure of pharmacological treatment. Methods: a competitive athlete with BMES underwent a four-month individualized PEPT program. The intervention was adapted to the athlete’s sport specific demands, progressively increasing exercise intensity, load, and volume. Outcome measures included the Foot and Ankle Ability Measure (FAAM), Numeric Pain Rating Scale (NPRS), dynamometric strength assessment, jump performance (drop jump, countermovement jump), and balance assessment using force plates. Assessments were conducted at baseline and at two follow-up points over a four-month period. Results: the patient showed improvement in strength and function, achieving a full return to sport without pain or discomfort by November 2025. FAAM scores approached maximum values, strength testing revealed increased inter-limb symmetry. Despite some fluctuations in pain levels (NPRS), functional capacity improved steadily, indicating tolerance to physical activity. Conclusions: this case suggests that Pain Exposure Physical Therapy (PEPT) may represent a safe and functionally effective alternative for athletes with BMES after pharmacological treatment failure. Although causality cannot be established due to the single case design, the results highlight the potential of PEPT as a complementary rehabilitation approach worthy of further investigation in larger, controlled studies across different clinical and athletic populations.