Imaging of the elbow in the overhead throwing athlete

Correlation of Joint Space Widening on Valgus Stress Magnetic Resonance Imaging With Level of Play and Innings Pitched in Professional Pitchers

Background

Previous studies have described various techniques and confirmed the clinical utility of valgus stress radiography and stress ultrasound in overhead athletes. The addition of valgus stress and a high-resolution anatomic assessment of the elbow with magnetic resonance imaging (MRI) in the active throwing position (flexed elbow valgus external rotation [FEVER] view) can add valuable diagnostic or prognostic information in throwing athletes.

Purpose/Hypothesis

The purpose of this study was to evaluate findings on MRI and subsequent performance in professional throwing athletes. It was hypothesized that joint space widening in the FEVER view would be predictive of performance and the risk of subsequent injuries.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

All pitchers on 2 Major League Baseball teams who consented to participate during their preseason screening in 2019 and 2020 underwent standard and FEVER MRI, and performance data from the following season were recorded, including injuries, mean throwing velocity, number of innings pitched, strikeout percentage, walk percentage, weighted on-base average, and level of play reached (not signed, minor league, or major league). Categorical variables were compared using the Fisher exact test or chi-square test, and continuous variables were compared using the Kruskal-Wallis test, as appropriate. Ordered logistic regression was used to determine the independent factors predicting performance.

Results

A total of 91 players underwent preseason imaging, and all players had subsequent performance data available. Multivariate analysis revealed that when controlling for age, mean velocity, history of injuries, presence of symptoms, and history of ulnar collateral ligament reconstruction, increased absolute joint space widening was predictive of a lower level of play (β = -0.63; P = .042). Univariate analysis demonstrated a significant correlation between relative joint space widening and level of play reached (β = -0.54; P = .034). Relative joint space widening remained a significant predictor of level of play (β = -0.87; P = .012) on multivariate analysis. Multivariate analysis also showed that both absolute joint space widening (β = -13.50; P = .012) and relative joint space widening (β = -13.60; P = .026) were predictive of the number of innings pitched in the subsequent season.

Conclusion

The present study demonstrates that findings on MRI with valgus stress correlated with the level of play reached and number of innings pitched in professional throwing athletes.

Evaluation and management of elbow injuries in the adolescent overhead athlete

With an increased interest in youth sports, the burden of overhead throwing elbow injuries accompanying early single-sport focus has steadily risen. During the overhead throwing motion, valgus torque can reach and surpass Newton meters (N m) during the late cocking and early acceleration phases, which exceeds the tensile strength (22.7–33 N m) of the ulnar collateral ligament. While the ulnar collateral ligament serves as the primary valgus stabilizer between and degrees of elbow flexion, other structures about the elbow must contribute to stability during throwing. Depending on an athlete’s stage of skeletal maturity, certain patterns of injury are observed with mechanical failures resulting from increased medial laxity, lateral-sided compression, and posterior extension shearing forces. Together, these injury patterns represent a wide range of conditions that arise from valgus extension overload. The purpose of this article is to review common pathologies observed in the adolescent overhead throwing athlete in the context of functional anatomy, osseous development, and throwing mechanics. Operative and non-operative management and their associated outcomes will be discussed for these injuries.

Medial elbow injury in young throwing athletes

This report reviews the anatomy, overhead throwing biomechanics, injury mechanism and incidence, physical examination and diagnosis, diagnostic imaging and conservative treatment of medial elbow injuries in young throwing athletes. Based on the information a clinical management decision-making algorithm is presented.

Correlation of preoperative MRI and MRA with arthroscopically proven articular cartilage lesions of the elbow

OBJECTIVE

The purpose of this study was to evaluate the usefulness of magnetic resonance imaging (MRI) in detecting elbow articular cartilage injuries through comparison of preoperative MRI and magnetic resonance arthrography (MRA) with arthroscopic findings.

DESIGN

Retrospective case analysis.

SETTING

Tertiary care orthopedic private practice.

PATIENTS

Consecutive series of 31 patients presenting with elbow pain and diagnosed at arthroscopy with articular cartilage defects of the elbow. All patients had a preoperative MRI or MRA using a 1.5 T magnet.

INTERVENTIONS

Each patient had a systematic elbow arthroscopy, with careful inspection and recording of chondral injuries in 4 anatomical regions: capitellum, radius, trochlea, and ulna. Each MRI/MRA was then independently reviewed by 2 radiologists blinded to the arthroscopic findings.

MAIN OUTCOME MEASURES

The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy were calculated for MRI and MRI compared with arthroscopy as the gold standard, for each of the anatomical regions.

RESULTS

The accuracy of MRI was 45% for chondral injuries of the radius, 65% for the capitellum, 20% for the ulna, and 30% for the trochlea. The accuracy of MRA was 45% for chondral injuries of the radius, 64% for the capitellum, 18% for the ulna, and 27% for the trochlea.

CONCLUSION

We conclude that the ability of MRI and MRA using a 1.5 T magnet to detect articular cartilage lesions is limited. Neither MRI nor MRA demonstrates the intraarticular surface as accurately as direct visualization with the arthroscopy. This may be improved with the use of 3 T MRI.

CLINICAL RELEVANCE

This study demonstrates that MRI and MRA with a 1.5 T magnet, as used in community practice, have limited ability to detect cartilage lesions of the elbow.

Magnetic resonance imaging of the elbow: update on current techniques and indications

The utility of magnetic resonance imaging of the elbow has noticeably improved over the past decade. Advances in equipment and refinement of pulse sequences has allowed for superior visualization of many pathologic processes involving the elbow joint and its surrounding structures. At this time, magnetic resonance imaging is most valuable in detecting occult fractures, osteochondritis dissecans, collateral ligament tears, nonossified intra-articular loose bodies, and soft tissue masses. It may also aid in the diagnosis of tendinous injuries, compression neuropathies, and synovial disorders. This article serves as an educational update for hand surgeons and illustrates the features of normal anatomy and specific disorders of the elbow.

The thrower's elbow: arthroscopic treatment of valgus extension overload syndrome

Injury to the medial collateral ligament of the elbow (MCL) can be a career-threatening injury for an overhead athlete without appropriate diagnosis and treatment. It has been considered separately from other athletic injuries due to the unique constellation of pathology that results from repetitive overhead throwing. The past decade has witnessed tremendous gains in understanding of the complex interplay between the dynamic and static stabilizers of the athlete's elbow. Likewise, the necessity to treat these problems in a minimally invasive manner has driven the development of sophisticated techniques and instrumentation for elbow arthroscopy. MCL injuries, ulnar neuritis, valgus extension overload with osteophyte formation and posteromedial impingement, flexor pronator strain, medial epicondyle pathology, and osteochondritis dissecans (OCD) of the capitellum have all been described as sequelae of the overhead throwing motion. In addition, loose body formation, bony spur formation, and capsular contracture can all be present in conjunction with these problems or as isolated entities. Not all pathology in the thrower's elbow is amenable to arthroscopic treatment; however, the clinician must be familiar with all of these problems in order to form a comprehensive differential diagnosis for an athlete presenting with elbow pain, and he or she must be comfortable with the variety of open and arthroscopic treatments available to best serve the patient. An understanding of the anatomy and biomechanics of the thrower's elbow is critical to the care of this population. The preoperative evaluation should focus on a thorough history and physical examination, as well as on specific diagnostic imaging modalities. Arthroscopic setup, including anesthesia, patient positioning, and portal choices will be discussed. Operative techniques in the anterior and posterior compartments will be reviewed, as well as postoperative rehabilitation and surgical results. Lastly, complications will be reviewed.

Radiographic and special studies: recent advances in imaging of the elbow

Advanced imaging techniques such as computed tomography, ultrasound, and magnetic resonance imaging provide clinically useful information by detecting and characterizing pathologic conditions of the elbow. The information provided by these techniques can help establish an anatomic diagnosis in a noninvasive fashion. A timely and accurate imaging diagnosis may be an important piece of the puzzle in a diagnostic workup that allows implementation of proper treatment and improved outcome. In this article, the authors focus on recent advances in diagnostic imaging of the elbow joint.

Return to sport following elbow surgery

Although less common than injuries to the knee or shoulder, elbow injuries can be a substantial challenge to sports medicine providers. Many elbow problems respond to routine nonoperative measures including periods of activity modification and physical therapy, but others may ultimately require surgery. Following surgery, appropriate attention to rehabilitation is important to achieve optimal function. This article addresses some of the more common sports-related operative elbow pathology, basic principals of surgery (with an emphasis on techniques only where it may impact rehabilitation or return-to-sport decisions), and return-to-play decisions (including typical "targeted" time frames). The emphasis is on an understanding of sport-specific functional demands and the difficult assessment of reinjury risk following surgery.