MRI of the Elbow – Update 2024

Abstract

Background

Elbow pain can result in significant morbidity. MRI can help diagnosing the cause of elbow pain.

Methods

Based on a systematic literature search as well as knowledge gained through frequent participation in conferences dedicated to advances in musculoskeletal imaging, this review aims to give a brief overview of normal anatomy and common pathologies of tendons and ligaments of the elbow on magnetic resonance imaging.

Results

Stabilization of the elbow joint is provided by osseous structures and passive ligamentous and active muscular support. Loss of these important stabilizers, due to trauma and overuse, can result in elbow instability. Additional MR views or intra-articular contrast media can be useful for the detection of specific pathologies.

Conclusion

MRI is frequently used to detect posttraumatic or chronic conditions, which can lead to posterolateral or posteromedial elbow instability. Knowledge of normal anatomy, variants, pathologies, as well as appropriate imaging is crucial to make the diagnosis.

Key Points

• Epicondylitis occurs due to chronic degeneration with tendinosis and partial tendon tearing and is not related to an acute inflammatory reaction.

• Posterolateral or posteromedial elbow instability can be the result of trauma with loss of passive ligamentous and active muscular stabilization.

• The most common elbow instability is posterolateral rotatory instability with the LUCL being the most important stabilizer affected by injury.

Citation Format

• Schinnerl C, Weber M, Benninger E et al. MRI of the Elbow – Update 2024. Fortschr Röntgenstr 2024; DOI 10.1055/a-2416-1491

Zusammenfassung

Hintergrund

Ellbogenschmerzen können eine signifikante Morbidität hervorrufen. Die MRT kann helfen, den Grund der Ellbogenschmerzen zu diagnostizieren.

Methoden

Basierend auf einer systematischen Literaturrecherche sowie Erkenntnissen, die durch eine häufige Teilnahme an Konferenzen zu Fortschritten in der muskuloskelettalen Bildgebung gewonnen wurden, soll dieser Review einen kurzen Überblick über die normale Anatomie und häufige Pathologien der Sehnen und Ligamente des Ellenbogens in der Magnetresonanztomografie geben.

Ergebnisse

Die Stabilisierung des Ellenbogens wird durch knöcherne Strukturen, passive Ligamente und aktive muskuläre Unterstützung gewährleistet. Ein Verlust dieser wichtigen Stabilisatoren, durch Trauma oder Überbeanspruchung, kann in einer Ellbogeninstabilität resultieren. Zusätzliche MR-Ansichten oder intraartikulär appliziertes Kontrastmittel können in der Detektion spezifischer Pathologien nützlich sein.

Schlussfolgerung

Die MRT dient zum Erkennen posttraumatischer und chronischer Pathologien, welche eine posterolaterale oder posteromediale Ellbogeninstabilität hervorrufen können. Kenntnis der normalen Anatomie, Varianten, Pathologien sowie der geeigneten Bildgebung ist entscheidend, um die Diagnose zu stellen.

Kernaussagen

• Eine Epikondylitis entsteht aufgrund einer chronischen Degeneration, Tendinose und Partialruptur der Sehnen und beruht nicht auf einer akuten inflammatorischen Reaktion.

• Die posterolaterale oder posteromediale Ellbogeninstabilität kann Resultat eines Traumas sein mit konsekutivem Verlust der passiven ligamentären und aktiven muskulären Stabilisatoren.

• Die häufigste Ellbogeninstabilität ist die posterolaterale Instabilität mit Verletzung des LUCL, welches der wichtigste Stabilisator ist.

Keywords

elbow - MR-imaging - posterolateral rotatory instability - posteromedial rotatory instability - symptomatic minor instability of the lateral elbow (SMILE)

Publication History

Received: 30 June 2024

Accepted after revision: 03 September 2024

Article published online:
12 November 2024

• References

• 1 Karbach LE, Elfar J. Elbow Instability: Anatomy, Biomechanics, Diagnostic Maneuvers, and Testing. J Hand Surg Am 2017; 42: 118-126
• 2 Safran MR, Baillargeon D. Soft-tissue stabilizers of the elbow. J Shoulder Elbow Surg 2005; 14: 179s-185s
• 3 Husarik DB, Saupe N, Pfirrmann CW. et al. Ligaments and plicae of the elbow: normal MR imaging variability in 60 asymptomatic subjects. Radiology 2010; 257: 185-194
• 4 Floris S, Olsen BS, Dalstra M. et al. The medial collateral ligament of the elbow joint: anatomy and kinematics. J Shoulder Elbow Surg 1998; 7: 345-351
• 5 Janßen R, Falkowski AL, Hirschmann A. Assessment of ligament and tendon injuries of the elbow using magnetic resonance imaging. Radiologe 2018; 58: 996-1003
• 6 King GJ, Morrey BF, An KN. Stabilizers of the elbow. J Shoulder Elbow Surg 1993; 2: 165-174
• 7 Mirowitz SA, London SL. Ulnar collateral ligament injury in baseball pitchers: MR imaging evaluation. Radiology 1992; 185: 573-576
• 8 Joyner PW, Bruce J, Hess R. et al. Magnetic resonance imaging-based classification for ulnar collateral ligament injuries of the elbow. J Shoulder Elbow Surg 2016; 25: 1710-1716
• 9 Wilson FD, Andrews JR, Blackburn TA. et al. Valgus extension overload in the pitching elbow. Am J Sports Med 1983; 11: 83-88
• 10 Cain EL Jr, Dugas JR, Wolf RS. et al. Elbow injuries in throwing athletes: a current concepts review. Am J Sports Med 2003; 31: 621-635
• 11 Graf DN, Fritz B, Bouaicha S. et al. Elbow Instability. Semin Musculoskelet Radiol 2021; 25: 574-579
• 12 Timmerman LA, Andrews JR. Undersurface tear of the ulnar collateral ligament in baseball players. A newly recognized lesion. Am J Sports Med 1994; 22: 33-36
• 13 Lund P, Waslewski GL, Crenshaw K. et al. FEVER: The Flexed Elbow Valgus External Rotation View for MRI Evaluation of the Ulnar Collateral Ligament in Throwing Athletes-A Pilot Study in Major League Baseball Pitchers. AJR Am J Roentgenol 2021; 217: 1176-1183
• 14 Schwartz ML, al-Zahrani S, Morwessel RM. et al. Ulnar collateral ligament injury in the throwing athlete: evaluation with saline-enhanced MR arthrography. Radiology 1995; 197: 297-299
• 15 Timmerman LA, Schwartz ML, Andrews JR. Preoperative evaluation of the ulnar collateral ligament by magnetic resonance imaging and computed tomography arthrography. Evaluation in 25 baseball players with surgical confirmation. Am J Sports Med 1994; 22: 26-31
• 16 Pazahr S, Sutter R, Zubler V. MRI of the Elbow: How to Do It. Semin Musculoskelet Radiol 2021; 25: 538-545
• 17 An KN, Hui FC, Morrey BF. et al. Muscles across the elbow joint: a biomechanical analysis. J Biomech 1981; 14: 659-669
• 18 Chung CB, Chew FS, Steinbach L. MR imaging of tendon abnormalities of the elbow. Magn Reson Imaging Clin N Am 2004; 12: 233-245
• 19 Granger A, Sardi JP, Iwanaga J. et al. Osborne’s Ligament: A Review of its History, Anatomy, and Surgical Importance. Cureus 2017; 9: e1080
• 20 Anderson MW, Chung CB. IDKD Springer Series Elbow Imaging with an Emphasis on MRI. In: Hodler J, Kubik-Huch RA, von Schulthess GK, Hrsg. Musculoskeletal Diseases 2021–2024: Diagnostic Imaging. Cham (CH). Springer Copyright; 2021: 23-39
• 21 Stevens KJ. Magnetic resonance imaging of the elbow. J Magn Reson Imaging 2010; 31: 1036-1053
• 22 Bozkurt M, Acar HI, Apaydin N. et al. The annular ligament: an anatomical study. Am J Sports Med 2005; 33: 114-118
• 23 Stein JM, Cook TS, Simonson S. et al. Normal and variant anatomy of the elbow on magnetic resonance imaging. Magn Reson Imaging Clin N Am 2011; 19: 609-619
• 24 Cage DJ, Abrams RA, Callahan JJ. et al. Soft tissue attachments of the ulnar coronoid process. An anatomic study with radiographic correlation. Clin Orthop Relat Res 1995; 154-158
• 25 Terada N, Yamada H, Toyama Y. The appearance of the lateral ulnar collateral ligament on magnetic resonance imaging. J Shoulder Elbow Surg 2004; 13: 214-216
• 26 O’Driscoll SW, Morrey BF, Korinek S. et al. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop Relat Res 1992; 186-197
• 27 Cohen MS, Hastings 2nd H. Rotatory instability of the elbow. The anatomy and role of the lateral stabilizers. J Bone Joint Surg Am 1997; 79: 225-233
• 28 Conti Mica M, Caekebeke P, van Riet R. Lateral collateral ligament injuries of the elbow – chronic posterolateral rotatory instability (PLRI). EFORT Open Rev 2016; 1: 461-468
• 29 Al-Ani Z, Wright A, Ricks M. et al. Posteromedial rotatory instability of the elbow: What the radiologist needs to know. Eur J Radiol 2021; 141: 109819
• 30 O’Driscoll SW. Classification and evaluation of recurrent instability of the elbow. Clin Orthop Relat Res 2000; 34-43
• 31 Fedorka CJ, Oh LS. Posterolateral rotatory instability of the elbow. Curr Rev Musculoskelet Med 2016; 9: 240-246
• 32 Ebrahimzadeh MH, Amadzadeh-Chabock H, Ring D. Traumatic elbow instability. J Hand Surg Am 2010; 35: 1220-1225
• 33 Hwang JT, Shields MN, Berglund LJ. et al. The role of the posterior bundle of the medial collateral ligament in posteromedial rotatory instability of the elbow. Bone Joint J 2018; 100-b: 1060-1065
• 34 Arrigoni P, Cucchi D, D’Ambrosi R. et al. Intra-articular findings in symptomatic minor instability of the lateral elbow (SMILE). Knee Surg Sports Traumatol Arthrosc 2017; 25: 2255-2263
• 35 Arrigoni P, Cucchi D, Luceri F. et al. Lateral Elbow Laxity Is Affected by the Integrity of the Radial Band of the Lateral Collateral Ligament Complex: A Cadaveric Model With Sequential Releases and Varus Stress Simulating Everyday Activities. Am J Sports Med 2021; 49: 2332-2340
• 36 Zagarella A, Folco G, Monti CB. et al. Semiquantitative index of symptomatic minor instability of the lateral elbow at CT arthrography (SMILE index): clinical applicability and reproducibility study. Eur Radiol 2024; 34: 2742-2750
• 37 Tan JW, Mu MZ, Liao GJ. et al. Pathology of the annular ligament in paediatric Monteggia fractures. Injury 2008; 39: 451-455
• 38 Fowler KA, Chung CB. Normal MR imaging anatomy of the elbow. Magn Reson Imaging Clin N Am 2004; 12: 191-206
• 39 Savoie 3rd FH, O’Brien MJ. Arthroscopic tennis elbow release. Instr Course Lect 2015; 64: 225-230
• 40 Field LD, Savoie FH. Common elbow injuries in sport. Sports Med 1998; 26: 193-205
• 41 Giuffrè BM, Moss MJ. Optimal positioning for MRI of the distal biceps brachii tendon: flexed abducted supinated view. AJR Am J Roentgenol 2004; 182: 944-946
• 42 Festa A, Mulieri PJ, Newman JS. et al. Effectiveness of magnetic resonance imaging in detecting partial and complete distal biceps tendon rupture. J Hand Surg Am 2010; 35: 77-83
• 43 Derias M, Phadnis J. Disorders of the distal biceps and triceps tendons. Orthopaedics and Trauma 2020; 34: 186-196
• 44 Dirim B, Brouha SS, Pretterklieber ML. et al. Terminal bifurcation of the biceps brachii muscle and tendon: anatomic considerations and clinical implications. AJR Am J Roentgenol 2008; 191: W248-W255
• 45 Safran MR. Elbow injuries in athletes. A review. Clin Orthop Relat Res 1995; 257-277
• 46 Kijowski R, Tuite M, Sanford M. Magnetic resonance imaging of the elbow. Part II: Abnormalities of the ligaments, tendons, and nerves. Skeletal Radiol 2005; 34: 1-18
• 47 Downey R, Jacobson JA, Fessell DP. et al. Sonography of partial-thickness tears of the distal triceps brachii tendon. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine 2011; 30: 1351-1356
• 48 Nocerino EA, Cucchi D, Arrigoni P. et al. Acute and overuse elbow trauma: radio-orthopaedics overview. Acta Biomed 2018; 89: 124-137
• 49 Jacobson JA, Jebson PJ, Jeffers AW. et al. Ulnar nerve dislocation and snapping triceps syndrome: diagnosis with dynamic sonography-report of three cases. Radiology 2001; 220: 601-605
• 50 Łasecki M, Olchowy C, Pawluś A. et al. The Snapping Elbow Syndrome as a Reason for Chronic Elbow Neuralgia in a Tennis Player – MR, US and Sonoelastography Evaluation. Pol J Radiol 2014; 79: 467-471
• 51 Husarik DB, Saupe N, Pfirrmann CW. et al. Elbow nerves: MR findings in 60 asymptomatic subjects--normal anatomy, variants, and pitfalls. Radiology 2009; 252: 148-156
• 52 Kim N, Stehr R, Matloub HS. et al. Anconeus Epitrochlearis Muscle Associated With Cubital Tunnel Syndrome: A Case Series. Hand (N Y) 2019; 14: 477-482