Baseball players experiencing medial elbow pain are more precisely imaged by a combination of stress ultrasound and magnetic resonance arthrography (MRA) than by either of those two modalities alone, even though the latter modality is widely considered the gold standard in its own right.

The improved diagnostic accuracy of the combined approach could mean the difference between a short stint in rehab and a year or so recovering from costly and unnecessary reconstructive surgery.

That’s from a study running in the June edition of Radiology.

Johannes Roedl, MD, PhD, of Sidney Kimmel Medical College in Philadelphia and colleagues looked at 10-year data on 144 baseball players (126 pitchers, 18 position players) across levels of competition from recreational to professional.

There were 191 findings of medial elbow pain, including 53 ulnar collateral ligament (UCL) tears.

For diagnosing the UCL tears with MRA, the sensitivity, specificity and accuracy were 81 percent, 91 percent and 88 percent, respectively. These increased to 96 percent, 99 percent and 98 percent, respectively, when ultrasound was added to form the dual-modality imaging algorithm. 

For 31 patients with ulnar neuritis, the sensitivity, specificity and accuracy increased from 74 percent, 92 percent and 88 percent, respectively, with MRA alone to 90 percent, 100 percent and 98 percent with the imaging combination.

The authors describe their use of stress ultrasound as follows:

“With the patient standing, the elbow was flexed at approximately 30° and the elbow was held in that position by one of our resident physicians, either from the radiology or physical medicine and rehabilitation department. … For the stress images, maximal valgus stress was applied manually to the ulnotrochlear joint and the joint gap, in millimeters, was again documented. … A diagnosis of ulnar nerve subluxation is made when the nerve moves anteriorly and onto or over the medial epicondyle with elbow flexion when made visible with ultrasonography.”

The differential diagnosis for medial elbow pathologic changes “is broad, and the correct diagnosis is important to avoid unnecessary surgery,” Roedl et al. write in their conclusions. “MR arthrography and ultrasonongraphy are complementary in the assessment of medial elbow pathologic changes, and the combination of both may provide improved diagnostic accuracy.”