When physiology becomes pathology: the role of magnetic resonance imaging in evaluating bone marrow oedema in the humerus in elite tennis players with an upper limb pain syndrome

Abstract

Upper limb stresses are well recognised in tennis, and the normal physiological responses of the humerus to externally applied forces are well defined. Changes to both the microscopic and macroscopic bony architecture are often not apparent on plain radiographs in the early stages of a stress reaction. Bone scintigraphy is more sensitive, but not very specific to subtle changes, as is computer aided tomography. Magnetic resonance imaging (MRI) scans are now used to assess many musculoskeletal injuries, and may allow earlier recognition of changes. This study reports on eight high level tennis players (seven professionals, one highly ranked amateur), who all presented during the course of the 2002 Australian Open and its lead up events. All had an upper limb pain syndrome centred around the elbow. Each underwent an MRI scan. A group of asymptomatic players also had scans of the same area to serve as controls. All symptomatic patients had various levels of bone marrow oedema in their distal humerus, some with periosteal reactions, although most without. No scans revealed a cortical breach. The management of these reactions is problematic in players on an international circuit, as review is sporadic and not always coordinated. The timetabling of international tournaments means it is difficult for top players to obtain adequate rest to avoid injury. Awareness of this early overuse reaction needs to be raised to allow preventive and therapeutic options to be considered to reduce the incidence of this humeral stress response producing an upper limb pain syndrome.

Stress reaction of the humerus in tennis players

“…The injuries were characterised by damage to the periosteum, with or without oedema, as well as by a variety of bone medullary oedema patterns (fig 1). The MRI is mainly positive in T2 and STIR sequences (fig 2), which is consistent with the findings of previous studies that focused on the stress reactions of bone 3 4 11. At the initial phase, the MRI is usually negative in T1 sequences, however, one of the subjects analysed in this study was found to be positive at this phase, which led us to characterise his injury as a Type 3 injury 11…”

“…Muscle and tendon overuse injuries have been well documented in tennis players 2. However, only a limited number of studies have focused on bone stress injuries associated with overuse 3 – 5. Furthermore, most of the studies examining tennis-related bone stress injuries concentrate on injuries to the trunk and lower limbs 5 6.…”

“…Furthermore, most of the studies examining tennis-related bone stress injuries concentrate on injuries to the trunk and lower limbs 5 6. In fact, only three articles were retrieved that reported stress reactions involving the humerus in tennis players 3 4 7…”

Bone marrow lesions: a universal bone response to injury?

“…2). Accompanying the BML at the insertion point of the tendon into bone is often cortical erosions and calciWcations [25][26][27][28][29]. Often the tendon appears swollen, which has been related to increased vascularization [30].…”

An Added Perspective on the 2009 SPARTAN and IGAS Report: An Innate Axial Myofascial Hypertonicity: Figure 1.

“…In patients with AS, these lesions are usually referenced as inflammatory. However, studies of osteoarthritis 30 and sports-related injuries 31 show analogous hyperintensities, but are commonly described as bone marrow edema or edema-like lesions. Those MRI findings are mainly attributed to altered biomechanical/degenerative origins or excessive tissue stresses, rather than being inflammatory.…”