‘FEVER’ pitch: New MRI approach improves detection of arm injuries among MLB pitchers

LEESBURG, Va. — Tearing the UCL in the elbow is an injury which has become synonymous with baseball pitchers. The surgery which reconstructs the ulnar collateral ligament is literally named Tommy John surgery, after the first MLB pitcher to undergo the procedure. However, even as more and more hurlers leave the field with this injury, not every UCL tear is the same and some can still go undetected. Now, scientists say looking at this problem from an entirely different angle can help find more of these devastating injuries.

The UCL supplies stability to the inner elbow. Unfortunately, the repeated throwing motions common for pitchers of any age puts tremendous stress on that area and can eventually cause a tear. The new report stresses the importance of incorporating the FEVER (flexed elbow valgus external rotation) view as a practical addition to standard elbow MRI protocols.

Researchers report adding a FEVER view to MRI UCL evaluations can improve overall accuracy and potential tear detection among MLB pitchers.

“The increased joint space width confirms elbow valgus stress with FEVER view,” writes corresponding author Thomas Knoblauch at the University of Nevada Las Vegas, in a media release. “Diagnostic confidence increased, and additional UCLs were identified as abnormal.”

The study finds standard arm positioning during an MRI can lead to suboptimal results when it comes to examining the UCL. So, the research team (which includes Arizona Diamondbacks head team physician Gary Waslewski) set out to determine if adding a FEVER view would help. More specifically, study authors combined the FEVER view with a conventional elbow MRI to assess if “impact on ulnotrochlear (UT) joint space measurement and UCL reader evaluation” would subsequently improve.

Reproducing pitching stress spots more MLB arm injuries

UCL fever view
(Credit: American Roentgen Ray Society (ARRS), American Journal of Roentgenology)

A total of 44 MLB pitchers underwent an elbow MRI including “both standard sequences and a coronal fat-saturated proton density-weighted sequence in the FEVER view.” Researchers bent each player’s arm in different positions while immobilizing the limb with sandbags during the procedure. These positions helped the team to reproduce the valgus stress on the ligament during the pitching motion. Next, two radiologists independently evaluated the results.

“Among 44 MLB pitchers undergoing elbow MRI,” study authors write, “the FEVER view, compared with standard view, yielded increased UT joint space width (mean increase, 1.80 mm) and increased confidence for three of five UCL-related findings (mean increase, -0.14 to 0.98).”

In comparison to a standard MRI view, adding the FEVER view helped spot five additional UCL abnormalities among the athletes.

“The findings support the FEVER view as a practical addition to standard elbow MRI protocols for achieving elbow valgus stress in throwing athletes,” researchers conclude, “thereby providing functional information to complement the high-resolution anatomic assessment provided by MRI.”

Tommy John surgery, which replaces the torn ligament with tendon from elsewhere in the body (usually the leg), is now a commonplace surgery among athletes. For professional pitchers, it usually takes between 12 and 18 months to recovery from the operation and return to the mound.

The study appears in the American Journal of Roentgenology.

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