© Pol J Radiol 2020; 85: e440-e460

DOI: https://doi.org/10.5114/pjr.2020.98691

Received: 21.05.2020
Accepted: 20.07.2020
Published: 21.08.2020 http://www.polradiol.com

Magnetic resonance imaging of the elbow

Alecio Lombardi1,2,A,B,E,F, Aria Ashir2,3,B,E,F, Tetyana Gorbachova4,A,B,E, Mihra S. Taljanovic5,6,A,B,E,F, Eric Y. Chang1,2,A,B,E
1
Research Service, VA San Diego Healthcare System, San Diego, CA, USA
2
Department of Radiology, University of California, San Diego, CA, USA
3
Drexel University College of Medicine, Philadelphia, PA, USA
4
Department of Radiology, Einstein Healthcare Network, Philadelphia, PA, USA
5
Department of Medical Imaging, University of Arizona/Banner University Medical Center, Tucson, AZ, USA
6
Simon Med Imaging, Scottsdale, AZ, USA

Abstract
Elbow pain can cause disability, especially in athletes, and is a common clinical complaint for both the general
practitioner and the orthopaedic surgeon. Magnetic resonance imaging (MRI) is an excellent tool for the evaluation
of joint pathology due to its high sensitivity as a result of high contrast resolution for soft tissues. This article aims
to describe the normal imaging anatomy and biomechanics of the elbow, the most commonly used MRI protocols
and techniques, and common MRI findings related to tendinopathy, ligamentous and osteochondral injuries, and
instability of the elbow.
Key words: MRI, elbow, epicondylosis, biceps brachii, cubital tunnel syndrome, radial tunnel syndrome.

extend between 0 and 140° and can rotate about 80°,

although for the typical daily tasks only 30 to 130° of
Introduction flexion and extension, and 50° of rotation are necessary
It is essential to understand the anatomy and function of [1,2]. Flexion-extension occurs at the humeral trochlea,
the elbow in order to recognise common pathological im- and supination-pronation occurs mostly along the capi-
aging findings and correlate them with clinical manifesta- tellum and the radial head, with some contribution of the
tions. The understanding and proper implementation of distal radioulnar joint [3]. The elbow has a slight normal
the magnetic resonance imaging (MRI) protocol is also valgus position between the humeral and ulnar shafts in
crucial for the correct interpretation of these findings. extension called the carrying angle. This angle is higher in
Finally, knowing the mechanisms of the most common males compared to females and higher in adults compared
elbow injuries and how they can affect joint function will to children [4,5]. An increased carrying angle may be as-
facilitate communication between the radiologist and re- sociated with ulnar neuropathy [6].
ferring physician. Therefore, this article intends to review The trochlea and the capitellum present mild internal
the use of MRI in the clinical evaluation of the elbow. rotation, valgus, and anterior rotation in relation to the
long axis of the humerus. The capitellum is round and
occupies a small portion of the distal humerus, while
Anatomy and biomechanics the trochlea is more extensive with a central depression
The elbow is a complex joint consisting of three articu- that may present different angles among individuals [7].
lations: the humeroradial, humeroulnar, and proximal The coronoid and olecranon fossa are located anteriorly
radioulnar. The humeroulnar is a hinge joint that allows and posteriorly in the distal humerus, serving as recesses
flexion and extension movements, while the radioulnar for the coronoid process and olecranon of the ulna, re-
joint is a trochoid joint, which enables pivot motion trans- spectively, during flexion and extension of the elbow.
lated in supination and pronation. The elbow can flex and There is a difference in the extent of cartilage coverage

Correspondence address:
Dr. Eric Y. Chang, Research Service, VA San Diego Healthcare System, San Diego, CA, USA, e-mail: [email protected]
Authors’ contribution:
A Study design ∙ B Data collection ∙ C Statistical analysis ∙ D Data interpretation ∙ E Manuscript preparation ∙ F Literature search ∙ G Funds collection

This is an Open Access journal, all articles are distributed under the terms of the Creative Commons Attribution-Noncommercial-No Derivatives 4.0
e440 International (CC BY-NC-ND 4.0). License (https://creativecommons.org/licenses/by-nc-nd/4.0/).
 Magnetic resonance imaging of the elbow

between the trochlea, which has around 330° of cartilage bands or bundles: the anterior, posterior, and transverse
coverage, and the capitellum, which has only 180° of car- (Figure 1A). The anterior bundle can be further subdi-
tilage coverage and ends abruptly in its posterior contour. vided into anterior and posterior bands [12,13] or super-
This particular anatomy was previously called the pseudo ficial and deep capsular portions [14]. The anterior bundle
defect of capitellum and should not be interpreted as an serves as the main restraint to valgus overload to the el-
osteochondral defect [8,9]. bow, which is particularly important in athletes involved
The proximal ulna has a mild posterior rotation that in overhead activities and weightlifting. The anterior bun-
complements the anterior rotation of the humeral troch- dle originates from the inferior portion of the medial epi-
lea. The radial head and neck, on the other hand, pres- condyle and inserts distally onto the medial aspect of the
ent a slight internal angulation to its long axis, which also coronoid process (sublime tubercle of the ulna) or along
suits the valgus and internal rotation of the distal humerus a ridge of bone distal to the sublime tubercle. The exact
[1]. The anterolateral portion of the radial head and the distal insertion of the anterior bundle may vary among
centre of the articular surface of the ulna (sigmoid fossa) individuals [15,16]. It is better visualised in the coronal
are devoid of articular cartilage, which may be a reason oblique plane on proton density and T1-weighted MRI
why fractures commonly occur at these sites. as a low-signal-intensity structure with a broad origin in-
Elbow stability is maintained primarily by the humer- terspersed by fat under the medial epicondyle and a thin
oulnar joint and the anterior bundle of the ulnar collat- distal insertion. There is improved sensitivity in its as-
eral ligament (UCL), with a small contribution from the sessment on MR arthrography compared to conventional
lateral ulnar collateral ligament (LUCL). The common MRI [17,18].
flexor-pronator and extensor tendons, together with the The posterior bundle of the UCL arises from the pos-
humeroradial joint, are considered secondary stabilisers teroinferior aspect of the medial epicondyle, inserting
[1,10,11]. distally onto the posteromedial margin of the trochlear
Regarding joint movement, the primary elbow flexors notch forming the floor of the cubital tunnel. It is better
are the brachialis, biceps, and brachioradialis muscles, visualised on axial proton density (PD) and T1-weighted
whereas the triceps muscle is the primary extensor. As for MR images. The posterior bundle has increased impor-
the supination and pronation, the biceps and the pronator tance in valgus stabilisation of the elbow in higher degrees
teres are the leading muscles, respectively. of flexion because of its origin slightly posterior to the
centre of the movement, making it taut from 60° to full
flexion. The anterior bundle origin is in the centre of the
Ulnar collateral ligament complex
flexion-extension movement, which makes it taut from
The elbow joint is enveloped by a single capsule and has 60° to full extension, acting as the main stabiliser in that
two ligament complexes at the medial and lateral sides. range of motion [2]. Surgical reconstruction of the pos-
The medial UCL, also known as the UCL, has three terior bundle of the UCL demonstrated good outcome in

A B

Anterior bundle:
posterior band
anterior band Radial collateral
ligament
Annular ligament

Posterior bundle

Transverse ligament
Lieral ulnar colleral ligament
Figure 1. Schematics of the medial and lateral ligamentous complexes about the elbow. A) The ulnar collateral ligament complex is composed of the anterior,
posterior, and transverse bundles. The anterior bundle is further subdivided into anterior and posterior bands. B) The lateral collateral ligament is composed
of the radial collateral ligament, the lateral ulnar collateral ligament, and the annular ligament

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Alecio Lombardi, Aria Ashir, Tetyana Gorbachova et al. 

valgus extension overload (VEO) syndrome and varus The posterior compartment contains the triceps mus-
posteromedial rotatory instability of the elbow (VPMRI), cle that inserts distally onto the olecranon with complex
which will be discussed later in this article [19,20]. footprint anatomy [31]. It is important to note that the
The thin transverse bundle of the UCL connects the medial head of the triceps has a muscular insertion at the
distal attachments of the anterior and posterior bundles, olecranon deep to the lateral and long heads [31,32]. The
does not have an important biomechanical role, and is not anconeus has its origin in the lateral humeral epicondyle
routinely characterised on MRI. and inserts in the olecranon. The anconeus epitrochlearis
is an accessory muscle present in a small proportion of
individuals, originating from the medial epicondyle and
Lateral collateral ligament complex
inserting into the olecranon, and it has been associated
The lateral collateral ligament complex (LCL), also known with ulnar nerve compression [33].
as the radial collateral ligament complex, has four ele- The medial muscle group of the elbow is responsible
ments: the LUCL, the radial collateral ligament (RCL), for flexion-pronation of the forearm and is comprised of
the annular ligament, and the accessory lateral collateral six muscles: the pronator teres, flexor carpi radialis (FCR),
ligament (Figure 1B). The LUCL and radial collateral liga- palmaris longus (PL), flexor digitorum superficialis (FDS),
ments have a common origin from the lateral humeral flexor carpi ulnaris (FCU), and flexor digitorum profun-
epicondyle. The LUCL courses posterior to the radial head dus (FDP). Five of these muscles form a common flexor
and inserts into the lateral aspect of the ulna (supinator tendon that includes a portion of the pronator teres, the
crest) being the main stabiliser of the lateral elbow during FCR, PL, the humeroulnar head of the FDS, and humeral
varus stress. The RCL runs slightly anterior to the LUCL head of the FCU. The FCU arises from two heads, one
and blends distally with the annular ligament and supi- originates from the humeral epicondyle and another from
nator muscle [21]. Both are better visualised on coronal the olecranon. A fibrous band, referred to as ligament of
oblique T1- or PD-weighted MRI as thin, elongated, low Osborne, arcuate ligament, or cubital retinaculum, crosses
signal intensity structures. The RCL is located anteriorly over these two origins and constitutes the roof of the ulnar
and sometimes can be visible in a single slice, whereas the cubital tunnel.
LUCL is located posteriorly and, because of its oblique The lateral muscle group of the elbow is responsible
longitudinal course, is typically visualised in two or three for the extension-supination of the forearm and consists
slices. The annular ligament inserts on the anterior and of another seven muscles: the brachioradialis, exten-
posterior portions of the radial facet of the ulna (the lesser sor carpi radialis longus (ECRL), extensor carpi radialis
sigmoid notch), encircling the radial head, and serves as brevis (ECRB), extensor digitorum (ED), extensor digiti
the primary stabiliser of the proximal radioulnar joint minimi (EDM), extensor carpi ulnaris (ECU), and the
during supination and pronation [22,23]. It is better vi- supinator. Four of these muscles (ECRB, ED, EDM, and
sualised on axial PD- or T1-weighted MRI, which is also ECU) have a common origin at the lateral epicondyle and
useful to depict the distal insertion of the LUCL. Finally, form a common extensor tendon. The other components
the accessory lateral collateral ligament originates from present a complex origin that includes the humeral supra-
the annular ligament and inserts into the supinator crest, condylar ridge, lateral collateral ligament, and supinator
stabilising the annular ligament during varus stress, but it crest of the ulna [15,19].
is not routinely characterised on MRI.

Muscles and tendons

The muscles around the elbow are considered dynamic
stabilisers. The anterior compartment contains the long Long head of biceps Short head of biceps
and short head of the biceps, which inserts distally onto
the bicipital tuberosity of the radius, and the brachialis,
originating along the anterior surface of the humerus and Biceps tendon rotates
through
inserting into the ulnar tuberosity [24–27]. The tendon of approximately 90o Bicepital aponeurosis or
the long head of the biceps inserts proximal to the short lacertus fibrosus (covers
head and occupies most of the radial tuberosity [28] (Fig- median nerve and brachial
Radial tuberosity (long artery)
ure 2). The superficial layers of the biceps tendon merge head proximal, short
with those of the medial muscle bulk of the proximal fore- head distal)
arm at the elbow to form the bicipital aponeurosis (lacer- Figure 2. Schematic of the distal biceps tendon showing the long and
tus fibrosus). Studies have shown that this structure can short head insertions onto the radial tuberosity. The bicipital aponeurosis
strengthen the distal biceps tendon and help reduce its originates from the distal tendon and expands medially, blending with the
retraction when ruptured [29,30]. fascia of the forearm. PT – pronator teres muscle

e442 © Pol J Radiol 2020; 85: e440-e460

 Magnetic resonance imaging of the elbow

setting of septic and inflammatory arthropathies, trauma,

Nerves
and repetitive stress [25,37].
The nerve anatomy in the upper extremity is complex, and Synovial plicae or folds are remnants of the embryo-
a thorough description is beyond the scope of this article. logical formation of the joints [38]. At the elbow they have
At the level of the elbow there are three primary nerves: been described in the posterior, medial, lateral, and an-
the radial, ulnar, and median. The radial nerve passes terior compartments as thin intraarticular projections of
between the brachial and brachioradialis muscles, bifur- the synovial capsule in both symptomatic and asymptom-
cating into superficial sensory and deep motor branches. atic patients. They can be considered physiological com-
The deep branch pierces the supinator muscle between ponents and only occasionally cause clinical symptoms.
its superficial and deep heads, at which point it is also The radiocapitellar synovial plica can be particularly
referred to as the posterior interosseous nerve, while the prominent and may be associated with joint pain [39].
superficial branch continues in the forearm between the
brachioradialis and the superficial head of the supinator.
The ulnar nerve passes posterior to the medial epicon-
Magnetic resonance imaging technique
dyle inside the cubital tunnel, which is an anatomic space
and protocol
roofed by Osborne’s ligament, or the cubital retinaculum. The patient can be scanned in the supine position with
Finally, the median nerve passes between the lacertus fi- the arm fully extended, or in the prone position with the
brosus and the brachial muscle, continuing between the shoulder abducted and the arm above the head (the su-
two heads of the pronator teres muscle in the medial as- perman position). In the prone position, the elbow stays
pect of the forearm [10,34]. Before crossing the elbow, the in the centre of the magnetic field, which can reduce in-
median nerve passes over the anteromedial aspect of the homogeneities and artifacts, but this has the disadvantage
humerus in the distal arm, where a bone spur, referred to of being uncomfortable for the patient, eventually lead-
as the supracondylar process of the humerus, can be pres- ing to motion artifacts. It is essential to always cover the
ent in some individuals. This structure may be connected biceps tendon insertion onto the radial tuberosity within
to the medial epicondyle through a ligament (ligament of the field of view. A conventional MRI protocol commonly
Struthers), forming a canal that has been associated with includes a combination of non-fat-suppressed T1-weight-
median neuropathy [34]. ed, non-fat-suppressed PD-weighted, fat-suppressed
T2-weighted, or short tau inversion recovery sequences,
in axial, coronal oblique, and sagittal oblique planes [40]
Bursae and plicae
(Table 1). It is crucial to first plan the coronal oblique
The distal biceps tendon does not have a tendon sheath. plane using both humeral epicondyles in the axial plane,
Two bursae can be seen about the distal biceps tendon: and then, perpendicular to it, the sagittal and axial planes
the bicipitoradial and the variably present interosseous can be programmed (Figure 3). As stated previously, the
bursa. The bicipitoradial bursa is located between the dis- distal humerus has an internal rotation compared to the
tal biceps tendon and the radial bicipital tuberosity and long axis of the humerus, so the coronal oblique plane
is responsible for reducing friction between these two should be used as a reference for proper visualisation
structures. It may be a cause of pain when distended by of the tendons and ligaments of the elbow. MRI of the
fluid, usually in inflammatory arthropathies or mechani- flexed elbow, abducted shoulder, forearm supinated –
cal overload [35,36]. The interosseous bursa is present the so-called FABS position – can be used to better show
in about 20% of individuals and is located at the medial the biceps tendon insertion into the radial tuberosity [41].
aspect of the antecubital fossa, between the brachialis Administration of gadolinium-based contrast is not
muscle and the radius. routinely recommended; however, MR arthrography can be
The olecranon bursa is located in the subcutaneous re- helpful to assess intra-articular bodies and stability of os-
gion posterior to the olecranon and can be inflamed in the teochondral lesions. Between 5 and 10 ml of total injectate

Table 1. Sample non-contrast elbow imaging protocol at 3T

Sequence TR (ms) TE (ms) TI (ms) Slice thickness (mm) FOV (mm) Matrix
Axial T2 FS 4000 65 3.0 130 320 × 288
Coronal T1 750 10 3.0 150 384 × 288
Coronal STIR 5900 30 220 3.0 150 384 × 288
Sagittal T1 750 10 3.0 150 384 × 288
Sagittal T2 FS 4000 65 3.0 150 384 × 288
FOV – field of view, FS – fat-suppressed, PD – proton density, STIR – short tau inversion recovery, TE – echo time, TI – inversion time, TR – repetition time

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Alecio Lombardi, Aria Ashir, Tetyana Gorbachova et al. 

A B C

Figure 3. A) Axial, (B) coronal oblique, and (C) sagittal oblique proton density-weighted fat-suppressed magnetic resonance imaging shows typical planning
of the imaging planes during the exam. Correlation between axial, coronal oblique, and sagittal oblique planes is shown (B and C, inset)

should be used with direct MR arthrography using a variety injuries at the elbow, and can be particularly helpful for
of different approaches [40,42]. The optimum gadolinium medial collateral ligament lesions [49].
concentration for maximal signal-to-noise ratios at 1.5–3T At the medial compartment, the anterior bundle of
ranges from 0.7 to 3.4 mmol/l (or less than 2 mmol/l if io- the UCL is the most commonly injured. Although elbow
dinated contrast is also used) [43,44]. Frequently used pro-
tocols include fat-suppressed T1-, PD-, and T2-weighted
sequences in the coronal oblique, sagittal oblique, and axial
planes. The addition of a non-fat-suppressed sequence can
be helpful in a variety of scenarios where the visualisation
of fat is desirable, such as for improved boundary delinea-
tion for certain tendons and ligaments as well as evaluation
of intra-muscular fat. At times it is also useful for tissue
characterisation and troubleshooting.

Ligament abnormalities
Despite being a relatively stable joint, the elbow is the sec-
ond most commonly dislocated joint in adults, and the
most commonly dislocated major joint in the paediatric
population [45]. There is a calculated incidence of 5.21
dislocations per 100,000 person-years in the United States,
according to a study by Stoneback et al. [46]. Traumatic
and sports-related injuries are the most common causes
and can lead to chronic joint instability [11]. Physical
exam manoeuvres show high sensitivity for most of the
injuries about the elbow [47], but pain in the acute set-
ting of trauma or chronic adaptive changes in athletes can
reduce its accuracy.
An injured ligament can present on MRI with high
signal intensity on fluid-sensitive sequences, wavy con-
tours, or complete discontinuity. Oedema and joint cap-
sule rupture with effusion and fluid extravasation are also
usually observed. Conventional MRI has a high sensitivity Figure 4. Adaptive changes in throwing elbow. 36-year-old asymptomatic
for complete ligament tears, but only moderate sensitivity professional baseball pitcher with adaptive ulnar collateral ligament (UCL)
for partial tears [48]. MR arthrography, however, has the thickening. Coronal oblique proton density-weighted fat-suppressed magnetic
highest reported accuracy for the evaluation of ligament resonance imaging shows thickening of the anterior bundle of the UCL (arrow)

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 Magnetic resonance imaging of the elbow

Figure 6. Valgus extension overload syndrome and posteromedial impinge-

ment in a 23-year-old professional pitcher, presenting with posteromedial
elbow pain, post ulnar collateral ligament (UCL) reconstruction. T1-weight-
ed magnetic resonance imaging shows small posteromedial osteophytes at
Figure 5. Sequela of chronic ulnar collateral ligament (UCL) injury in the olecranon (arrow). Note UCL graft (arrowhead)
a 21-year-old baseball pitcher. AP radiograph from pre-magnetic resonance
imaging arthrogram injection shows a well-defined ossicle in the pathway
of the anterior bundle of the UCL consistent with chronic trauma (arrow)

A B

Figure 7. Full-thickness tear of the anterior bundle of the ulnar collateral ligament (UCL) and a prominent synovial fringe in a baseball pitcher. A) Coronal
T1-weighted fat-suppressed and (B) short tau inversion recovery magnetic resonance imaging shows extravasation of the intra-articular contrast through
the distal aspect of the anterior bundle of the UCL (arrows) consistent with a full-thickness tear. In (B), note a prominent synovial fringe at the lateral aspect
of the elbow (arrowhead)

dislocations can cause acute lesions to the UCL, the most eration phases of the throwing movement cause increased
common cause of UCL injury is chronic valgus stress tension over the medial compartment of the elbow, high
from overhead activities, like baseball pitching and jav- shear stress on the posterior compartment, and compres-
elin throwing. Swimming, gymnastics, and tennis are sion forces at the lateral compartment, due to transfer of
other sports activities that predispose to UCL injuries high humeral torque to rapid elbow extension [53].
[50]. In a recent study of the prevalence of elbow injuries Repetitive valgus stress leads to chronic degeneration
in athletes at the summer Olympic Games, 80% of lesions with increased laxity of the UCL and joint instability. Pos-
included UCL [51]. However, it is difficult to differenti- terior contact between the humerus and ulna leads to the
ate adaptive asymptomatic abnormalities, typically found formation of posteromedial bone spurs, cartilage and sub-
in the throwing athlete, from symptomatic findings. One chondral bone degeneration, and ultimately osteoarthritic
study found that asymptomatic baseball pitchers com- changes. Avulsion fractures of the medial epicondyle and
monly had ligamentous thickening, bone osteophytes, and olecranon stress fractures are common findings seen on
tendinopathy in the posteromedial compartment of the radiograph and computed tomography (CT). The combi-
elbow [52] (Figure 4). These adaptive changes are caused nation of these abnormalities can lead to decreased elbow
by repetitive stress across the medial aspect of the joint terminal extension with posterior elbow pain during ball
from overhead throwing. The late cocking and early accel- release, a condition called VEO syndrome or pitcher’s

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Alecio Lombardi, Aria Ashir, Tetyana Gorbachova et al. 

A B

Figure 8. Ulnar collateral ligament (UCL) abnormalities on coronal fluid-sensitive magnetic resonance imaging from different pitchers. A) 16-year-old with
stripping and low-grade partial tearing of the anterior bundle of the UCL at the ulna with underlying marrow oedema in the coronoid process (arrow).
B) 15-year-old with cortical discontinuity at the sublime tubercle with bone marrow oedema, consistent with an avulsion fracture (arrow)

A B

Figure 9. Partial-thickness tear of the anterior bundle of the ulnar collateral ligament (UCL) at the sublime tubercle in an 18-year-old pitcher with medial
elbow pain depicted on magnetic resonance imaging (MRI). A) Coronal short tau inversion recovery MRI shows minimal bone marrow oedema in the
coronoid process of the ulna consistent with stress reaction (arrow) and no evidence of the UCL tear. B) Coronal T1-weighted fat-suppressed MR arthrography
shows contrast insinuating along the medial margin of the sublime tubercle and the anterior bundle of the UCL (arrow) creating T sign

elbow. The differential diagnosis with an acute UCL in- Table 2. O’Driscoll classification system of posterolateral rotatory instability
jury can be inferred by the history and physical exam: the of the elbow
patient with VEO syndrome complains of posterior el-
Stage Description
bow pain during terminal extension due to impingement,
whereas the patient with ULC acute injury refers pain 1 LUCL lesion
during the beginning of throwing. Physical exam shows 2 LUCL + Anterior joint capsule lesion
the reproduction of pain with valgus stress placed by the 3a LUCL + Anterior joint capsule lesion + MCL posterior bundle lesion
examiner onto the elbow while forcing terminal exten-
3b Stage 3a + MCL anterior bundle lesion
sion. The osseous and soft tissue hypertrophic changes
can also lead to ulnar nerve impingement and secondary 3c Stage 3b + Flexor-pronator muscles disruption
cubital tunnel syndrome. The examiner must palpate the LUCL – lateral ulnar collateral ligament, MCL – medial collateral ligament

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 Magnetic resonance imaging of the elbow

A B

Figure 10. 31-year-old female with O’Driscoll stage 3c posterolateral rotatory instability after reduced posterior elbow dislocation. A) Coronal oblique and
(B) axial proton density-weighted fat-suppressed magnetic resonance imaging of the elbow shows complete tears of the radial collateral and lateral ulnar
collateral ligament (black arrow in A) as well as the annular ligament (arrowhead in B). Oedema is present in the flexor-pronator muscles (thin arrows),
indicative of muscle strain

ulnar nerve area during flexion-extension of the elbow, The LCL is less frequently injured compared to the
searching for pain or nerve dislocation. UCL, with traumatic joint subluxation/dislocation as the
Imaging may show ossification of the UCL (Figure 5), most common aetiology. Attention should be paid to the
posteromedial humeroulnar osteophytes (Figure 6), os- LUCL because it is particularly important for maintain-
teochondral lesions, avulsions of the medial epicondyle, ing lateral elbow stability. LUCL injury can present with
and sublime tubercle as well as intra-articular bod- attenuation, signal alteration, thinning, and complete dis-
ies. MRI is particularly useful to depict UCL injuries continuity.
(Figure 7 and 8), which occur most commonly at its prox- Posterolateral rotatory instability of the elbow (PLRI)
imal and distal insertions, as well as associated tendon and is a condition first described by O’Driscoll et al. [3],
muscle injuries, and joint effusions [54]. MR arthrography caused by a lesion of the LUCL that leads to posterolateral
has higher sensitivity for partial-thickness ligament tears subluxation of the radius on the capitellum. The injury
and may show intra-articular contrast insinuating along mechanism is a fall onto an outstretched hand with the
the medial margin of the sublime tubercle and under the shoulder abducted, associated with forearm axial load-
UCL (called T sign due to similarity with the letter T lying ing, external elbow rotation, and valgus overload. Later,
on its side) (Figure 9). It is important to remember that O’Driscoll et al. described a classification system for better
the ulnar footprint of the UCL can be several millimetres clinical staging and treatment [57] (Table 2). This classi-
distal to the articular margin, which can be an imaging fication is based on the grade of elbow instability accord-
pitfall for ligament injuries [16,55,56]. Treatment of VEO ing to the increasing injury pattern. First, there is a lesion
syndrome initiates with conservative measures like active of the LUCL, with or without RCL injury, which leads to
rest, physiotherapy, and non-steroid anti-inflammatory posterior subluxation of the elbow. An additional ante-
medication but may require arthroscopy with osteophyte rior joint capsule injury causes increased posterolateral
removal and medial corner olecranon osteotomy in re- subluxation. The final stages of PLRI include lesions of
fractory cases [50]. the UCL and flexor-pronator muscle bulk, with conse-
Treatment of partial UCL tears is initially conservative quently gross joint instability [11] (Figure 10). A specific
with active rest, non-steroidal anti-inflammatory drugs finding associated with PLRI is a compression fracture
(NSAIDs), rehabilitation, and strengthening exercises. in the posteroinferior aspect of the capitellum, caused by
Overhead throwing athletes with complete disruption of subluxation-dislocation of the posterior radial head [9].
the anterior bundle of the UCL or those with incomplete The impaction between the two articular surfaces is simi-
tears but who are unable to return to competitive throw- lar in pattern to the anterior glenoid bone defect seen in
ing may require surgical ligament reconstruction, which anterior shoulder dislocation, and it has been referred to
can be done through several techniques, the most famous as the Osborne-Cotterill lesion [58] (Figure 11). Patients
been the Tommy John surgery, named after the baseball complain of chronic pain and a clicking sensation. Surgi-
pitcher Tommy John, and first performed by doctor Frank cal treatment options include LUCL repair or ligament
Jobe in 1974. reconstruction, depending on chronicity and tissue status.

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Alecio Lombardi, Aria Ashir, Tetyana Gorbachova et al. 

A B

Figure 11. Osborne-Cotterill lesion characteristic of posterolateral rotatory instability. A) Sagittal oblique proton density-weighted fat-suppressed magnetic
resonance imaging post-reduction of a posterior elbow dislocation shows an impaction fracture of the posterior aspect of the capitellum with associated
bone marrow oedema (arrowhead), known as an Osborne-Cotterill lesion. B) Sagittal reformatted computed tomography image confirms the impaction
and better depicts small fracture fragments (arrowhead)

In children, a common lesion is the subluxation or MRI can show secondary findings associated with tendon
dislocation of the radial head from the annular ligament pathology, such as bone marrow oedema and periostitis.
with the traction of the forearm and hand, which is also Tendon overuse, characterised by mechanical stress
referred to as the nursemaid’s elbow. Conservative treat- with an inadequate healing/adaptation response, can re-
ment is generally indicated unless there is ligament dis- sult in a tendinopathy. When it involves the common
placement and interposition within the humeroradial extensor tendon, it is referred to as lateral epicondylosis,
joint, which may require operative treatment [23]. In or tennis elbow (Figure 12), and when it involves the
adults, the annular ligament is commonly involved in el- common flexor tendon it is referred to as medial epicon-
bow trauma and dislocation and is usually associated with dylosis, or golfer’s elbow (Figure 13). Lateral epicondy-
other ligament lesions. Ligament detachment and interpo- losis is the most common tendinopathy about the elbow,
sition in the radiocapitellar joint have also been described, and the most common cause of elbow pain in non-ath-
although isolated tears are uncommon. letes, presenting as a chronic burning pain at its lateral
aspect. It may be associated with LCL injury, particular
the LUCL origin at the lateral epicondyle. Studies have
Tendon abnormalities
Tendinopathy is caused by chronic repetitive stress or
degeneration that leads to microavulsions at the tendon
insertion. In the initial tendinosis MRI shows thickening
and intermediately increased signal intensity on T1- and
T2-weighted sequences, corresponding histologically to
collagen degeneration and neovascularisation. As the
disease progresses MRI shows fluid-like signal intensity
changes within the tendon on T2-weighted images, indi-
cating collagen disruption, which may evolve to tendon
thinning (partial tear) or a complete tear. It is crucial to
consider the magic angle effect, which is an MRI artifact
related to anisotropy, especially evident in high collagen-
containing tissues. The magic angle effect is maximally
present when the long axis of the structure is oriented
at approximately 54° to the main magnetic field, and in-
creased signal intensity may be evident, particularly on
Figure 12. 38-year-old man with lateral epicondylosis. Coronal oblique pro-
short TE sequences (such as T1-weighted images). In ton density-weighted fat-suppressed magnetic resonance imaging shows
these situations, the longer TE sequences (such as fat- a moderate-grade partial-thickness interstitial tear of the common exten-
suppressed T2-weighted images) should be used to more sor tendon origin (arrow). Note associated mild thickening of the subjacent
accurately characterise abnormalities [59]. In addition, proximal radial collateral ligament

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 Magnetic resonance imaging of the elbow

A B

Figure 13. 41-year-old woman with medial epicondylosis. A) Coronal oblique and (B) axial proton density-weighted fat-suppressed magnetic resonance
imaging shows a high-grade partial-thickness tear of the common flexor tendon origin (arrows). There is associated subjacent bone marrow oedema and
surrounding soft tissue oedema

A B

C D

Figure 14. 31-year-old man with distal biceps tendon rupture. A) Sagittal oblique and (B) axial proton density (PD)-weighted fat-suppressed magnetic
resonance imaging (MRI) shows rupture and retraction of the distal biceps tendon (arrows) with surrounding soft tissue oedema. The lacertus fibrosus is
partially torn (arrowhead in B). C) Flexed elbow, abducted shoulder, forearm supinated positioning MRI confirms distal biceps tendon rupture with 4 cm of
retraction (dashed line). D) Coronal MRI reformatted from 3D PD-weighted fast-spin echo dataset shows the partially intact lacertus fibrosus (arrowhead)
connecting the biceps tendon (arrow) to the flexor musculature (asterisk)

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Alecio Lombardi, Aria Ashir, Tetyana Gorbachova et al. 

suggested an association between lateral epicondylosis

and mild lateral elbow instability [60]. Medial epicondy-
losis is much less frequent than lateral epicondylosis, be-
ing most commonly associated with chronic stress from
sports activities like overhead throwing. Treatment for
tendinopathies are generally conservative, consisting of
physical therapy, analgesics, and rest, but in refractory
disease, percutaneous interventions or surgical treat-
ment may be indicated [25,61].
Complete rupture of the distal biceps tendon can be
observed on MRI as a discontinuity and proximal retrac-
tion, sometimes associated with bicipitoradial bursitis. It
is important to remember that the long and short heads
of the biceps tendon can have distinct insertions into the
radial tuberosity, and thus both components should be
evaluated on MRI [24,62,63]. Intact bicipital aponeuro-
sis, or lacertus fibrosus, may prevent proximal tendon
retraction when the biceps is ruptured, which may cause
underestimation of biceps tendon tear clinically and on
MRI (Figure 14). Figure 15. 28-year-old man with triceps tendon rupture. Sagittal oblique
Triceps tendon ruptures are rare but usually occur at proton density-weighted fat-suppressed magnetic resonance imaging shows
a high-grade tear of the conjoined tendon of the lateral and long heads of
the insertion site. MRI may show discontinuity of the long the triceps with proximal retraction (arrow). An associated osseous avulsion
and lateral heads (Figure 15). The deep medial head in- fragment is evident in the retracted tendon stump with oedema (arrowhead)
serts directly onto the olecranon and is rarely torn [31].

The typical MRI appearance is bone marrow oedema and

Osseous and chondral lesions subchondral cysts. Unstable injuries can be distinguished
MRI is crucial for the diagnosis and characterisation of from stable injuries by fluid interposed between the osteo-
bone and cartilage lesions at the elbow, showing high chondral fragment and the underlying bone for in situ le-
sensitivity for subchondral bone damage, intraarticular sions (Figure 16), or frank displacement of the fragment.
bodies, and stress fractures. Children and athletes are two Other signs suggestive of instability are subchondral and
groups commonly affected due to skeletal immaturity and medullary cysts around the fragment [66].
chronic repetitive stress, respectively. It is, therefore, es- Panner first described osteochondrosis of the capitel-
sential to understand the particular developmental anat- lum or Panner’s disease in 1927, in a series of cases of
omy of the elbow [64]. lateral elbow pain in young boys. Laurent and Lindstrom
The ossification centres and apophyses in the imma- later described similar cases [67]. Although the causes
ture skeleton have lower stability than the mature adult may be multifactorial, Panner’s disease is now recognised
skeleton due to the weaker mechanical properties of un- as a type of osteonecrosis of the capitellum that occurs
ossified cartilage. Also, the physes can be under tremen- in boys from 4 to 10 years, therefore earlier than in os-
dous tensile forces, which make them more vulnerable to teochondritis dissecans, and is usually associated with
trauma. The elbow has six ossification centres: capitellum, sports-related elbow valgus overload. Similar to other
radial head, medial epicondyle, trochlea, olecranon, and osteochondroses like Legg-Calvé-Perthes or Osgood-
lateral epicondyle, which appear in that order, by ages 1-5- Schlatter, Panner’s disease occurs in developing bone and
6-8-10-11 years, respectively (Table 3). They appear and
ossify earlier in girls than in boys [64].
Osteochondritis dissecans is a condition of the sub- Table 3. Ossification centres at the elbow and their respective age of ap-
chondral bone and articular cartilage occurring in differ- pearance
ent joints, which is characterised by a localised failure of Ossification centre Age of appearance (years)
normal ossification process, leading to fragmentation of
Capitellum 1
the articular surface, instability, and eventually fragment
detachment. In the elbow, this condition most commonly Radial head 5
occurs at the anterolateral aspect of the capitellum, typically Medial epicondyle 6
in young adolescents 11-15 years old, involved in throw- Trochlea 8
ing sports. The cause is unknown but probably involves
Olecranon 10
chronic repetitive trauma and impaired blood supply lead-
ing to disruption of normal endochondral ossification [65]. Lateral epicondyle 10

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 Magnetic resonance imaging of the elbow

A B

Figure 16. 16-year-old male basketball player with osteochondritis dissecans of the capitellum. A) Anteroposterior radiograph of the elbow shows subchon-
dral lucency in the capitellum (arrow). B) Sagittal oblique proton density-weighted fat-suppressed magnetic resonance imaging confirms the osteochondral
lesion characterised by an unstable in situ fragment with bone marrow oedema and subjacent fluid (arrow)

Table 4. Mason classification of radial head fractures

Type Injury
I Undisplaced
II Displaced partial articular
III Multifragmented/Displaced total articular

Table 5. Rayes and Morrey classification of coronoid fractures

Type Injury
I Coronoid tip fracture
II Fracture less than 50% of height of coronoid
III More than 50% of height of coronoid

The condition is self-limited, and conservative treatment

is recommended.
Medial epicondyle apophysitis, also known as little
leaguer’s elbow, due to its high incidence in adolescent
baseball pitchers, is a disease caused by repetitive stress
over the immature bone and physis at the medial elbow.
As in the adult athlete involved in an overhead throwing
Figure 17. Little leaguer’s elbow. Coronal proton density-weighted fat-sup- activity, this condition is related to the late cocking and
pressed magnetic resonance imaging of a 15-year-old boy shows bone early acceleration phases of overhead throwing, which
marrow oedema centred in the medial epicondylar apophysis (asterisk), leads to chronic bone microtrauma and capsuloligamen-
extending to adjacent distal humerus with periostitis (arrow). Note intact tous injuries. In children, the characteristics of the imma-
ulnar collateral ligament (UCL) (arrowhead) and absence of bone avulsion
(no fluid interposed between UCL and sublime tubercle of the ulna or be- ture bone explain the higher frequency of medullary and
tween the apophysis and medial humeral epicondyle) physeal changes compared to ligamentous injuries. Bone
marrow oedema and increased physeal width on fluid-
sensitive sequences are seen on MRI [68] (Figure 17).
may present with sclerosis, characterised by low signal in- Elbow fractures are frequently associated with joint
tensity on all MRI sequences, along with oedema and joint subluxation or dislocation. There are specific classifi-
effusion on fluid-sensitive sequences. Usually there is no cations for radial head, coronoid, olecranon, and distal
bone fragment, and the cartilage remains intact, helping humeral fractures. Still they regularly occur simultane-
to further differentiate it from osteochondritis dissecans. ously depending on the mechanism of injury [69], and

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Alecio Lombardi, Aria Ashir, Tetyana Gorbachova et al. 

A B

Figure 18. 30-year-old man with elbow dislocation after a fall. A) Sagittal oblique and (B) axial proton density-weighted fat-suppressed magnetic resonance
imaging shows a non-displaced fracture of the anteromedial facet of the coronoid process (arrows), consistent with posteromedial rotatory instability. Also
present is a joint effusion (arrowhead in A) with periarticular soft tissue oedema

very often the orthopaedic surgeon has to choose the Table 6. O’Driscoll classification of anteromedial olecranon fractures
best treatment option based on the combination between
them and the instability pattern they cause. CT is the most Type Description
important exam for evaluation of fracture location and I Anterior rim
extension, but MRI can be helpful, particularly with non- II Anteromedial rim (including sublime tubercle)
displaced fractures or stress fractures [70]. MRI is also
III Base of olecranon
particularly useful for evaluation of stress reactions. On
MRI, fracture lines are visualised as low signal intensity
lines on all pulse sequences with abundant bone marrow supinated elbow. The proximal ulna and radial head dislo-
oedema on fluid-sensitive sequences. cate posteriorly in relation to the humerus. There are also
Radial head fractures are frequently classified using lateral and medial collateral ligament and tendon injuries.
the Mason system (Table 4), which considers the grade Terrible triad injuries do not have any specific classifica-
of comminution and displacement of bone fragments, tion system, but treatment follows individual classification
with higher grades showing increased comminution and systems for radial head and coronoid process fractures.
instability. Type I (undisplaced) fractures can be treated Operative treatment with surgical fracture fixation with
conservatively, while type II (partially displaced) and III or without ligament reconstruction is usually necessary.
(comminuted) fractures require operative management A distinct type of coronoid process fracture involv-
[71,72]. ing the anteromedial rim (or facet) is associated with
Coronoid fractures are frequently classified using VPMRI of the elbow and is accompanied by lesions of the
the Regan & Morrey system (Table 5), which takes into LUCL and the posterior bundle of the UCL (Figure 18).
consideration the height of the coronoid bone fragment. The mechanism of injury is a fall onto an outstretched
Larger fragments (involving 50% or more of the coronoid hand, with subsequent internal rotation of the elbow and
process height) are associated with poorer prognoses and varus overload. The anteromedial facet of the coronoid
should be surgically fixated. process is a medial extension of the ulnar articular sur-
The combination of a radial head fracture, ulnar coro- face and plays an essential role in the varus stability of the
noid fracture, and posterior elbow dislocation is referred elbow. A fracture at this site leads to humeroulnar joint
to as the terrible triad of the elbow, because it is associated incongruity and subsequently osteoarthritis. The larger
with increased elbow instability, complications, and poor the osseous fragment, the more likely the development
prognosis even after operative treatment. A high-force of osteoarthritis if not surgically fixated [73,74]. For this
trauma usually causes this type of complex fracture, and specific type of coronoid fracture, O’Driscoll described
the injury mechanism is axial load to an extended and a classification system that considers the fracture exten-

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 Magnetic resonance imaging of the elbow

A B C

Figure 19. 18-year-old male pitcher with an olecranon stress fracture. A) Axial proton density-weighted fat-suppressed and (B) coronal T1-weighted
magnetic resonance imaging shows an olecranon stress fracture (arrows) with associated bone marrow and soft tissue oedema. C) Sagittal reformatted
computed tomography image confirms the non-displaced olecranon stress fracture (arrow)

sion from those involving only the anterior rim of the

Radial nerve
coronoid process to those also involving the anteromedial
facet and the sublime tubercle (Table 6). In general, these Radial tunnel syndrome is a condition characterised by
fractures are treated operatively, although some cases of pain at the lateral aspect of the elbow and forearm, in the
type I fractures with small bone fragments may be treated area involving the proximal extensor muscles, without
with lateral ligament repair only, whereas types II and III motor deficit, caused by compression of the radial nerve
always require bone fragment fixation [69]. within the radial tunnel, and worsened by pronation-su-
Olecranon fractures are relatively common and asso- pination of the forearm. The radial tunnel is an anatomic
ciated with high-energy trauma in adults and low-energy space between the brachioradialis, brachialis, and ECRB
trauma in the elderly [75]. There is some debate over the best muscles and the capitellum, which extends from the capi-
classification system: of the several proposed classification tellum to the lower portion of the supinator [80]. Poten-
systems, the Mayo classification is the most commonly used; tial confounders are lateral epicondylosis and distal biceps
however, criticism and controversy exist in the literature [76]. tendinopathy [74]. One important clinical finding that
The grade of comminution is the most important feature. can help is that pain associated with radial tunnel syn-
Olecranon stress fractures may occur in the throw- drome usually occurs distal to the lateral epicondyle. MRI
ing athlete, either due to the pull of the triceps or from findings may show denervation changes involving both
impingement in the olecranon fossa (Figure 19) in the set- the proximal extensor muscle group (like the triceps, an-
ting of VEO syndrome. In adolescent baseball pitchers, coneus, and brachioradialis) and the distal extensor mus-
medial supracondylar stress fractures can also rarely occur cle group, characterised by muscle oedema in acute and
[77]. Of note, stress fractures about the elbow occur less subacute stages, and muscle atrophy in advanced stages.
frequently than ligament injuries [78]. After passing the lateral epicondyle, the radial nerve
Distal humeral fractures occur in young adults submit- bifurcates into a superficial sensory branch that gives
ted to high-energy trauma or in the osteoporotic elderly sensation to the anterolateral forearm, and a deep motor
population. The recommended treatment is operative, branch that continues distally to the dorsum of the wrist
and it is based most commonly on the AO classification, and innervates the common extensor muscles at the fore-
which divides fracturs types into groups A (extra-articular), arm [81]. Once it pierces the supinator muscle the deep
B (partial intra-articular), and C (complete articular) with motor branch is called the posterior interosseous nerve
subdivisions according to the grade of comminution [79]. (PIN), which can be compressed at several sites along its
trajectory giving rise to PIN syndrome. The most com-
mon site of compression is at the proximal edge of the
Neuropathies supinator, between its two heads, by a tendinous structure
Nerves can be seen on MRI as small tubular structures known as the arcade of Frohse. Other possible points of
with low to intermediate signal intensity on T1-weighted compression are the medial edge of the ECRB, the recur-
images and intermediate to high signal intensity on fluid- rent radial vessels (known as the leash of Henry), and the
sensitive sequences. The elbow has three primary nerves inferior margin of the supinator muscle [82].
(radial, ulnar, and median), and a thorough understand- PIN syndrome is a neuropathy characterised by pain
ing of anatomy is essential for the evaluation of common and muscle weakness at the lateral aspect of the forearm
neuropathies. and hand [83], which differentiates it from radial tunnel

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Alecio Lombardi, Aria Ashir, Tetyana Gorbachova et al. 

A B C

Figure 20. 50-year-old female with history of radial neuropathy. A) Axial proton density (PD)-weighted fat-suppressed and (B) T1-weighted magnetic res-
onance imaging (MRI) shows the deep branch of the radial nerve (arrows), which is hyperintense on the fluid-sensitive sequence (A). C) Axial PD-weighted
fat-suppressed MRI shows muscle denervation changes in the extensor carpi radialis brevis (thin arrow), extensor digitorum (arrowhead), and extensor
carpi ulnaris (asterisk), all innervated by the posterior interosseous nerve

A B C

Figure 21. 52-year-old man with cubital tunnel syndrome caused by a ganglion cyst. A) Axial and (B) sagittal proton density-weighted fat-suppressed
magnetic resonance imaging (MRI) shows a ganglion cyst (arrows) in the cubital tunnel adjacent to the ulnar nerve which demonstrates mildly increased
size and signal. C) Axial proton density-weighted fat-suppressed MRI shows mild oedema in the flexor digitorum profundus (asterisk) and flexor carpi ulnaris
(arrowhead) muscles without atrophy adjacent to mildly hyperintense ulnar nerve (arrow)

syndrome that has classically been described as causing larity with compression of the lateral femoral cutaneous
pain without motor deficit. There is no sensory deficit, nerve at the tight (meralgia paraestetica).
and electrodiagnostic testing may be normal. MRI can Compression of the radial nerve and its branches can
show features of distal muscle denervation, in this case be caused by ganglion cysts, bicipitoradial bursitis, trauma
involving only the distal common extensor muscle group with radial head dislocation, repetitive movements of su-
and the supinator muscle, characterised by high signal pination and pronation, infectious diseases, and tumours
intensity on fluid-sensitive sequences, and atrophy with [85–87]. Treatment of non-tumoral causes begins with
fatty infiltration in T1-weighted images (Figure 20). immobilisation, analgesics, and physiotherapy, followed
The superficial branch of the radial nerve can also by surgical decompression in refractory cases, which has
be compressed at the distal forearm, most commonly at shown good clinical outcomes [88].
the posterior border of the brachioradialis tendon, as the
nerve transitions from a deep to a subcutaneous location
Ulnar nerve
through the fascia that binds the brachioradialis tendon
to the ECRL tendon, usually during pronation. Such com- Ulnar neuropathy is the second most common peripheral
pression may cause burning pain and paraesthesia at the nerve compression syndrome. It usually occurs at the level
dorsum of the thumb and radial side of the hand, a condi- of the cubital tunnel, an anatomical space bounded by the
tion called Wartenberg’s syndrome [84]. Other descriptive medial epicondyle medially and olecranon laterally, the
names have been used like handcuff neuropathy, wrist- Osborne ligament as its roof, and the posterior bundle of
watch neuritis, and cheiralgia parestetica due to its simi- the medial collateral ligament and joint capsule as its floor.

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 Magnetic resonance imaging of the elbow

A C

Figure 22. Anconeus epitrochlearis muscle in a 48-year-old female with left elbow pain and limited range of motion. A) Axial T1-weighted and (B) proton
density-weighted fat-suppressed magnetic resonance imaging (MRI) shows a large accessory anconeus epitrochlearis muscle at the posteromedial aspect
of the elbow (arrows) and mildly hyperintense ulnar nerve (arrowhead). C) Sagittal oblique T1-weighted MRI confirms the large accessory muscle (arrows),
which compress the mildly hyperintense ulnar nerve (arrowheads)

A B C

Figure 23. Pronator syndrome. A-B) Coronal oblique and (C) axial proton density-weighted fat-suppressed magnetic resonance imaging of the elbow shows
early median nerve denervation changes characterised by mild oedema in the pronator teres muscle (arrows)

Cubital tunnel syndrome is a condition that manifests It may be primary or secondary, caused by nerve dislo-
as medial elbow and forearm pain and paraesthesia, par- cation, ganglion cysts, and inflammatory arthropathies
aesthesia at the medial aspect of the hand, and weakness [89–92]. The diagnosis starts with clinical examination
with loss of coordination of the fingers due to muscle atro- and electrophysiological studies. MRI plays a significant
phy at the forearm and hand (involvement of the FDP, in- role in the diagnosis and, as in previously described neu-
terossei, medial two lumbricals, and hypothenar muscles). ropathies, may show secondary signs of muscle denerva-

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Alecio Lombardi, Aria Ashir, Tetyana Gorbachova et al. 

A B

Figure 24. 66-year-old female with olecranon bursitis. A) Axial proton density-weighted fat-suppressed magnetic resonance imaging (MRI) shows fluid
distension of the olecranon bursa (arrowhead). B) Sagittal oblique T1-weighted MRI shows the conjoined tendon of the distal triceps inserting onto the
fragmented olecranon enthesophyte (arrow) with overlying olecranon bursitis (arrowhead)

tion in the territory of the ulnar nerve (e.g. oedema or tigators suggested that the use of MRI should focus more
atrophy in the flexor muscles of the forearm and hand). on the nerve size, or a combination of both, and not only
MRI can also show local osteophytes, ganglion cysts, or in nerve signal abnormalities [97].
dislocation of the ulnar nerve (Figure 21). The anconeus Cubital tunnel syndrome treatment depends on the
epitrochlearis, an accessory muscle at the posteromedial severity of the neuropathy but starts with conservative
aspect of the elbow that runs from the medial epicondyle measures like arm splinting and rest. Refractory cases may
to the olecranon as previously described, has been im- require surgical intervention, which includes decompres-
plicated as a cause of external compression of the ulnar sion, decompression with anterior transposition, or de-
nerve [93,94] (Figure 22). This anatomical variant, howev- compression with epicondylectomy [89,98]. There are re-
er, was also found in 23% of asymptomatic patients, thus current symptoms in up to 20-35% of the patients, which
highlighting the importance of correlation with physical makes follow-up imaging of these patients relatively com-
exam findings [95]. mon, requiring some familiarity from the radiologist, with
The use of MRI for direct assessment of ulnar nerve normal and complicated postoperative findings. In medial
abnormalities in the setting of cubital tunnel syndrome epicondylectomy and anterior nerve transposition, for ex-
has been studied in the past. Husarik et al. found that ample, it is normal to find bone marrow oedema and soft
increased signal intensity of the ulnar nerve on fluid- tissue scarring, as well as ulnar nerve thickening. Haema-
sensitive sequences was present in 60% of asymptomatic tomas, seromas, and soft tissue scarring can cause new
patients, suggesting that ulnar neuropathy could be over- nerve compression [99].
estimated using this method of evaluation [95]. In a later
study by Baumer et al., MR neurography was shown to
Median nerve
have high diagnostic accuracy for ulnar neuropathy at the
elbow when increased signal intensity on T2-weighted se- Median neuropathy at the elbow most commonly results
quences and increased calibre on T1-weighted sequences from compression between the superficial and deep heads
were present [96]. These findings were later corroborated of the pronator teres muscle, hence the name pronator
in a study by Keen et al., which showed statistically sig- syndrome, but can also be caused by median nerve com-
nificant differences in nerve size and signal intensity be- pression at the bicipital aponeurosis, the origin of flexor
tween symptomatic patients and normal volunteers using muscles, or at the supracondylar process of the humerus
T1-weighted and fluid-sensitive sequences on MR [100]. Clinical findings are similar to other neuropathies
arthrography, respectively [97]. They also found that the and include pain and numbness in the area of median
nerve size (with the cut-off of 0.08 cm2) showed higher nerve distribution, especially during pronation of the
accuracy for the diagnosis of ulnar neuropathy compared forearm. MRI can also show indirect signs of muscle
to signal alterations, probably because of the high inci- denervation like oedema in the pronator teres or other
dence of nerve signal alterations found in normal volun- flexor tendons [34,100] (Figure 23). Anterior interosseous
teers. The high false-positive rate in nerve signal altera- nerve syndrome, also known as Kiloh-Nevin syndrome, is
tions was hypothesised as being caused by early changes caused by compression of the anterior interosseous nerve
in nerve signal that could remain clinically silent until the (AIN, a motor branch of the median nerve) in the proxi-
nerve begins to increase in calibre. Another possibility is mal forearm typically distal to the level of entrapment
that the way signal abnormalities were calculated (as fo- that produces pronator syndrome. Patients with AIN
cal region of signal alteration), compared to calibre size syndrome present with weakness of the thumb and index
measurements (average of several points along the course finger with a disturbance of the pinch mechanism, which
of the nerve), could have played a role. Finally, the inves- may mimic ruptures of the flexor tendons [100].

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 Magnetic resonance imaging of the elbow

A B

C D

Figure 25. 55-year-old man with left elbow pain after weightlifting injury. A-B axial and C-D sagittal proton density-weighted fat-suppressed magnetic
resonance imaging shows a high-grade partial-thickness tear of the short head (arrow) and a low-grade partial-thickness tear of the long head (arrowhead)
of the biceps tendon. There is adjacent bone marrow oedema in the radial tuberosity and oedema and haematoma in the bicipitoradial bursa

erosion, raising concern for a malignant tumour [36,105].

Bursae and plicae FABS (flexion of the elbow with abduction of the shoulder
Olecranon bursitis may present in the MRI as a collection and supination of the forearm) position can help visualise
of fluid in the posterior olecranon subcutaneous region, the typical bursa location involving the biceps tendon, but
with thickened walls, with or without septation and gado- sometimes imaging is insufficient to establish the aetiol-
linium contrast enhancement. The causes include chronic ogy of the bursitis, and tissue sampling and histological
mechanical friction, inflammatory arthropathies, and in- analysis are necessary. Biceps tendinopathy and tear, me-
fectious conditions [37,101] (Figure 24). Differentiation chanical stress, systemic inflammatory conditions, and in-
between septic and aseptic bursitis can be challenging fection have been described as potential causes [106,107]
both in the physical exam and imaging because the MRI (Figure 25). Radial nerve compression and radial tunnel
findings in these conditions show considerable overlap syndrome can also result as an associated complication.
[102,103]. Treatment is usually conservative for aseptic Treatment is initially conservative with aspiration and
aetiologies, with rest, ice, and NSAIDs. In patients with steroid injection; however, surgical excision may be nec-
repeated episodes, bursectomy can be considered [104]. essary in refractory cases.
Bicipitoradial bursitis is an uncommon condition Synovial plica syndrome or synovial fringe syndrome
characterised by bursal fluid distention or synovial pro- is a rare cause of posterolateral elbow pain, usually de-
liferation around the distal biceps tendon on MRI. Some- scribed as elbow tenderness that increases with move-
times it can present as a solid mass with contrast enhance- ment, associated with mechanical blocking and a snap-
ment, often associated with radial tuberosity oedema and ping sensation. MRI shows long and thick plica at the

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Alecio Lombardi, Aria Ashir, Tetyana Gorbachova et al. 

anterior, posterior, or external aspects the radiocapitel- anatomy and biomechanics is the first step towards ac-
lar joint. The variation in the plica length and thickness curate evaluation and diagnosis of common pathologies
among individuals may cause an overlap between symp- using MRI. Diseases that can be observed include bone
tomatic and asymptomatic patients, so MRI has to be used fractures and joint dislocation, osteochondroses, osteo-
as an adjunctive tool in diagnosis and treatment, always chondritis dissecans, ligament lesions, tendon abnormali-
accompanied with clinical findings. Lateral epicondylo- ties, neuropathies, and bursal conditions. Athletes and
sis must be considered as the main differential diagnosis, children are particularly at-risk populations for chronic
given the similar presenting symptoms. Current treatment overuse syndromes and traumatic injuries. Familiarity
is arthroscopic plica resection or debridement, although with current treatments is also important both to improve
the former has shown better results [39]. communication with the referring physician and to in-
terpret postoperative imaging and surgical complications.
Conclusions
The elbow is a complex joint frequently subjected to
Conflict of interest
trauma and chronic mechanical stress. Understanding its The authors report no conflict of interest.

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