Correlation of Joint Space Widening on Valgus Stress Magnetic Resonance Imaging With Level of Play and Innings Pitched in Professional Pitchers.

Background: Previous studies have described various techniques and confirmed the clinical utility of valgus stress radiography and stress ultrasound in overhead athletes. The addition of valgus stress and a high-resolution anatomic assessment of the elbow with magnetic resonance imaging (MRI) in the active throwing position (flexed elbow valgus external rotation [FEVER] view) can add valuable diagnostic or prognostic information in throwing athletes. Purpose/Hypothesis: The purpose of this study was to evaluate findings on MRI and subsequent performance in professional throwing athletes. It was hypothesized that joint space widening in the FEVER view would be predictive of performance and the risk of subsequent injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: All pitchers on 2 Major League Baseball teams who consented to participate during their preseason screening in 2019 and 2020 underwent standard and FEVER MRI, and performance data from the following season were recorded, including injuries, mean throwing velocity, number of innings pitched, strikeout percentage, walk percentage, weighted on-base average, and level of play reached (not signed, minor league, or major league). Categorical variables were compared using the Fisher exact test or chi-square test, and continuous variables were compared using the Kruskal-Wallis test, as appropriate. Ordered logistic regression was used to determine the independent factors predicting performance. Results: A total of 91 players underwent preseason imaging, and all players had subsequent performance data available. Multivariate analysis revealed that when controlling for age, mean velocity, history of injuries, presence of symptoms, and history of ulnar collateral ligament reconstruction, increased absolute joint space widening was predictive of a lower level of play (ß = -0.63; P = .042). Univariate analysis demonstrated a significant correlation between relative joint space widening and level of play reached (ß = -0.54; P = .034). Relative joint space widening remained a significant predictor of level of play (ß = -0.87; P = .012) on multivariate analysis. Multivariate analysis also showed that both absolute joint space widening (ß = -13.50; P = .012) and relative joint space widening (ß = -13.60; P = .026) were predictive of the number of innings pitched in the subsequent season. Conclusion: The present study demonstrates that findings on MRI with valgus stress correlated with the level of play reached and number of innings pitched in professional throwing athletes.

The Use of Biologics in NFL Athletes: An Expert Consensus of NFL Team Physicians.

Background: There is a lack of published information outlining the use of biologics in National Football League (NFL) athletes and limited data to guide biologic treatment strategies. Purpose: To develop a consensus on the use of biologics among NFL team physicians. Study Design: Consensus statement. Methods: A working group of 6 experts convened a consensus process involving NFL team physicians using validated Delphi methodology. Physicians from 32 NFL teams as well as NFL London were invited to take part. This iterative process was used to define statements on the use of biologics in NFL athletes. A recent scoping review exploring biologics in professional athletes was used to inform the first of 3 rounds of surveys, with statements considered under 7 headings: biologics in general, challenges of treating NFL athletes, terminology/nomenclature, autologous blood products, cell-based therapies, guidance for NFL team physicians, and biologic research in the NFL. In addition to rating agreement, experts were encouraged to propose further items or modifications. Predefined criteria were used to refine item lists after each survey. For a consensus within the final round, defined a priori, items were included in the final information set if a minimum of 75% of respondents agreed and fewer than 10% disagreed. Results: Physicians from 26 NFL teams and NFL London responded to the initial invitation to participate in the Delphi process; 88.9% of participating team physicians completed the round 1 survey, with response rates of 87.5% in round 2 and 95.2% in round 3. After 3 rounds, 47 statements reached a consensus. A consensus was achieved that platelet-rich plasma has a positive impact on patellar tendinopathy and on symptoms in early osteoarthritis but not for other indications. NFL team physicians agreed that while cell therapies have the potential to improve symptoms, the misrepresentation of uncharacterized preparations as "stem cells" has contributed to the widespread use of unproven therapies. Conclusion: This study established an expert consensus on 47 statements relating to the use of biologics in NFL athletes. In addition to providing clinical guidance for the use of biologics in NFL athletes, this study identified key areas for future focus including the development of athlete education materials.

Surgical Excision of a Thrombosed Persistent Median Artery in a Professional Hockey Player.

A persistent median artery is a rare anatomical variant found in approximately 10% of the population. Carpal tunnel syndrome due to a thrombosed persistent median artery is exceptionally rare. A 29-year-old professional hockey player presented with a 2 months history of hand pain and intermittent paresthesias without vascular symptoms. Magnetic resonance imaging and angiography demonstrated a 2-cm thrombosis in a persistent median artery at the level of the carpal tunnel, with otherwise normal vascular anatomy. He was treated with surgical excision of the thrombus and carpal tunnel decompression. The patient's symptoms resolved rapidly and he was able to return to sport without restrictions. Incidental imaging performed several months after surgery demonstrated a normal vascular pattern in the treated hand.

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.

BACKGROUND. Ulnar collateral ligament (UCL) injuries are common in throwing athletes owing to repetitive extreme valgus stress during overhead throwing maneuvers. Conventional positioning for elbow MRI provides suboptimal rendering of the UCL. OBJECTIVE. The purpose of this prospective pilot study was to assess the effect of flexed elbow valgus external rotation (FEVER) on ulnotrochlear joint space measurement and reader evaluation of the UCL when the FEVER view is incorporated into standard elbow MRI of throwing athletes. METHODS. A total of 44 Major League Baseball pitchers underwent elbow MRI including standard sequences and a coronal fat-saturated proton density-weighted sequence in the FEVER view. To achieve the FEVER view, specific positioning maneuvers are performed, and sandbags are placed to immobilize the elbow in valgus stress so that the UCL can be visualized parallel to its long axis. Patients recorded pain during FEVER on a scale of 0 (none) to 10 (maximal). Two radiologists independently evaluated standard and FEVER images to measure the ulnotrochlear joint space, assess confidence in UCL-related findings, and assess the UCL as normal or abnormal. RESULTS. Pain during FEVER was rated 0 by 29 patients, 1-3 by 11 patients, 4-7 by four patients, and 8-10 by no patients. Intrareader agreement on ulnotrochlear joint space measurement was higher for FEVER (intraclass correlation coefficient [ICC], 0.92) than standard (ICC, 0.54) views. Averaged between readers, the mean increase in ulnotrochlear joint space in the FEVER compared with the standard view was 1.80 mm (95% CI, 1.58-2.03). Confidence was higher for the FEVER than for the standard view for reader 1 in assessment of the UCL as normal versus abnormal (mean increase in confidence, 0.40), intensity of abnormal signal (0.39), injury grade (1.04), and retraction (0.25) and for reader 2 in assessment of the UCL as normal versus abnormal (0.50), location of abnormal signal (0.46), intensity of abnormal signal (0.51), injury grade (0.96), and retraction (0.53). Readers 1 and 2 classified three and two additional UCLs as abnormal on FEVER view compared with standard view images; neither reader classified any UCL as abnormal on standard view but normal on FEVER view images. CONCLUSION. The increased joint space width confirmed elbow valgus stress in the FEVER view. Diagnostic confidence increased, and additional UCLs were identified as abnormal. CLINICAL IMPACT. Use of the FEVER view may improve MRI evaluation of the UCL in throwing athletes.