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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
  1. G Hoy1,
  2. T Wood2,
  3. N Phillips1,
  4. D Connell3
  1. 1Melbourne Orthopaedic Group, Melbourne, Victoria, Australia
  2. 2Glenferrie Private Hospital, Hawthorn, Victoria, Australia
  3. 3Victoria House Radiology, Melbourne
  1. Correspondence to:
 Dr Hoy
 Melbourne Orthopaedic Group, 33 The Avenue, Windsor, Melbourne, Victoria 3181, Australia; gahoy{at}


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.

  • humerus
  • stress fracture
  • magnetic resonance imaging
  • tennis

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  • Competing interests: none declared

  • Patient consent has been obtained for publication of the figures.