Diagnostics

Elbow diagnostics: imaging modalities & clinical correlation for fractures, ligament injuries, OCD, and overuse conditions (tennis/golfer’s elbow).

Overview

Standardized diagnostic protocols are warranted to further optimize diagnostic accuracy in the diagnosis of fracture-related infections [3]. Early diagnosis, appropriate antimicrobial therapy, and surgical intervention when necessary are crucial for improving patient outcomes in spondylodiscitis [18]. There is a need for consensus on well-defined, unambiguous radiological criteria to define lumbar spinal stenosis in order to improve diagnostic accuracy and to formulate reliable inclusion criteria for clinical studies [69]. Further research is needed to obtain universally accepted diagnostic criteria for carpal tunnel syndrome to consistently improve outcomes [49].

Understanding the initial evaluation and conservative treatment of cartilage defects is essential to achieving excellent outcomes after surgical intervention for articular cartilage lesions of the knee [16]. An MRI is justified at three months, one year, two years, and five years after third-generation autologous chondrocyte implantation surgery, unless clinical symptomatology and individual patient needs dictate otherwise [17]. Diskography remains a second-line diagnostic modality in select patients with recalcitrant back pain to clarify surgical indications, despite its controversial validity and inconsistent postdiskography surgical outcomes [66].

Each available test for joint aspiration in the diagnosis of chronic periprosthetic joint infection has advantages and disadvantages and should be used in conjunction with the overall clinical picture to guide further evaluation and treatment [73]. Future studies on periprosthetic joint infections should encourage sound clinical design, patient selection, and testing procedures [67]. Outpatient core needle biopsy of musculoskeletal tumors should be used only in a small subset of patients due to potential disadvantages such as non-diagnostic or indeterminate results [10].

Anatomy & Pathophysiology

Biomechanics and Kinematics

Evaluation of the elbow requires an understanding of the anatomy, biomechanics, and diagnostic tests for this complex joint, with particular attention paid to functional biomechanics necessary when treating complex pathology [52]. Physical examination of the elbow is a critical component in formulating an accurate diagnosis [114]. The elbow joint angle of 60° flexion was the most reliable for joint position sense (JPS) testing [95]. Joint congruence of healthy elbows on MRI increased significantly when changing from supination to pronation [107]. With elbow flexion, the ulnar nerve did not move appreciably in the distal–proximal direction directly at the cubital tunnel, but maximal excursion was in the fatty region proximal to the elbow [108]. The ulnar nerve moves medially and is flattened with the elbow flexed between 90 and 120 degrees [117].

Dynamic Stability and Loading

Gripping does not change ulnohumeral joint space width or medial elbow tissue stiffness in the joint testing configuration and external loading conditions applied in the study [86]. Elbow valgus torque increases contact pressure in the radiocapitellar joint [101]. Elbow valgus torque is poorly suited as a standalone metric for predicting injury risk due to narrow data ranges, modeling noise, and crude assumptions [96]. Pitchers with increased dynamic elbow laxity experience reduced medial elbow torque while pitching [104]. Pitching 100 balls induces a significant reduction in dynamic stabilizing ability against elbow valgus laxity in high school baseball players [111].

Diagnostic Imaging and Assessment Tools

Four-dimensional computed tomography (4D CT) is a promising diagnostic tool in the management of dynamic elbow disorders and may be considered in clinical practice [105]. Tridimensional electromagnetic sensor system provides an accurate evaluation of the elbow joint in clinical settings [113]. Arm abduction angle measured on smartphone provides a convenient and precise tool in assessment of arm motion [109]. Smartphone “selfies” are a reliable and accurate tool for measuring elbow range of motion [118].

Neuromuscular and Soft Tissue Evaluation

Preoperative dynamic electromyography findings in the biceps brachii appeared to predict incapacitated force production and may have promise for guiding more targeted surgical procedures to other elbow flexors [116]. In patients treated with surgery for snapping triceps syndrome, it is crucial to ensure full resolution of the snapping by examining all dislocating structures during passive elbow motion and/or myoelectrical stimulation [106].

Classification

Classification systems provide a common language to define condition severity, guide treatment decisions, and facilitate clinical research [44]. The choice of system has implications for operative and non-operative management [19].

Visotsky-Seebauer: This system classifies partial distal biceps tendon tears. It possesses sufficient reliability for use in everyday practice and for scientific purposes [47].

Hamada: This system classifies partial distal biceps tendon tears. It possesses sufficient reliability for use in everyday practice and for scientific purposes [47].

Rockwood: Commonly used in Japan, this system assesses the severity of acromioclavicular joint separations [56]. There is disagreement regarding the assessment for the diagnosis of type IV acromioclavicular joint separation using this classification [56].

Pipkin: This system classifies femoral head fractures. It is not comprehensive and lacks both interobserver and intraobserver reliability [65]. Consequently, its lack of reliability limits its utility as a guide for operative intervention [65].

Acromial Morphology: This system assesses acromion shape. It is an unreliable method for this assessment [71]. Furthermore, the acromial index shows no association with the presence of rotator cuff disease [71].

Glenoid Morphology: Clusters based on glenoid morphology indicate that patterns exist in the types of glenoid defects in failed shoulder arthroplasties [88]. These patterns highlight a need to further investigate a three-dimensional classification system and potentially develop new standardized revision implant component designs [88].

Lunate Fossa Fractures: A new classification for lunate fossa fractures of the distal radius exists. Its reproducibility and reliability for guiding treatment and prognostic judgment must be further confirmed and perfected in the clinical setting [78].

PARMa: This system classifies radial head and neck fractures based on 2D/3D CT imaging [80]. It demonstrated good intraobserver and interobserver reliability [80].

Bone Marrow Lesions: A proposed six-location classification of bone marrow lesions in the knee is highly reproducible [91]. This system can help researchers develop studies and share information in a more accurate and reliable way [91].

Other Considerations: * Distal radius bone mineral density has the potential to be integrated into future osteoporosis classification systems [59]. * Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair [63]. * A new classification system for long-term unreduced hip joint dislocation, secondary osteoarthritis, and pseudoarthrosis could help surgeons estimate potential difficulties during total hip arthroplasty [74]. * A deep learning model has shown great potential in assisting clinicians with the accurate diagnosis and classification of hip fractures [76].

Clinical Presentation

A thorough clinical history and physical examination are foundational for distinguishing the source of upper extremity pain, facilitating the appropriate diagnostic measures for neurologic, musculoskeletal, vascular, or other etiologies [28]. For undifferentiated wrist complaints, expert clinicians recommend specific diagnostic tests tailored to the patient’s age, location, and duration of symptoms [38]. In cases of knee pain, presentation factors that increase the likelihood of a diagnostic X-ray include pain persisting for longer than 6 months, the presence of medial or diffuse pain, and mechanical symptoms [37].

Insidious clinical findings characterize meniscal mucoid degeneration, which differs from traumatic tears; consequently, a lack of trauma history may delay diagnosis [2]. Combining physical diagnostic tests increases the diagnostic accuracy for meniscal tears [31]. However, diagnosis should not rely on a single MRI section or sign, as the double PCL sign does not always indicate a bucket-handle tear of the medial meniscus [4].

The Hook Test for distal biceps tendon avulsion demonstrates 100% specificity and 100% sensitivity, allowing for an accurate diagnosis independent of MRI findings [9]. Using the Resisted Supination External Rotation Test, in the context of a thorough clinical history and physical examination, enables a more reliable diagnosis of superior labrum lesions [39]. For carpal tunnel syndrome, there is no perfect clinical diagnostic test; six clinical diagnostic tests exist with differing sensitivities and specificities [36].

Osteoid osteoma of the patella must always be included in the differential diagnosis, even if age, sex distribution, or location is unusual [29]. Early onward referral is recommended for glomus tumour of the elbow to confirm diagnosis, alleviate patient concerns and symptoms, and improve function [30]. Prompt recognition of subacromial bony erosion as a presentation of pigmented villonodular synovitis leads to earlier diagnosis, appropriate treatment, less joint destruction, and better outcomes [34].

Muscle imaging aids in recognizing atypical clinical presentations of Pompe disease [1]. Detection of musculoskeletal manifestations of transthyretin-mediated (ATTR) amyloidosis may enable earlier diagnosis and administration of effective treatments before disease progression [33]. Clinical and radiological findings mimicking malignant soft tissue tumor due to calcium pyrophosphate dihydrate crystal deposition disease must be backed up by histopathological examination for true diagnosis [35].

Standardized diagnostic protocols are warranted to optimize diagnostic accuracy for fracture-related infections [3]. Current European diagnostic practice for prosthetic knee joint infection highlights areas of divergence from the state of evidence, demonstrating the need for development of standard diagnostic algorithms [40]. No single test is diagnostic for most immune-mediated disorders, requiring a combination of clinical, serologic, and radiographic tests for diagnosis [6]. A sufficient basic diagnosis for overactive bladder includes a detailed medical history and, if necessary, urodynamic evaluation [8].

Investigations

Plain radiography: Weight-bearing radiographs can help identify patients aged 40 years and older in whom MRI is unlikely to be helpful for evaluating knee pain [51]. In osteochondritis dissecans of the capitellum, loose bodies are often missed on standard X-rays [43]. For ambulant children with cerebral palsy, EOS® standing full-leg radiographs use lower radiation doses and contain more radiographic information than other images for measuring migration percentage [54].

MRI: Advanced imaging such as MRI is invaluable for identifying infectious spondylitis, assessing its extent, and guiding treatment [7]. MRI scans allow detailed characterization of expected findings and assist in therapy planning [11]. However, diagnosis should not be based on a single MRI section or a single sign [4]. Advanced imaging should not replace the history and physical examination [5]. In workers' compensation patients, MRI may not be the standard for accurate diagnosis and can misdirect care [32]. For early-stage sacral stress fractures, MRI is not always definitive, and repeat imaging may be necessary [41]. MRI is valuable in the early detection and diagnosis of acute multiple ligament knee injuries, but its accuracy in classifying these injuries is limited [58]. Extension MR scans could provide a more accurate diagnosis of cervical spondylotic myelopathy than other images [46]. Higher accuracy in diagnosing scapholunate ligament injury may be achieved with more sophisticated MRI techniques in the future [50]. Selective magnetic resonance imaging does not provide enhanced diagnostic utility over clinical examination, particularly in children, and should be used judiciously only where clinical diagnosis is uncertain and MRI input will alter the treatment plan [60]. The negative results of MRI should not prevent diagnostic arthroscopy when grading knee chondral defects [53].

Ultrasound: Ultrasonography is an inexpensive and easily available examination modality compared to MRI for old quadriceps tendon ruptures [45]. Ultrasound imaging and MRI provide variable diagnostic accuracy for lateral elbow tendinopathy depending on the entities reported and should be recommended with caution when differential diagnosis is necessary [62].

Bone scan: Thallium-201 scanning should be used in conjunction with other imaging modalities for the diagnosis, treatment planning, and follow-up evaluation of osteosarcoma and soft-tissue sarcoma [42].

Other Considerations: The Hook Test for distal biceps tendon avulsion has specificity and sensitivity of 100%, allowing diagnosis with accuracy and confidence independent of MRI findings [9]. In-office diagnostic imaging can provide a more detailed and accurate diagnostic assessment of intra-articular knee pathology than MRI [55]. All available imaging modalities, including conventional imaging such as plain radiography, CT, MRI, and WBC scintigraphy, have limited accuracy and should not be used as standalone tests to identify osteomyelitis in periprosthetic joint infection [48].

Treatment

Non-Operative

Conservative management is the primary approach for several conditions, though outcomes vary by pathology. First-line treatment for lumbar facet cysts involves nonsurgical management, although this is associated with a high rate of recurrence and relatively low satisfaction [94]. For lateral epicondylitis, initial management ranges from simple analgesia and conservative therapies to surgical intervention only for refractory cases [99]. In professional baseball pitchers with ulnar collateral ligament injuries, tear location must be considered when deciding between operative and nonoperative management [97]. Acute fractures of medial and lateral great toe sesamoids in athletes have been shown to heal uneventfully after non-surgical treatment [98]. Nonoperative treatment is recommended for anterior horn meniscal tears noted on MRI among patients without mechanical symptoms and whose clinical examination is inconsistent with a pathologic meniscal condition [83]. For Achilles tendinopathy, neovascularization at baseline did not predict clinical outcome after conservative treatment [75]. In pediatric and young adult populations with thoracic outlet syndrome, few patients were successfully managed with nonoperative activity modification and physical therapy [84].

Operative

Indications: Surgery is indicated when nonoperative measures fail or when specific structural pathologies are present. Bilateral subluxating popliteus tendons can be successfully treated with surgical stabilization if nonoperative treatment fails [61]. Operative options for osteochondritis dissecans of the elbow trochlea in adolescents are available with excellent results if non-operative management fails [85]. Management of osteochondritis dissecans of the elbow depends on lesion stability, with surgical intervention reserved for unstable or symptomatic cases [93]. Surgery is strongly recommended for severe carpal tunnel syndrome, while moderate and mild cases are initially treated conservatively [100]. Early diagnosis, appropriate antimicrobial therapy, and surgical intervention when necessary are crucial for improving patient outcomes in spondylodiscitis [18]. Classification of distal biceps tendon tears may have implications for operative and non-operative management [19]. Appropriate patient selection and indications for treatment are essential to achieving excellent outcomes after surgical intervention for articular cartilage lesions [16].

Surgical Approach / Technique: Treatment for Kienböck’s disease is stage-dependent, ranging from nonoperative management in early stages to revascularization, unloading procedures, or arthrodesis in advanced stages [87]. Endoscopic treatment of ischiofemoral impingement was effective at two years in patients with consistent clinical and imaging diagnostic findings [77].

Adjuncts: Machine learning-based prediction models may enhance the success rate of fracture treatments by improving the accuracy of treatment decisions [57].

Complications

Other Considerations: Clinical findings for meniscal mucoid degeneration are insidious, and lack of trauma history may delay diagnosis [2]. Patients with a history of ulnar nerve lesions are at a significantly increased risk of developing carpal tunnel syndrome, especially within the first 2 years [119]. The clinical significance of bone bruises detected by MRI following lateral ankle sprains in the long term remains to be determined [20]. A 90-day follow-up after management of an open long-bone fracture is inadequate for postoperative surveillance, especially for research purposes [21]. No recommendations can be made for the long-term effectiveness of biophysical agents for carpal tunnel syndrome due to low-quality primary studies with short follow-ups [23].

Long-term follow-up is essential to confirm whether repair tissue has the durability required to maintain long-term patient quality of life after matrix-induced autologous chondrocyte implantation [12]. Long-term results after autologous osteochondral transplantation reflect an impairment in clinical scores in the first 2 years, with stable conditions observed between 2 and 7 years after surgery [13]. The pathological features of pre-existing changes may not substantially impact long-term functional recovery after Achilles tendon rupture repair [14]. Long-term results are required to assess the survivorship of the Discovery Elbow System [15]. Longer-term follow-up studies are necessary to fully assess surgical management of osteochondritis dissecans of the capitellum [22]. Further prospective investigation is warranted to better describe long-term outcomes using radial plate fixation for distal radius fractures [92]. There is no evidence-based time interval that divides acute from chronic periprosthetic joint infection, as the natural history of infection is a continuum from initiation to chronicity [25].

Recovery

Light activity (weeks): Evidence does not provide specific week ranges for light activity or desk work return across the included studies. However, a 90-day follow-up after management of an open long-bone fracture is inadequate for postoperative surveillance, especially for research purposes [21].

Full activity (months): Autologous osteochondral transplantation (OCT) in the knee results in impaired clinical scores during the first 2 years [13]. Stable conditions are observed between 2 and 7 years after autologous osteochondral transplantation (OCT) in the knee [13].

Complete recovery / outcome plateau (months): Long-term follow-up is essential to confirm if repair tissue durability maintains long-term patient quality of life after matrix-induced autologous chondrocyte implantation [12]. Long-term results are required to assess the survivorship of the Discovery Elbow System [15]. Longer-term follow-up studies are necessary to fully assess surgical management of osteochondritis dissecans of the capitellum [22]. The long-term outcome of ethanol sclerotherapy for a ulnar artery aneurysm in a 6-month-old is unknown [122]. The short follow-up of patients treated with ethanol sclerotherapy for symptomatic musculoskeletal hemangiomas requires additional long-term studies to assess the duration of results [124].

Rehabilitation protocol: No specific rehabilitation protocols, immobilisation durations, or weight-bearing progressions are detailed in the provided evidence base.

Functional milestones: Improvements in MRI scores after platelet-rich plasma injection for lateral epicondylitis followed and continued longer than improvements assessed by clinical scores [90]. Both physiotherapist-led and standard assessments resulted in significantly higher health-related quality of life at the 12-month follow-up for patients with suspected knee osteoarthritis in primary care [103]. Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior patient-reported outcomes (PRO) or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up after high tibial osteotomy [127].

Other Considerations: Muscle imaging aids in recognizing atypical clinical presentations of Pompe disease [1]. Muscle imaging helps in understanding the natural history of Pompe disease [1]. Muscle imaging helps determine which patients with Pompe disease are suited for treatment [1]. Clinical findings in meniscal mucoid degeneration are insidious compared to traumatic tears [2]. Lack of trauma history may delay the diagnosis of meniscal mucoid degeneration [2]. Pre-existing pathological features may not substantially impact long-term functional recovery after Achilles tendon rupture repair [14]. The clinical significance of bone bruises detected by MRI following lateral ankle sprains in the long term remains to be determined [20]. No recommendations can be made for the long-term effectiveness of biophysical agents in treating carpal tunnel syndrome due to low-quality primary studies, unclear or high risk of bias, small sample sizes, and short follow-ups [23]. MRI scans are not a reliable tool for predicting symptomatic acromioclavicular arthritis [24]. Surgical decision-making for acromioclavicular arthritis should rely on focused history and clinical examination rather than MRI scans [24]. There is no evidence-based time interval that divides acute from chronic periprosthetic joint infection (PJI) [25]. The natural history of periprosthetic joint infection (PJI) is a continuum from initiation to chronicity [25]. Clinicians should always correlate MRI findings with patients' medical history and clinical presentation for lumbo-sacral nerve root compromise [26]. The decision-making process for shoulder surgery depends on the underlying pathology and patient history [27]. Patients with osteochondritis dissecans of the capitellum must be counseled appropriately [22]. Osteoid osteoma (OO) of the ankle joint exhibits a progressive course and is difficult to diagnose at an early stage [123]. Patients with a shorter diagnosis time (less than 3 months) and more joint involvement (more than 4 active joints) showed significantly better improvement in sacroiliac joint lesions after treatment for enthesitis-related arthritis [125]. The decline in clinical outcome for distal radial fractures starts at 5 degrees of dorsal tilt [126]. There is unlikely to be a noticeable difference in capability as measured with the QuickDASH until 20 degrees of dorsal tilt in distal radial fractures [126].

Key Evidence

• [L5] Muscle imaging can help for recognition of atypical clinical presentations, for understanding the natural history of the disease, and for determining patients suited for treatment. (10.1186/1471-2474-14-s2-o2)
• [L4] Clinical findings are insidious compared to traumatic tears, and lack of trauma history may delay diagnosis. (10.1007/s00167-003-0412-5)
• [L4] Standardized diagnostic protocols are warranted to further optimize diagnostic accuracy. (10.1186/s13018-021-02460-z)
• [L4] Diagnosis should not be based on a single MRI section or a single sign. (10.1007/s00167-014-3468-5)
• [L5] Advanced imaging, such as MRI, can then be used as necessary but should not replace the history and physical examination. (10.5435/jaaos-d-15-00464)
• [L5] A combination of clinical, serologic, and radiographic tests are undertaken to arrive at a diagnosis, as no single test is diagnostic for most immune-mediated disorders. (10.1016/j.jhsa.2011.01.036)
• [L5] Imaging techniques, especially MRI, are invaluable tools for clinicians in identifying this condition, assessing its extent, and guiding treatment. (10.1186/s13018-025-05781-5)
• [L5] A sufficient basic diagnosis including a detailed medical history and, if necessary, urodynamic evaluation is crucial. (10.1007/s00120-014-3718-7)
• [L2] Its specificity and sensitivity are very high (both 100%), allowing diagnosis with accuracy and confidence independent of MRI findings. (10.1177/0363546507305016)
• [L3] It should be used only in a small subset of patients, and clinicians must recognize potential disadvantages such as non-diagnostic or indeterminate results. (10.2106/00004623-199605000-00002)
• [L3] However, MRI scans do allow a more detailed characterization of the expected findings and can therefore be helpful in therapy planning. (10.1007/s00167-009-0835-8)
• [L4] Long-term follow-up is essential to confirm whether the repair tissue has the durability required to maintain long-term patient quality of life. (10.1177/0363546510390476)
• [L4] Long-term results reflect an impairment in clinical scores in the first 2 years with good results during follow-up, and stable conditions were observed between 2 and 7 years after surgery. (10.1007/s00167-014-2834-7)
• [L3] The pathological features may not substantially impact long-term functional recovery. (10.1302/0301-620x.107b10.bjj-2024-1662.r1)
• [L4] Long-term results are required to assess the survivorship of this system. (10.1016/j.jse.2014.08.013)
• [L5] Outcomes are intimately associated with appropriate patient selection and indications for treatment; therefore, understanding the initial evaluation and conservative treatment of cartilage defects is essential to achieving excellent outcomes after surgical intervention, regardless of the chosen procedure. (10.5435/jaaos-d-14-00241)
• [L1] An MRI is justified at three months, one year, two years and five years after surgery, unless the clinical symptomatology and individual patient needs dictate otherwise. (10.1007/s00167-020-06339-0)
• [L4] Early diagnosis, appropriate antimicrobial therapy, and surgical intervention when necessary are crucial for improving patient outcomes. (10.1186/s12891-025-08748-z)
• [L3] Classification of tears may have implications for operative and non-operative management. (10.5397/cise.2023.00458)
• [L4] Their clinical significance in the long term remains to be determined. (10.1007/s001670050036)
• [L3] Follow-up of 90 days after the management of an open long-bone fracture is inadequate for postoperative surveillance, especially for research purposes. (10.1097/corr.0000000000001911)
• [L5] Longer-term follow-up studies are necessary to fully assess surgical management, and patients must be counseled appropriately. (10.5435/00124635-201009000-00007)
• [L1] The findings were based on low-quality primary studies with unclear or high risk of bias, small sample sizes, and short follow-ups, so no recommendations can be made for the long-term effectiveness of any biophysical agents. (10.1186/s12891-023-06778-z)
• [L3] Surgical decision-making should rely on focused history and clinical examination rather than MRI scans. (10.1177/1758573217724080)
• [L5] There is no evidence-based time interval that divides acute from chronic periprosthetic joint infection (PJI); the natural history of infection is a continuum from initiation to chronicity. (10.1016/j.arth.2018.09.069)
• [L1] Therefore, clinicians should always correlate the findings of MRI with the patients' medical history and clinical presentation in clinical decision making. (10.1186/s12891-016-1236-z)
• [L4] The decision-making process for shoulder surgery depends on the underlying pathology and patient history. (10.1186/s12891-022-05541-0)
• [L5] Knowledge of the characteristic clinical presentation and physical examination findings of neurologic, musculoskeletal, vascular, and other etiologies can help distinguish the source of upper extremity pain quickly to facilitate appropriate diagnostic measures and treatment. (10.5435/jaaos-d-11-00086)
• [Case_report] Therefore, it should be always included in differential diagnosis, even if age and sex distribution or location is unusual. (10.1007/s00167-005-0653-6)
• [Case_report] Early onward referral for further investigation and management is recommended to confirm diagnosis, alleviate patient concerns and symptoms, and improve function. (10.1177/1758573214522019)
• [L2] Combining physical diagnostic tests increases the diagnostic accuracy. (10.1007/s00167-009-0803-3)
• [L3] Magnetic resonance imaging scans may not be the standard for accurate diagnosis and can misdirect care. (10.1016/j.jhsa.2011.12.008)
• [L1] Detection of MSK manifestations may enable earlier diagnosis and administration of effective treatments before disease progression occurs. (10.1186/s12891-023-06853-5)
• [L4] Prompt recognition leads to earlier diagnosis, appropriate treatment, less joint destruction, and better outcomes. (10.1007/s00167-009-0752-x)
• [L4] Clinical and radiological findings must be backed up by histopathological examination for true diagnosis. (10.1007/s00167-002-0339-2)
• [L3] There is no perfect clinical diagnostic test, with the 6 clinical diagnostic tests having differing sensitivities and specificities. (10.1177/1558944719833709)
• [L2] Presentation factors that increase the likelihood of a diagnostic X-ray included pain for longer than 6 months, the presence of medial or diffuse pain, and mechanical symptoms. (10.1007/s00167-014-3003-8)
• [L5] This is the first scientific study where expert clinicians recommended diagnostic tests when assessing patients with undifferentiated wrist complaints, varying in age of the patient, location, and duration of complaints. (10.1016/j.jht.2023.12.002)
• [L2] By using this test in the context of a thorough clinical history and physical examination, lesions of the superior labrum can be more reliably diagnosed. (10.1177/0363546504273050)
• [L4] The results highlight the current state of European diagnostic practice, emphasizing the areas of divergence from state of evidence and demonstrating the need for development of standard diagnostic algorithms. (10.1007/s00167-016-4303-y)
• [L4] Repeat imaging may be necessary as MRI is not always definitive for early stage injuries. (10.1177/0363546506296519)
• [L4] It should be used in conjunction with other imaging modalities for diagnosis, treatment planning, and follow-up evaluation. (10.2106/00004623-199304000-00008)
• [L4] Loose bodies are often missed, especially on standard X-rays and MRIs. (10.1177/1758573218756866)
• [L5] A good classification system serves as a common language to define the severity of a condition, guide treatment, and facilitate clinical research. (10.5435/jaaos-d-15-00034)
• [L2] It is furthermore an inexpensive and easily available examination modality, compared to MRI. (10.1007/s00167-004-0576-7)
• [L3] In particular, extension MR scans could provide a more accurate diagnosis than other images. (10.1186/s12891-022-06097-9)
• [L1] Both the Visotsky-Seebauer classification system and the Hamada classification system possess sufficient reliability to be used in everyday practice as well as for scientific purposes. (10.1016/j.jse.2011.01.012)
• [L3] All available imaging modalities, including conventional imaging such as plain radiography, CT, MRI, and WBC scintigraphy, have limited accuracy and should not be used as standalone tests to identify osteomyelitis. (10.1016/j.arth.2025.10.083)
• [L5] Further research is needed to obtain universally accepted diagnostic criteria to consistently improve outcomes. (10.1016/j.jhsa.2012.07.041)
• [L3] In the future higher accuracy may be achieved with more sophisticated MRI techniques. (10.1054/jhsb.2000.0450)
• [L3] Weight-bearing radiographs can help identify those patients in whom MRI is unlikely to be helpful. (10.5435/jaaos-d-15-00681)
• [L1] The negative results of MRI should not prevent a diagnostic arthroscopy. (10.1016/j.arthro.2012.04.138)
• [L3] These images use lower radiation doses and contain more radiographic information. (10.1186/s12891-019-2746-2)
• [L2] In-office diagnostic imaging can provide a more detailed and accurate diagnostic assessment of intra-articular knee pathology than MRI. (10.1016/j.arthro.2018.03.010)
• [L4] The Rockwood classification is commonly used in Japan to assess severity, but there is some disagreement regarding the assessment for the diagnosis of type IV. (10.1016/j.jseint.2019.11.006)
• [L4] By improving the accuracy of treatment decisions, this model may enhance the success rate of fracture treatments, guiding clinical decisions and improving efficiency in clinical settings. (10.1186/s13018-025-05830-z)
• [L3] MRI is valuable in early detection and diagnosis of acute MLKIs, however, the accuracy of MRI in classifying MLKIs is limited. (10.1186/s12891-021-04976-1)
• [L3] Consequently, it has the potential to be integrated into future osteoporosis classification systems. (10.1186/s12891-025-09431-z)
• [L3] Selective magnetic resonance imaging does not provide enhanced diagnostic utility over clinical examination, particularly in children, and should be used judiciously in cases where the clinical diagnosis is uncertain and magnetic resonance imaging input will alter the treatment plan. (10.1177/03635465010290030601)
• [L4] If nonoperative treatment fails, this condition can be successfully treated with surgical stabilization. (10.1177/03635465990270031901)
• [L1] USI and MRI provide variable diagnostic accuracy depending on the entities reported and should be recommended with caution when differential diagnosis is necessary. (10.1016/j.jht.2021.02.002)
• [L4] Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair. (10.1007/s00167-014-3486-3)
• [L3] SPECT-CT can benefit clinicians by predicting the treatment response from conservative management. (10.1186/s12891-015-0628-9)
• [L4] The Pipkin classification system is not comprehensive and lacks interobserver and intraobserver reliability, limiting its utility as a guide for operative intervention. (10.1007/s11999.0000000000000045)
• [L5] Diskography remains a second-line diagnostic modality in select patients with recalcitrant back pain to clarify surgical indications, despite its controversial validity and inconsistent postdiskography surgical outcomes. (10.5435/00124635-200601000-00008)
• [L2] As the committee continues to adjust these guidelines, they should encourage future studies with sound clinical design, patient selection, and testing procedures. (10.1016/j.arth.2019.06.044)
• [L3] The application of TCD and EEG can be considered in the early diagnosis, curative effect, and prognosis evaluation of VBI patients to improve diagnostic accuracy. (10.1186/s13018-020-01915-z)
• [L1] There is a need for consensus on well-defined, unambiguous radiological criteria to define lumbar spinal stenosis in order to improve diagnostic accuracy and to formulate reliable inclusion criteria for clinical studies. (10.1186/1471-2474-12-175)
• [L1] Case series published to date have demonstrated significant improvements in functional outcomes and low rates of major complications, with evidence surrounding several potential indications beyond osteochondritis dissecans. (10.1016/j.arthro.2021.01.047)
• [L3] The acromial morphology classification system is an unreliable method to assess the acromion, and the acromial index shows no association with the presence of rotator cuff disease. (10.1016/j.jse.2011.09.028)
• [L4] There is no general recommendation for the utilization of the MEPS-G as outcome measurement for patients with elbow pathologies. (10.1186/s13018-022-03210-5)
• [L5] Each available test has advantages and disadvantages and should be used in conjunction with the overall clinical picture to guide further evaluation and treatment. (10.1186/s42836-023-00199-y)
• [L4] The new classification system could help surgeons estimate potential difficulties during total hip arthroplasty. (10.1186/s12891-020-03678-4)
• [L2] Neovascularization at baseline did not predict clinical outcome after conservative treatment. (10.1177/0363546507303116)
• [L4] The model has shown great potential in assisting clinicians with the accurate diagnosis and classification of hip fractures. (10.1302/0301-620x.107b2.bjj-2024-0791.r1)
• [L4] The endoscopic treatment of IFI was effective at 2 years in 5 patients with consistent clinical and imaging diagnostic findings. (10.1016/j.arthro.2014.07.031)
• [L4] However, the reproducibility of our classification and its reliability for guiding the clinician to appropriate treatment and prognostic judgment must be further confirmed and perfected in the clinical setting. (10.1186/s13018-016-0455-1)
• [L3] Although the effectiveness of diagnosing stage 1 COCD is satisfactory, US is a helpful tool for detecting stage 2 and higher-stage COCD. (10.1016/j.jse.2018.07.018)
• [L4] The proposed PARMa classification system based on 2D/3D CT imaging demonstrated good intraobserver and interobserver reliability. (10.1016/j.jseint.2024.09.031)
• [L3] It cannot be used in the presence of metallosis and is currently not recommended as a single test to rule out infection. (10.1016/j.arth.2016.05.033)
• [L2] Instead, a positive (++) result is more appropriate as a secondary confirmatory rule-in test due to high specificity. (10.1016/j.arth.2018.03.005)
• [L4] We recommend nonoperative treatment of anterior horn tears noted on MRI among patients without mechanical symptoms and whose clinical examination is inconsistent with the presence of a pathologic meniscal condition. (10.1177/03635465020300020701)
• [L4] Few patients were successfully managed with nonoperative activity modification and physical therapy. (10.1016/j.jhsa.2023.12.013)
• [L4] However, if non-operative management fails, operative options are available with excellent results reported. (10.1177/17585732221079585)
• [L4] Gripping does not change ulnohumeral joint space width or medial elbow tissue stiffness in the joint testing configuration and external loading conditions applied in this study. (10.1186/s12891-025-08343-2)
• [L5] Treatment is stage-dependent, ranging from nonoperative management in early stages to revascularization, unloading procedures, or arthrodesis in advanced stages. (10.5435/00124635-200103000-00006)
• [L4] The formation of clusters based on glenoid morphology indicates that patterns exist in the types of glenoid defects, highlighting a need to further investigate a three-dimensional classification system and potentially new standardized revision implant component designs. (10.1016/j.jse.2026.04.002)
• [L2] The finding can be useful in the clinical setting in predicting potential non-copers to conservative therapy and aid in the individualization of the reconstructive procedures of patients. (10.1007/s00167-016-4157-3)
• [L4] Improvements in the MRI scores followed and continued longer than improvements assessed by the clinical scores. (10.1016/j.jse.2022.01.147)
• [L5] The proposed six-location classification of bone marrow lesions is highly reproducible and can help researchers develop studies and share information in a more accurate and reliable way. (10.1007/s00167-020-05957-y)
• [L4] Further prospective investigation is warranted to better describe long-term outcomes using this technique. (10.1177/1558944716669136)
• [L5] Management depends on lesion stability, with nonsurgical treatment for stable lesions and surgical intervention for unstable or symptomatic cases. (10.5435/jaaos-d-25-00181)
• [L4] First-line treatment is nonsurgical management, though it is associated with a high rate of recurrence and relatively low satisfaction. (10.5435/jaaos-d-14-00461)
• [L4] The elbow joint angle of 60° flexion was the most reliable for JPS testing, providing insight for JPS assessment in clinical practice. (10.1016/j.jht.2023.08.015)
• [L5] Elbow valgus torque is poorly suited as a standalone metric for predicting injury risk due to narrow data ranges, modeling noise, and crude assumptions; future efforts should focus on integrated, longitudinal metrics rather than single-session proxies. (10.1002/arj.70098)
• [L3] Thus, tear location should be considered when deciding between operative and nonoperative management. (10.1177/0363546517699832)
• [L4] The fractures healed uneventfully after non-surgical treatment. (10.1007/s00167-003-0472-6)
• [L5] Management ranges from simple analgesia and conservative therapies to surgical intervention for refractory cases. (10.1302/0301-620x.95b9.29285)
• [L3] Surgery is strongly recommended for severe CTS, while moderate and mild cases are initially treated conservatively. (10.1177/1753193408087119)
• [L5] Elbow valgus torque increases contact pressure in the radiocapitellar joint. (10.1177/0363546513490652)
• [L1] Both assessments resulted in significantly higher health-related quality of life at the 12-month follow-up. (10.1186/s12891-019-2690-1)
• [L2] Pitchers with increased dynamic elbow laxity were found to experience reduced medial elbow torque while pitching. (10.1016/j.arthro.2020.12.208)
• [L4] 4D CT is a promising diagnostic tool in the management of dynamic elbow disorders and may be considered in clinical practice. (10.1016/j.jseint.2021.09.013)
• [L4] In patients treated with surgery, it is crucial to make sure full resolution of the snapping by examining all dislocating structures during passive elbow motion and/or myoelectrical stimulation to achieve excellent results. (10.1016/j.xrrt.2025.08.017)
• [L4] Joint congruence of healthy elbows on MRI increased significantly when changing from supination to pronation. (10.1177/03635465251330152)
• [L5] With elbow flexion, the ulnar nerve did not move appreciably in the distal–proximal direction directly at the cubital tunnel, but maximal excursion was in the fatty region proximal to the elbow. (10.1016/j.jhsa.2012.03.016)
• [L4] This method provides a convenient and precise tool in assessment of arm motion. (10.1186/s12891-016-0957-3)
• [L5] Pitching 100 balls induces a significant reduction in dynamic stabilizing ability against elbow valgus laxity. (10.1016/j.jse.2023.11.001)
• [L4] The current results demonstrated the possibility of using the electromagnetic system to provide an accurate evaluation of the elbow joint in clinical settings. (10.1186/s13018-022-02961-5)
• [L5] Physical examination of the elbow is a critical component in formulating an accurate diagnosis. (10.5435/jaaos-d-16-00622)
• [L4] Preoperative dynamic electromyography findings in the biceps brachii appeared to predict incapacitated force production and may have promise for guiding more targeted surgical procedures to other elbow flexors. (10.1177/17531934251323078)
• [L4] The ulnar nerve moves medially and is flattened with the elbow flexed between 90 and 120 degrees. (10.1016/j.jse.2014.01.039)
• [L4] This important parameter of elbow function can therefore be obtained outside a normal clinic visit, thereby improving frequency of follow up assessments (and minimizing loss to follow up) necessary for quality control and research. (10.1016/j.jse.2018.11.007)
• [L2] Patients with a history of ulnar nerve lesions are at a significantly increased risk of developing carpal tunnel syndrome, especially within the first 2 years. (10.1016/j.jhsg.2026.100970)
• [Case_report] Although the early result was good, the long-term outcome of this approach is unknown. (10.1177/1558944717695748)
• [Case_report] OO of the ankle joint exhibits a progressive course and is difficult to diagnose at an early stage. (10.1186/s12891-017-1413-8)
• [L4] However, the short followup of our patients requires additional long-term studies to assess the duration of the results. (10.1007/s11999-009-0919-2)
• [L3] Patients with a shorter diagnosis time (less than 3 months) and more joint involvement (more than 4 active joints) showed significantly better improvement in sacroiliac joint lesions after treatment. (10.1186/s12891-022-06028-8)
• [L2] The decline in clinical outcome starts at 5 degrees, but there is unlikely to be a noticeable difference in capability as measured with the QuickDASH until 20 degrees of dorsal tilt. (10.2106/jbjs.22.01096)
• [L4] Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. (10.1016/j.jisako.2022.03.003)

See Also

• Patient Outcomes
• Surgical Procedures
• Ligament Injuries

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[86] An ultrasound and shear wave elastography study: effect of grip on medial elbow joint morphology during valgus stress. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08343-2

[87] Kienböck’s Disease: Diagnosis and Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2001. DOI: 10.5435/00124635-200103000-00006

[88] Three-Dimensional Characterization of Glenoid Defects in Failed Shoulder Arthroplasties. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.04.002

[89] Increased lateral tibial slope predicts high-grade rotatory knee laxity pre-operatively in ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4157-3

[90] Repeated magnetic resonance imaging at 6 follow-up visits over a 2-year period after platelet-rich plasma injection in patients with lateral epicondylitis. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.147

[91] Validation of a new topographic classification of bone marrow lesions in the knee: the six‐letter system. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-05957-y

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[94] Evaluation and Treatment of Lumbar Facet Cysts. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-14-00461

[95] Test-retest reliability of joint position sense in the elbow among healthy adults. Journal of Hand Therapy. 2024. DOI: 10.1016/j.jht.2023.08.015

[96] Editorial Commentary : The Limitations of Elbow Valgus Torque as an Injury Predictor. Arthroscopy. 2026. DOI: 10.1002/arj.70098

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[107] Joint Position and General Hypermobility Affect Elbow Joint Congruence on Magnetic Resonance Imaging: A Prospective Cohort Study. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251330152

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[109] Validity and reliability of arm abduction angle measured on smartphone: a cross-sectional study. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-0957-3

[111] Weakening and factors of medial elbow dynamic stabilizers against elbow valgus laxity after repetitive pitching in high school baseball players. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.11.001

[113] Accuracy and reliability of tridimensional electromagnetic sensor system for elbow ROM measurement. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-02961-5

[114] Comprehensive Review of the Elbow Physical Examination. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-16-00622

[116] The potential of preoperative dynamic electromyography in guiding targeted surgical procedures for elbow spasticity. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251323078

[117] Dynamic analysis of the ulnar nerve in the cubital tunnel using ultrasonography. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.01.039

[118] Smart phone “selfies”—a reliable and accurate tool for measuring elbow range of motion. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.11.007

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