Imaging of the painful shoulder in throwing athletes

A wide spectrum of abnormalities can affect the throwing shoulder. The injuries are often particular to a specific phase of the throw and are well demonstrated with MR imaging. In this article, the authors review the phases of the throw, MR imaging techniques, and the MR appearances of the injuries associated with particular phases.     

Imaging of the overhead throwing athlete

Knowledge of overhead throwing biomechanics is crucial to understand specific injuries encountered in throwing athletes on diagnostic imaging. Most specific injuries of overhead throwing athletes occur at the shoulder and elbow. Throwing athletes are susceptible to rotator cuff tears from tensile overload and external and internal impingement. The labrum is also commonly degenerated or torn secondary to overuse syndrome, internal impingement, and microtrauma. The elbow is typically injured secondary to excessive valgus forces during throwing. The ulnar collateral ligament, ulnar nerve, and common flexor tendon origin are all at increased risk of injury. Capitellar osteochondral injuries and loose intra-articular bodies are also frequent. Knowledge of injury pathophysiology is crucial to understanding the treatment rationale in throwing athletes.     

Muscle recruitment during plyometric exercises in overhead athletes with and without shoulder pain

ObjectivesTo investigate if there is a difference in muscle activity patterns during high load plyometric shoulder exercises between overhead athletes with and without shoulder pain.DesignControlled laboratory EMG study.SettingUniversity EMG Laboratory.ParticipantsSixty overhead athletes, 30 with shoulder pain and 30 healthy controls were included.Main outcome measuresThe EMG activity of Upper Trapezius (UT), Middle Trapezius (MT), Lower Trapezius (LT), Serratus Anterior (SA), Latissimus Dorsi (LD) and Pectoralis Major (PM) on the tested side and bilateral on Abdominal Obliques Externus (OE) muscles was registered with wireless surface EMG during 3 rotational plyometric shoulder exercises in 3 positions, prone, sidelying and standing.ResultsA significant higher muscle activity was found in the shoulder pain group for MT together with an overall significant higher activity in the thoraco-humeral and abdominal muscles compared to healthy controls.ConclusionsWhen rehabilitating the overhead athlete with shoulder pain, shoulder muscles together with both thoraco-humeral and abdominal muscles need to be engaged.     

Imaging of the elbow in the overhead throwing athlete

Elbow injuries in athletes who perform overhead throwing motions often present diagnostic challenges because of the undue stresses and often chronic, repetitive patterns of injury. Accurate and efficient assessment of the injured elbow is essential to maximize functional recovery and expedite return to play. Radiographic evaluation should be tailored to the specific injury suspected and requires a thorough understanding of normal anatomic relationships as well as familiarity with common injuries affecting these athletes.     

Avulsion fracture of the ulnar sublime tubercle in overhead throwing athletes

BACKGROUND: Injuries to the ulnar collateral ligament are relatively common in throwing athletes and result from either acute traumatic or repeated valgus stress to the elbow. Avulsion fracture of the sublime tubercle of the ulna is a rarely reported site of ulnar collateral ligament injury. PURPOSE: We retrospectively reviewed our cases of ulnar collateral ligament injuries to study avulsion fractures of the sublime tubercle of the ulna. STUDY DESIGN: Case series. METHODS: Data, including radiographs and magnetic resonance imaging scans, were obtained by review of hospital and office records and by follow-up examination. Of 33 consecutive patients treated for ulnar collateral ligament injuries, 8 had avulsion fractures of the sublime tubercle of the ulna. All eight were male baseball players with dominant arm involvement, an average age of 16.9 years, and an average follow-up of 23.6 months. RESULTS: Six of eight patients had failure of nonoperative treatment and required surgical repair. Two of the six underwent ulnar collateral ligament reconstruction and four had direct repair of the sublime tubercle avulsion with bioabsorbable suture anchors. At last follow-up, all eight had returned to their preinjury level of activity. No patient had residual medial elbow pain or laxity. CONCLUSIONS: Diagnosis of sublime tubercle avulsion fracture is made with history, physical examination, and radiographic studies. Magnetic resonance imaging can help identify an avulsion fracture not visible radiographically and can help determine whether direct repair or reconstruction is needed.     

Correlation between upper limb function and clinical measures of shoulder and trunk mobility and strength in overhead athletes with shoulder pain

ObjectiveTo investigate the correlation between functional performance and self-reported upper limb function and between these two functional measures and clinical measures of shoulder and trunk in overhead athletes with shoulder pain.DesignCross-sectional study.SettingsLaboratory.ParticipantsTwenty-one volleyball and handball athletes (23.6 ± 3.7 years) with shoulder pain in the dominant limb.Main outcome measuresSelf-reported dominant upper limb function using Penn Shoulder Score and Disabilities of the Arm, Shoulder, and Hand; shoulder and trunk range of motion; isometric strength of shoulder, periscapular, and trunk muscles; endurance time of trunk muscles; and functional upper limb performance using the Upper Quarter Y-Balance Test (UQYBT).ResultsA moderate correlation was observed (r = 0.45–0.58; p < 0.05) between UQYBT performance and strength of serratus anterior, lower trapezius, trunk rotators, and trunk flexors. No significant correlation was observed between UQYBT performance and the other clinical measures of shoulder and trunk (r = 0.01–0.39, p > 0.05). Self-reported upper limb function was neither significantly correlated with clinical measures (r = 0.01–0.40, p > 0.05) nor with UQYBT performance (r = 0.02–0.19, p > 0.05).ConclusionWe observed a correlation between UQYBT performance and strength of periscapular and trunk muscles.     

Scapular positioning in overhead athletes with and without shoulder pain: a case–control study

Abnormalities of scapular positioning are considered important risk factors for developing shoulder disorders. This study analyses the scapular positioning pattern in a group of overhead athletes with and without shoulder pain. In a multi‐center blinded case–control study, 36 shoulder pain athletes (19 men, 17 women), were compared with 36 unimpaired athletes free of shoulder pain, matched for gender, age, hand dominance and body mass index. The blinded assessor performed visual observation, the measurement of the distance between the acromion and the table, inclinometry and the kinetic medial rotation test for dynamic scapular control in random order. Athletes with shoulder pain demonstrate scapular asymmetry in the sagittal plane, observed visually as anterior tilting on the painful side. Athletes with shoulder pain show a lack of scapular motor control on their painful side in contrast to their pain‐free side. No scapular positioning or motor control differences were found in athletes with or without shoulder pain.     

Osteochondrosis dissecans of the shoulder glenoid fossa diagnosed in four throwing athletes

The aim of this study was to report 4 observations of osteochondrosis dissecans (OCD) of the shoulder glenoid fossa diagnosed in throwing athletes. A retrospective review of medical and radiological records of throwing athletes, performed for the period 1992 to 2002, revealed 215 studies of the shoulder. The patients were elite throwing athletes suffering for recurrent shoulder pain. Four cases (1.86%) of OCD of the glenoid fossa were identified; conventional radiographs of the shoulder were taken for all patients followed by MR examination. All cases received a definitive surgical diagnosis.     

Isokinetic performance at diagonal pattern and shoulder mobility in elite overhead athletes

The purpose of this study was to measure isokinetically glenohumeral joint movement peak torque and work in professional basketball, volleyball, handball and baseball players and determine whether significant differences exist between the dominant and non-dominant extremity in athletes and controls. Eighty healthy professional overhead athletes (basketball, volleyball, handball and baseball players) and 20 controls were tested bilaterally on a CYBEX 6000 isokinetic dynamometer at 60 degrees and 180 degrees s(-1) for diagonal pattern of the glenohumeral joint. A standardized protocol and testing guidelines were strictly followed. The range of motion of internal rotation (IR) on the dominant side of baseball players was significantly smaller than those on the dominant side of basketball, handball and volleyball players, and controls (P<0.01). Flexion/abduction/external rotation were consistently higher on the dominant arm (8.5%) for peak torque at 60 degrees s(-1) in baseball players, and bilateral ratios were lower on the dominant arm (14.8%) for peak torque at 180 degrees s(-1) in basketball players. The results of this study are important for the application and interpretation of isokinetic data and flexibility and mobility characteristics on unilaterally dominant overhead athletes. Functional weakness in external rotators, mobility impairments in IR and muscle imbalance have been shown in the dominant arm of these overhead athletes.     

Diagnosis and treatment of distal biceps and anterior elbow pain in throwing athletes

Despite the activity of the musculature around the elbow and the high angular velocity and stresses, distal biceps tendon injury is rare in the overhead athlete. The biomechanics of the throwing motion and electromyographic studies of the elbow provide useful clues as to why the biceps stays relatively healthy. Anterior elbow complaints are not uncommon in this population and can easily be mistaken for distal biceps pathology. In the event that a thrower does demonstrate biceps tendon pathology, it should be treated in a similar fashion to all other athletic individuals. It is more important to review the differential diagnosis for anterior elbow pain when an athlete has symptoms that might be attributed to the distal biceps tendon. Once the other possible causes of biceps-related pain have been evaluated, the sports medicine physician can then proceed with appropriate treatment to return that athlete to the playing field as quickly and safely as possible.     

Diagnostic evaluation of athletes with posttraumatic chronic shoulder pain

We examined 20 consecutively admitted athletes suffering from chronic shoulder pain for more than 6 months following a single shoulder trauma without dislocation. All had pain during loading, especially during over-the-head activities with a clicking sensation, and symptoms of dead arm were also present. On examination, 8 patients had decreased range of motion and 14 patients had a positive apprehension test. Three had signs of impingement. Diagnostic evaluation with special X-ray, ultrasonography, magnetic resonance imaging (MRI) and arthroscopy identified IS lateral tears, 3 partial and 1 total rotator cuff lesions and 2 patients with synovitis of the rotator cuff with subacromial impingement. Three patients had tendinitis of the biceps tendon and 1 had a lesion of the greater tubercle. In conclusion, chronic shoulder pain after a single nondislocated shoulder trauma in athletes should be evaluated due to a possible intraarticular cause of the pain. MRI seems to be the most valuable noninvasive method of evaluating patients with chronic shoulder pain and should be performed before arthroscopy and operative procedures.     

Pathomechanics of the throwing shoulder

Many anatomic, physiological, and biomechanical alterations have been observed in overhead athletes who present with painful shoulders. This is probably due to the complex kinetic chain mechanics required in the overhead throwing or serving motion. Any alteration along the kinetic chain can result in deficits in force production or increase in joint loads in other parts of the chain. The "disabled throwing shoulder" (DTS) is a general term that describes the limitations in function that exist in symptomatic overhead athletes. DTS typically results from a "cascade to injury" with alterations in the kinetic chain. Evaluation of athletes with the DTS should include examination of the local and distant anatomic injuries and screening for physiological (muscle inflexibilities, weakness, or imbalances) or biomechanical (motions, positions) alterations.     

Rehabilitation of the throwing shoulder

Rehabilitation of the injured throwing arm should not be directed simply toward beginning strengthening exercises and returning the athlete to throwing as soon as possible. The total comprehensive program has been described and consists of seven phases that begin with making the proper diagnosis of a shoulder injury. Once the proper diagnosis is made, the pathophysiology of throwing injuries has to be understood by the physician, the trainer, and the athlete, and then the actual treatment begins in phase III. Initial treatment many times consists of a short period of relative rest as well as physical therapy modalities to relieve pain, and once pain is relieved phase IV begins, which is the actual techniques of range of motion, flexibility, and strengthening maneuvers. Once adequate flexibility, range of motion, and pain-free motion have been achieved, as well as adequate endurance strength, proper warm-up techniques are begun, and then a return to throwing is achieved in phase VI. The total rehabilitative cycle is concluded with phase VII, which consists of an off-season conditioning program to verify that the athlete will maintain year-round maximum condition of not only the throwing shoulder but of the entire athlete.     

Association of arm pain with overhead throwing and upper extremity range of motion,strength, and throwing velocity in collegiate baseball players

Sport Sciences for Health - To investigate whether shoulder and elbow range of motion (ROM), upper extremity (UE) strength, and throwing velocity differ between collegiate baseball players with UE...     

Shoulder rotational properties of throwing athletes

Throwing arm injuries are common and often related to the shoulder external and internal rotation. Quantitative assessment may provide new insights to physical assessment and options for treatment. After having signed IRB approved consents and filled out injury questionnaires, 96 baseball pitchers were examined on both shoulders using a custom-made wireless device. The resistance onset angle (ROA), end-point angle (EPA), shoulder rotational flexibility (SRF) in both external and internal rotation, and rotational ranges of motion (ROM) of both shoulders were determined. About 34% of subjects had surgeries on their throwing arm. Another 15% of subjects had throwing arm injuries that did not require surgical treatments. The throwing arm had significantly lower internal ROA, EPA and SRF, but significantly higher external ROA, EPA and SRF than the non-throwing arm. There were significant differences in shoulder rotational properties among groups with different surgery locations. Subjects with shoulder surgeries had greater internal rotation flexibility of their throwing arm than those with surgeries on the elbow. Throwers with injury and surgery history had significantly different shoulder rotational properties. Abnormal shoulder rotational properties may be related to throwing arm injuries. A better understanding of their relationship may lead us to effective preventive measures of throwing arm injuries.     

Imaging findings in the dominant shoulder of throwing athletes: comparison of radiography, arthrography, CT arthrography, and MR arthrography with arthroscopic correlation

OBJECTIVE: Conventional radiography, arthrography, CT arthrography, and MR arthrography--including use of the abduction and external rotation position--were compared, with arthroscopic correlation, to determine the spectrum of abnormalities encountered and the relative benefits of each imaging method in the evaluation of shoulder lesions occurring in 17 throwing athletes. SUBJECTS AND METHODS: Each of 36 athletes with shoulder pain aggravated by abduction and external rotation was examined in a single visit during which conventional radiography, arthrography, CT arthrography, and MR arthrography were performed. In 17 of these athletes, imaging findings were compared with those at arthroscopy. All images were independently evaluated by two groups of musculoskeletal radiologists. RESULTS: Structures found to be affected were, in decreasing order of frequency, the following: the posterosuperior labrum, supraspinatus tendon, infraspinatus tendon, humeral head, glenoid cavity and rim, acromioclavicular joint, anteroinferior capsulolabral complex, biceps tendon, and subscapularis tendon. MR arthrography without and with abduction and external rotation yielded the highest sensitivity and specificity for all lesions with the exceptions of bone sclerosis and enthesophytes (which were best seen with CT arthrography). MR arthrography with abduction and external rotation was most accurate for diagnosis of rotator cuff and anteroinferior capsulolabral complex tears. CONCLUSION: On the basis of these preliminary results, we believe that MR arthrography with abduction and external rotation should be part of the imaging evaluation of shoulder pain in throwing athletes, owing to the high sensitivity of this imaging technique.