Prevalence and variance of shoulder injuries in elite collegiate football players

BACKGROUND: Shoulder injuries are the fourth most common musculoskeletal injury encountered in American football players. There is little information in the literature on the role of playing position in the type of shoulder injuries seen. HYPOTHESIS: There is a high prevalence of shoulder injuries in elite collegiate American football players, with type of injury varying by playing position. STUDY DESIGN: Cohort study (prevalence); Level of evidence, 3. METHODS: A total of 336 elite collegiate American football players were invited to the National Football League Combine for physical testing and medical evaluation. Current and historical data were evaluated for the purpose of this study, and all players underwent radiographic examinations, including plain radiographs and/or magnetic resonance imaging when necessary. All shoulder pathological conditions and shoulder surgical procedures were recorded. Players were categorized by position for the analysis of position-specific trends. RESULTS: Of the players, 50% had a history of shoulder injuries, with a total of 226 shoulder injuries (1.3 injuries per player injured); 56 players (34%) had a total of 73 surgeries. The most common injuries were acromioclavicular separation (41%), anterior instability (20%), rotator cuff injury (12%), clavicle fracture (4%), and posterior instability (4%). The most common surgeries performed were anterior instability reconstruction (48%), Mumford/Weaver-Dunn surgery (15%), posterior instability surgery (10%), and rotator cuff surgery (10%). Shoulder injuries were more common in quarterbacks and defensive backs. Surgery was more common in linebackers or linemen. A history of anterior instability was more common in defensive players, with surgery required 76% of the time. Linemen had more rotator cuff injuries and posterior instability than players in other positions. CONCLUSION: Shoulder injuries are common injuries in elite collegiate football players, with one-third undergoing surgical procedures. There are definitive trends in the types of injuries per player position.     

Repair of full-thickness rotator cuff tears in professional baseball players

BACKGROUND: Despite the relative frequency of partial-thickness rotator cuff tears seen in baseball players, full-thickness rotator cuff tears in baseball players are uncommon. HYPOTHESIS: Return to competitive baseball is difficult after surgical treatment of a full-thickness rotator cuff tear. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We evaluated the results of 16 professional baseball players after a mini-open repair of a full-thickness rotator cuff tear. Twelve patients were pitchers with injury to their dominant shoulders. Four patients were position players; 2 had injuries involving their dominant shoulders, and 2 had injuries to their nondominant shoulders. RESULTS: At a mean follow-up of 66.6 months for the pitchers, only 1 player (8%) was able to return to a high competitive level of baseball with no significant shoulder dysfunction after mini-open repair of a full-thickness rotator cuff tear. Of the 2 position players with mini-open repairs of the full-thickness rotator cuff tear of their dominant shoulders, 1 was able to return to professional baseball. Of the 2 position players with mini-open repairs of the full-thickness rotator cuff tear of their nondominant shoulders, both were able to return to professional baseball at the same or higher level. CONCLUSION: It is very difficult for a professional baseball pitcher to return to a competitive level of pitching after a full-thickness rotator cuff repair with a mini-open approach.     

MR imaging of the shoulder in youth baseball players: Anatomy,pathophysiology, and treatment

With an increasing participation in youth sports and a growing popularity of overhead sports, shoulder pain and injuries are common in pediatric baseball players. In contrast to traumatic and collision injuries, which are more frequent with high-impact sports, many of the shoulder injuries are the result of repetitive overuse. Undiagnosed and untreated injury to the growth plates of skeletally immature athletes can lead to remodeling, which can negatively impact the biomechanics of the shoulder and produce long-term morbidity. Recently, there is an increasing emphasis on the association between skeletal maturation and injury patterns. The increasing use of magnetic resonance (MR) imaging has led to a better characterization of the traditionally radiographically-diagnosed growth plate injuries and awareness of other soft tissue and cartilaginous injuries that were previously thought to predominately occur in adult baseball players. The goal of this review is to: 1) highlight the normal anatomic changes that occur in the shoulder girdle during development and maturation; 2) discuss the biomechanical forces that are applied to the shoulder during a pitch; and 3) highlight the various injury patterns and adaptive remodeling that can occur in the shoulders of youth baseball athletes along with the current treatment options. These topics include growth plate injury, osteochondral injury, labral tear, capsular remodeling and rotator cuff tendinopathy.     

The painful shoulder: MR imaging of the glenohumeral joint

We used magnetic resonance imaging in 41 patients with shoulder pain. Magnetic resonance was found useful in depicting the spectrum of rotator cuff abnormalities associated with mechanical impingement including both large and small rotator cuff tears as well as tendinitis. Abnormalities of the capsular mechanism, osseous tumors, osteonecrosis, and injuries to the supporting musculature are also well depicted.     

Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study

BACKGROUND: Although several studies have described magnetic resonance imaging findings in shoulders of asymptomatic volunteers, no such investigation has been performed on asymptomatic dominant and nondominant shoulders of elite overhead athletes. HYPOTHESIS: Asymptomatic dominant shoulders of elite overhead athletes may have a higher incidence of magnetic resonance imaging abnormalities than either their nondominant shoulder or shoulders of asymptomatic volunteers. STUDY DESIGN: Prospective cohort study. METHODS: Detailed magnetic resonance imaging scans of asymptomatic dominant and nondominant shoulders of elite overhead athletes were obtained. Three experienced musculoskeletal radiologists interpreted each scan for multiple variables, including rotator cuff appearance. Images from a surgical control group were intermixed to assess accuracy and control for observer bias. A 5-year follow-up interview was performed to determine whether magnetic resonance imaging abnormalities found in the initial stage of the study represented truly clinical false-positive findings or symptomatic shoulders in evolution. RESULTS: Eight of 20 (40%) dominant shoulders had findings consistent with partial- or full-thickness tears of the rotator cuff as compared with none (0%) of the nondominant shoulders. Five of 20 (25%) dominant shoulders had magnetic resonance imaging evidence of Bennett's lesions compared with none (0%) of the nondominant shoulders. None of the athletes interviewed 5 years later had any subjective symptoms or had required any evaluation or treatment for shoulder-related problems during the study period. CONCLUSIONS: Magnetic resonance imaging alone should not be used as a basis for operative intervention in this patient population.     

Delayed union of a scapular fracture-an unusual cause of persistent shoulder pain

INTRODUCTION: Scapular fractures in athletes are rare, although they have been reported in football and baseball players. Most scapular fractures heal with nonoperative management; delayed union is rarely a problem. CASE SUMMARY: A 15-yr-old male fell onto his posterior shoulder after he had been pushed into the boards and then fell to the ice during a hockey check. He was diagnosed with a rotator cuff injury at an outside facility. Initial radiographs were negative. The patient was not immobilized, and he continued to play hockey despite intermittent pain. Seven months later, he presented to our sports medicine clinic, complaining of an aching pain at the base of his left shoulder. Examination revealed point tenderness along the base of the scapula, restriction of shoulder abduction, rhomboid weakness, scapular winging, and anterior impingement-type shoulder pain. A new radiograph, obtained at our sports medicine clinic, was nondiagnostic. Magnetic resonance imaging revealed increased signal on T2, with bone edema at the lateral margin of the scapular neck. A computed tomography scan revealed an unhealed, left-transverse, subglenoid scapular fracture. The fracture was nondisplaced. The patient was treated with transcutaneous electrical stimulation for 6 months and a physical therapy regimen focusing on periscapular strengthening. A final computed tomography scan, 6 months after initial presentation to our clinic, revealed healing of the fracture. Examination was normal. The patient was asymptomatic and was able to fully return to sports without any complications. CONCLUSIONS: Although scapular fractures in athletes are rare, they may occur, particularly in "contact sports" that share the energies of injury seen in high-speed motor vehicle collisions. Early identification and proper management are integral to decrease symptoms and to avoid protracted disability, particularly in athletes.     

Acute quadriceps muscle strains: magnetic resonance imaging features and prognosis

BACKGROUND: There has been no research examining the magnetic resonance imaging findings, and in turn the prognosis, for a series of acute quadriceps muscle strains. HYPOTHESIS: The magnetic resonance imaging findings of acute quadriceps muscle strain injuries are helpful in predicting their prognosis. STUDY DESIGN: Causal-comparative study. METHOD: Forty professional players of Australian Rules football were followed over 3 years. Magnetic resonance imaging examinations were performed within 24 to 72 hours of muscle-strain injury. Imaging features of muscle strain injury included the anatomical location, size (cross-sectional area and length), and site (proximal, middle, or distal). The time from injury to return to full training was termed the rehabilitation interval. RESULTS: 25 clinical quadriceps muscle strain injuries occurred, with 15 cases involving the rectus femoris. The rectus femoris injuries could be further categorized into cases with straining about the central tendon (n = 7, mean rehabilitation interval = 26.9 days) or cases with straining in the periphery (n = 8, mean rehabilitation interval = 9.2 days). Six cases involved one of the vastus muscles (mean rehabilitation interval = 4.4 days). Three players had normal magnetic resonance imaging examinations (mean rehabilitation interval = 5.7 days). CONCLUSIONS: The rectus femoris-central tendon injury is the red flag diagnosis associated with a significantly longer rehabilitation interval. CLINICAL RELEVANCE: Magnetic resonance imaging is helpful in predicting the prognosis for acute quadriceps strains.     

A comparison between clinical assessment and magnetic resonance imaging of acute hamstring injuries

BACKGROUND: Physicians evaluating hamstring strains in professional football players are increasingly turning to magnetic resonance imaging to support the clinical diagnosis and management of the injury. However, little information is available to assess how magnetic resonance imaging compares with the clinical evaluation in establishing the duration of rehabilitation required. HYPOTHESIS: Magnetic resonance imaging of hamstring strains can be useful in determining duration of rehabilitation. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 1. METHODS: Fifty-eight professional football players with a diagnosis of hamstring injury made by the team physician were enrolled in the study. All players underwent magnetic resonance imaging and a clinical evaluation by an independent physical therapist within 3 days of the injury. Presence, type, and location of injury were recorded in each examination. The physical therapist estimated the time required until return to competition, and the radiologist used the length of the injury (coronal view) to establish rehabilitation duration. Both clinicians were blinded to the other modality. RESULTS: Clinical and magnetic resonance imaging assessments were in agreement in 38 of 58 cases (65.5%). In 18 cases (31.0%), a clinically positive diagnosis was made, but no abnormalities were evident on magnetic resonance imaging. In 2 cases (3.4%), magnetic resonance imaging detected an injury, whereas the clinical examination had negative or equivocal findings. Both clinical examination and magnetic resonance imaging findings were strongly correlated with the actual time required to return to competition (r = .69, P < .001 and r = .58, P < .001, respectively). The correlation coefficient between clinical predictions and magnetic resonance imaging findings was moderate (r = .36, P = .006). CONCLUSION: This study shows that magnetic resonance imaging is not required for estimating the duration of rehabilitation of an acute minor or moderate hamstring injury in professional football players.     

MRI of the athletic knee. Findings in asymptomatic professional basketball and collegiate football players

For the dedicated athlete in whom minor injuries are frequent and major injuries relatively common, a noninvasive knee assessment could either obviate the need for arthroscopy or focus its direction. The opportunity to study asymptomatic athletes was not feasible before the advent of magnetic resonance imaging (MRI). In this preliminary work, we examined 40 knees in 20 asymptomatic volunteer athletes, including five professional basketball players and 15 collegiate football players. Images were obtained at 0.5 T or 1.5 T. Spin echo sequences were used to obtain 5.0 mm thick coronal and sagittal sections. Fifty percent of asymptomatic athletes (10/20) had significant baseline MRI abnormalities that could have adversely affected scan interpretation in the context of an acute injury. Half of these athletes with MRI abnormalities, or 25% of the total (5/20), had no previous surgery and were unaware of significant injury.     

Stress injury of the proximal ulna in professional baseball players

BACKGROUND: To date, stress injury of the proximal ulna has been infrequently reported as a cause of elbow pain in the throwing athlete. PURPOSE: We describe a syndrome of osseous stress injury of the proximal ulna in the professional throwing athlete. STUDY DESIGN: Retrospective review. METHODS: We evaluated the clinical, radiographic, and magnetic resonance imaging findings of seven professional baseball players with osseous stress injury of the proximal ulna. RESULTS: Plain radiographs of the involved elbows failed to demonstrate any significant findings. All of the clinically significant lesions were detected with magnetic resonance imaging. In addition, magnetic resonance imaging was found to be of value in following the course of healing of the injuries. All of the lesions originated on the posteromedial aspect of the proximal ulna. The ulnar collateral ligament was intact in all seven athletes. One athlete had two occurrences of this injury. Six of the seven athletes returned to their previous level of play after a nonoperative course of treatment. CONCLUSIONS: We believe that this injury should be considered in the differential diagnosis of elbow pain in the throwing athlete. Magnetic resonance imaging is the diagnostic test of choice when this injury is suspected.     

Patellotibial contusions in anterior cruciate ligament tears

Bone contusions are an important ancillary finding of many knee injuries. Not only are they a source of pain, they may suggest a mechanism of injury or a specific derangement of the knee joint. We have encountered a small number of patients being evaluated for anterior cruciate ligament (ACL) tears with unexplained patellar and tibial edema at magnetic resonance (MR) imaging. We present three individuals with contusions of the inferior patella with a corresponding contusion of the anteromedial tibial plateau. Internal derangements in these patients were similar to other individuals with acute ACL tears, however osseous contusions were more widespread. In conclusion, patellotibial contusions are rare and may indicate an injury with forces greater than usually encountered in most ACL tears. A careful search for uncommon associated injuries is prudent in these high-energy knee injuries.     

Shoulder imaging in athletes

Shoulder pain and injuries are common in athletes. Overhead athletes, in particular, place great demands on the shoulder and supporting structures. Magnetic resonance (MR) imaging is well suited to evaluation of the osseous structures and soft tissues of the shoulder and plays an important role in evaluation of shoulder pain in athletes. Primary extrinsic impingement is well evaluated on MR imaging as are the less common posterior superior glenoid impingement and subcoracoid impingement. Rotator cuff tendinosis as well as partial- and full-thickness tears are frequently encountered in the athletic shoulder. The biceps tendon and rotator interval capsular structures are important sources of shoulder pain. Glenohumeral instability that results from a traumatic event or atraumatic multidirectional recurrent instability is assessed. The biceps labral complex is a source of considerable anatomic variability and pathology.     

Diagnostic and prognostic value of clinical findings in 83 athletes with posterior thigh injury: comparison of clinical findings with magnetic resonance imaging documentation of hamstring muscle strain

BACKGROUND: Little is known about the clinical features of posterior thigh injuries and their contribution to accurate diagnosis and prognostic assessment of hamstring muscle strain injury. HYPOTHESES: The clinical features of posterior thigh injury can be used to diagnose hamstring muscle strain and to predict duration of absence from competition. STUDY DESIGN: Prospective clinical study. METHODS: For two playing seasons, the clinical features of posterior thigh injury, timing of injury, and playing days lost were recorded for Australian Rules football players. Magnetic resonance imaging was used to confirm hamstring muscle injury. RESULTS: Posterior thigh injuries associated with pain and tenderness were recorded for 83 players, with magnetic resonance imaging confirming hamstring injury in 68 (82%). Most of the hamstring injuries were sudden onset (62; 91%) and occurred after a significant warm-up period (57; 84%). Of the patients whose injuries were sudden onset and occurred after the warm-up period (N = 59), 57 (97%) had hamstring muscle strain detected on magnetic resonance imaging. Hamstring muscle injury confirmed by magnetic resonance imaging was associated with a longer absence from competition (mean, 27 days) than injuries where no hamstring injury was detected (mean, 16 days). CONCLUSIONS: The clinical features of hamstring injury typically include sudden onset, pain, and tenderness, although exceptions do occur. Muscle fatigue may be important in the pathogenesis of hamstring injury.     

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.     

Magnetic resonance imaging of the shoulder

Magnetic resonance imaging is rapidly becoming the procedure of choice to evaluate the shoulder. This article reviews the relevant technical, anatomic, and pathologic features important in imaging the joint with magnetic resonance, with an emphasis on rotator cuff disease and shoulder instability.     

A descriptive epidemiological study of shoulder injury in top level English male volleyball players

The aims of this study were to estimate the prevalence and incidence of shoulder sports injuries, to discover the main shoulder injury, and to survey outcome of treatment or injuries in top level male volleyball athletes. Furthermore, the actions which most commonly cause injuries and the differences of physical characteristics between injured and healthy players were also investigated. Fifty-nine English Volleyball Federation division one athletes were recruited in the 1997/98 and 1998/99 seasons. All subjects completed two different questionnaires; a First recruitment and monthly Follow-up questionnaire throughout the period in question. Twenty-seven of the fifty-nine athletes had a history of shoulder sports injury, with a total of 29 injuries reported. The results of the First recruitment showed that overuse type injuries (19/29) were the main shoulder injuries. Cuff muscle tendinitis was predominant in these injuries (14/29). Furthermore, spiking was the major action during which a shoulder injury (23/29) first occurred. In the follow-up phase the incidences of shoulder chronic injury (or pain), re-injury, and new injury in these twenty-seven players were 3.0, 9.3 and 1.0 injuries/1,000 hours of exposure respectively. The mean duration of chronic injury or pain was 2.3 +/- 1.3 (+/- SD) months. The distribution of history of regular training, between injured and healthy subject groups, was significantly different (p = 0.008). This study has identified rotator cuff muscle/tendon injuries or involved lesions as the main shoulder injuries in top level English male volleyball athletes. These injuries result in prolonged shoulder pain symptoms.     

Evaluation and treatment of rotator cuff tears

Rotator cuff injuries are common problems and a frequent reason for patients to present to primary care physicians. These injuries are seen more frequently now with the aging population. These muscles allow for movement of the arm in overhead activities and controlled movements through space. A thorough physical examination can lead to the diagnosis of rotator cuff pathology. Radiographic imaging may offer some insight into the underlying pathology, and magnetic resonance imaging provides for excellent visualization of the rotator cuff. Many rotator cuff tears, especially partial tears, will symptomatically improve with conservative management. Surgical treatment may offer improved pain relief and function in those patients for whom nonoperative care is insufficient. In cases in which rotator cuff repair is not possible, the reverse total shoulder arthroplasty is a possibility. New technologies are also under investigation that allow for biological augmentation of rotator cuff tears.     

MR imaging of shoulder injuries in professional baseball players.

Magnetic resonance (MR) imaging was used to evaluate the shoulders of 10 symptomatic professional baseball players and one asymptomatic player, with surgical correlation in six cases and arthrographic correlation in two cases. Seven small rotator cuff tears measuring 0.5-1 cm were identified on MR images, with arthrographic and surgical confirmation of these findings in two patients and surgical confirmation only in three patients. Cortical irregularity and/or subchondral cyst formation at the posterior aspect of the greater tuberosity near the insertion site of the infraspinatus tendon was found in five of the seven players with rotator cuff tears. Similar findings were noted in the asymptomatic volunteer and in one of the three players without cuff tear, who also had irregular thickening of the posterior capsule. These findings are believed to represent chronic avulsive changes resulting from the deceleration stresses of the follow-through motion.     

Scapular Fracture in a High School Football Player

Scapular fractures are rare in brief athletes, but they have been reported in professional football players who play high-collision positions. This case report of a painful, nondisplaced scapular fracture in a 17-year-old high school offensive and defensive lineman shows that these fractures can happen even in amateur athletes. A scapular fracture may mimic a rotator cuff injury, as happened initially in this case. Conservative treatment is usually appropriate for these fractures unless there is severe displacement.