Shoulder and Elbow Injuries in Adult Overhead

Throwers: Imaging Review

Paola Kuenzer Goes, MD • Dyan V. Flores, MD • Alameen Damer, MD • Brady K. Huang, MD
Author affiliations, funding, and conflicts of interest are listed at the end of this article.

Overhead throwing, particularly in baseball, subjects the

shoulder and elbow to various unique injuries. Capsular
contracture following repetitive external rotation shifts
the humeral head posterosuperiorly, predisposing to
glenohumeral internal rotation deficit (GIRD), Bennett,
posterosuperior internal impingement (PSI), and
superior labrum anterior-posterior (SLAP) lesions. GIRD
represents loss of internal rotation at the expense of
external rotation. Bennett lesion represents ossification
of the posteroinferior glenohumeral ligament due to
repetitive traction. PSI manifests with humeral head
cysts and “kissing” tears of the posterosuperior cuff
and labrum. Scapular dysfunction contributes to
symptoms of PSI and predisposes to labral or rotator
cuff disease. “Peel-back” or SLAP lesions occur when
torsional forces detach the biceps-labral anchor from
the glenoid. Finally, disorders of the anterior capsule,
latissimus dorsi, teres major, and subscapularis are well
recognized in overhead throwers. At the elbow, injuries
typically involve the medial-sided structures. The ulnar
collateral ligament (UCL) is the primary static restraint
to valgus stress and can be thickened, attenuated, ossified,
and/or partially or completely torn. Medial epicondylitis
can occur with tendinosis, partial tear, or complete rupture
of the flexor-pronator mass and can accompany UCL tears
and ulnar neuropathy. Posteromedial impingement (PMI) and
valgus extension overload syndrome are related entities that
follow abundant valgus forces during late cocking or acceleration,
and deceleration. These valgus stresses wedge the olecranon into
the olecranon fossa, leading to PMI, osteophytes, and intra-articular
bodies. Other osseous manifestations include olecranon stress fracture
and cortical thickening of the humeral shaft.
©
RSNA, 2023 • radiographics.rsna.org

Introduction tion from the overhead pitching motion place the shoulder
Overhead throwing injuries are common with many sports, and elbow stabilizers at considerable risk for multiple unique
most frequently impacting the shoulder and elbow. A study injuries. In a study of North American professional baseball
of 112 collegiate athletes found shoulder injuries to be com- players from 2011 to 2016, 3090 injuries were recorded, with
mon with baseball (41 cases), swimming (24 cases), softball 511 (17%) of them affecting the shoulder, making it the most
(17 cases ), tennis (15 cases), and volleyball (15 cases) (1). vulnerable joint (3). Amongst player positions, the pitcher
Overhead motion during a volleyball spike, tennis serve, or was the most prone to injury, occurring in 78% of cases (3).
swimming stroke can predispose an individual to injury (1,2), In terms of elbow disorders, data from the Major League
although the baseball pitch is by far the most commonly used Baseball Health and Injury Tracking System (4) revealed 3185
model. The abundant forces and rapid shifts in joint posi- elbow injuries (430 in major league, 2755 in minor league)

MUSCULOSKELETAL IMAGING
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Arm cocking starts with foot strike and concludes with the
RadioGraphics 2023; 43(12):e230094
https://doi.org/10.1148/rg.230094 shoulder in maximal external rotation. While the proximal
Content Codes: CT, MK, MR muscles (upper trunk and pelvis) are rotating and extending,
Quiz questions Abbreviations: ABER = abduction and external the distal muscles are externally rotating and abducting (shoul-
for this article are rotation, FEVER = flexed elbow valgus external ro- der), or flexing (elbow) (5). Scapular elevation and upward ro-
available in the tation, GIRD = glenohumeral internal rotation defi-
supplemental cit, PSI = posterosuperior internal impingement,
tation help to ensure that there is sufficient subacromial space
material. SLAP = superior labrum anterior-posterior, UCL = to accommodate the 80°–100° of humeral abduction and thus
ulnar collateral ligament, UN = ulnar neuropathy avoid impingement (5). As the shoulder externally rotates the
arm, valgus forces of up to 64 N are produced at the elbow
TEACHING POINTS (8). This valgus load subjects the medial elbow structures, es-
„ Loss of internal rotation may be adaptive and asymptomatic initially if the total
pecially the ulnar collateral ligament (UCL), to large tensile
arc of motion remains symmetric between the shoulders. Clinically relevant
GIRD may occur when the internal rotation loss exceeds the external rotation
forces. Maximal abduction and external rotation (ABER) of
gain, creating a deficit in the total arc of motion. the shoulder and valgus torque on the elbow mark the con-
„ The posterosuperior shift in contact point between the glenoid and the hu- clusion of this phase and are often termed the critical moment,
meral head may contribute to pathologic shearing forces on the rotator cuff as they are often implicated in both adaptive and pathologic
and labrum predisposing to tears. MRI features include humeral head cysts, changes in both joints (5). This movement is also referred to
articular-sided partial-thickness tears of the posterior supraspinatus and ante- as the external rotation set point, or “slot,” which is critical in
rior infraspinatus tendons and posterosuperior labrum tear.
maximizing pitching velocity (9).
„ The associated labral injury is a SLAP tear, classified as type II. While GIRD is
Acceleration is the time between maximal external rotation
considered the remote or chronic cause of dead arm, a SLAP II tear is consid-
ered the immediate or acute cause.
and ball release. As the shoulder moves rapidly from external
„ The UCL is the primary static restraint to valgus stress on the elbow and there-
rotation into horizontal adduction and internal rotation, the
by the most commonly injured structure in overhead throwers. elbow undergoes rapid extension from 120° of flexion to nearly
„ Posteromedial impingement and valgus extension overload syndrome are
25° of flexion at ball release (6). These rapid shifts in move-
related entities that follow abundant valgus forces from late cocking through ments of both joints create the shortest but most intense phase
deceleration. These valgus stresses result in olecranon wedging into the olec- of the pitching motion (2).
ranon fossa, leading to posteromedial impingement. Deceleration, which follows acceleration, is considered the
most violent phase. It begins at ball release and ends at maxi-
mal shoulder internal rotation and elbow extension. Glenohu-
during the 2011–2014 seasons. Pitchers were also the most meral joint loading is greatest during this phase, as the shoul-
likely players to have elbow injuries and require surgery, and der attempts to safely slow down forward arm progression (7).
they had the greatest mean number of days missed from play The scapula protracts, providing a stable base as the humerus
when they were treated nonsurgically. rapidly switches from external to internal rotation. The biceps,
brachialis, and elbow flexors prevent rapid elbow extension
Throwing Motion Overview and forearm pronation to avoid the olecranon from impinging
Overhead throwing in baseball involves one continuous motion on the olecranon fossa (10). An eccentric elbow flexion torque
(ie, kinetic chain) that can be divided into six phases: windup, of approximately 10–35 N ⋅ m is generated throughout the de-
stride, cocking, acceleration, deceleration, and follow-through celeration phase to slow down elbow extension (6).
(Fig 1). These six phases are relatively consistent in terms of Follow-through commences with the shoulder in maxi-
overhead throwing activities and can vary slightly on the ba- mal internal rotation and ends when the thrower reaches a
sis of competition level and pitching or throwing style. The balanced position. Movements of the larger muscles in the
overall motion to propel a ball forward at high speeds requires trunk and lower extremities dissipate energy in the throwing
coordinated efforts from the proximal joints (torso and lower arm (7). The phase concludes with the shoulder in internal
extremities) and distal (arm) segments (5). Shoulder and el- rotation and adduction while the elbow flexes into a comfort-
bow movements are emphasized in this review. able position as the trunk rotates forward and the arm moves
Throwing begins with windup, which involves shifting the across the body (6).
body’s overall center of mass from both legs to a single-leg To maximize the ball velocity, the elite thrower must max-
stance. This phase places minimal stress on the shoulder and imize internal rotation velocity of the arm. Depending on the
concludes with the joint in slight internal rotation and abduc- pitch type, elite baseball pitchers can reach angular velocities
tion (2). The elbow is flexed throughout this phase and, like of 7000°–7900° per second (2,9) by means of extreme external
the shoulder, is subjected to minor muscle activity (6). Stride rotation in late cocking, thereby maximizing the rotation arc.
begins with separation of the arms to nearly 180° apart and Burkhart and colleagues (9) concluded that repetitive postero-
ends at foot strike (6,7). The shoulder begins external rotation inferior capsular contracture from the follow-through phase
and horizontal abduction, while the elbow extensor and flexor is the first event in the “disease cascade” in the throwing
muscles are activated to control elbow motion. The elbow is shoulder. During the cocking phase, the contracted postero-
extended during the first half of this stage and flexed during inferior glenohumeral ligament translates below the humeral
the second half. At foot strike, the elbow is flexed between 80° head, acting as a lever and forcing the humeral head postero-
and 100° (6). Similar to windup, stride requires negligible el- superiorly. This shift in contact point allows clearance of the
bow kinetics and muscle activity. greater tuberosity to achieve maximal external rotation. Elite

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December 2023 Goes et al

Figure 1. Graphic illustration of the six phases of throwing: windup, stride, cocking, acceleration, deceleration, and follow-through. Injuries of the shoulder
are common during all phases except windup and stride, whereas injuries of the throwing elbow transpire mainly during late cocking and acceleration, when
maximal valgus forces are generated. ER = external rotation, IR = internal rotation.

Figure 2. Clinical photographs demonstrate preservation of the normal (180°) arc of motion in the nonthrowing arm (A), versus adaptive external rotation
in the throwing arm (B), versus GIRD in the throwing arm (C). In a thrower’s arm , the gain in external rotation is balanced by the loss of internal rotation, pre-
serving the total arc of motion (B). With GIRD (C), a pathologic loss of internal rotation results in a loss of the total arc of motion of 5° or greater (comparing A
vs C) and an absolute loss of internal rotation of 20° or greater (comparing B vs C).

pitchers recognize this “set point” to deliver effective pitching tive and asymptomatic initially if the total arc of motion re-
velocities (9). mains symmetric between the shoulders. Clinically relevant
GIRD may occur when the internal rotation loss exceeds the
Throwing Shoulder Injuries external rotation gain, creating a deficit in the total arc of mo-
tion (Fig 2). This is considered the remote or chronic cause
Glenohumeral Internal Rotation Deficit of “dead arm,” defined by the loss of pitching accuracy and
In the throwing arm, glenohumeral internal rotation deficit velocity (9).
(GIRD) represents internal rotation loss to achieve maximal The current threshold for total arc of motion deficit is a
external rotation (9). Loss of internal rotation may be adap- 5° or greater difference between the shoulders (11). The most

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December 2023 Goes et al

Figure 3. Posteroinferior glenohumeral lig-

ament and capsule thickening in a 20-year-
old former high school baseball pitcher with
clinical and physical examination findings of
GIRD. Axial (A) and sagittal (B) T2-weighted
fat-suppressed MR images show thickening
of the posteroinferior glenohumeral liga-
ment and capsule (arrows) adjacent to the
posteroinferior labrum (arrowheads).

Figure 4. Bennett lesion in a

45-year-old retired professional
baseball pitcher with a history of
long-standing right shoulder pain.
(A) Axillary radiograph shows a
bony exostosis (arrowhead) in the
posterior glenoid, consistent with a
Bennett lesion. (B) Findings on the
corresponding axial T1-weighted MR
arthrogram confirm the exostosis
(arrowhead) and complete fatty atro-
phy of the infraspinatus muscle (∗).

accepted threshold for relative loss of internal rotation com- showed that throwers tend to have a thicker labrum and pos-
pared to that of the contralateral shoulder is greater than or teroinferior capsule and a more shallow posterior capsule-re-
equal to 20°, with symptoms occurring beyond 25° (9). Gleno- cess angle than do nonthrower controls (Fig S1) (15).
humeral rotation is measured by using a goniometer, with the
shoulder abducted 90° and the scapula stabilized against the Bennett Lesion
examination table or with the patient sitting (12). A Bennett lesion, or thrower’s exostosis, is an extra-articu-
A widely accepted cause of GIRD is a severely contracted lar ossification along the posteroinferior glenoid rim. While
and thickened posteroinferior recess and capsule (9). Evi- this condition is commonly asymptomatic, the lesion may
dence supporting this model includes enhanced internal rota- be painful owing to nonunion of fragments, acute avulsion
tion after selective capsulotomy (9) and clinical improvement of the ossification, or capsular and axillary nerve irritation
following posterior capsular stretching (13). More recently, (16). Infraspinatus muscle atrophy from suprascapular nerve
other authors (11) have suggested humeral retroversion and impingement by the exostosis also has been reported in ath-
muscular stiffness due to repetitive strain as additional im- letes who play overhead sports (Fig 4), especially pitchers and
portant contributors. volleyball players (17). In pitchers, infraspinatus muscle atro-
The posteroinferior glenohumeral ligament and axillary re- phy may occur in the absence of the ossification and has been
cess capsular thickening are well depicted on axial and coronal reported in up to 4% of major league starting pitchers (18).
oblique MR images (Fig 3) (14). At arthroscopy, a posteroinfe- Cummins and colleagues (18) hypothesize that this is related
rior glenohumeral ligament thicker than 6 mm has been sug- to cumulative neuropraxia on the suprascapular nerve at the
gested (9), although to date, no available reference value for spinoglenoid notch, even in the absence of ossification.
posterior capsular thickness exists. An MR arthrography study The pathophysiology of a Bennett lesion is still being de-
by Tuite et al (15) of 26 overhead throwing athletes with patho- bated. Hypotheses include traction of the posteroinferior gleno-
logic posterosuperior internal impingement (PSI) and GIRD humeral ligament during the deceleration phase and humeral
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December 2023 Goes et al

Figure 5. Graphic illustrations of PSI show abnormal contact

of the undersurface of the posterior rotator cuff (specifically, the
posterior supraspinatus and anterior infraspinatus) between the
greater tuberosity and the posterosuperior glenoid and labrum
(between arrowheads in B) during late cocking (arrow). The bi-
ceps tendon (highlighted in blue in B) is shown as a landmark.

head impingement on the posterior glenoid during the cocking Nakagawa et al (21) proposed four criteria for diagnosing
phase (19). Although the lesion may be a marker for repeti- a symptomatic Bennett lesion: (a) posterior glenoid rim bony
tive capsular traction in throwers, there is no consensus as to spur on radiographs; (b) posterior shoulder pain while throw-
whether it is truly pathologic. Wright and Paletta (20) reported ing, particularly during follow-through; (c) posteroinferior
a Bennett lesion in 22% of 55 asymptomatic major league pitch- glenohumeral joint tenderness; and (d) pain improvement fol-
ers and found no correlation between the presence of the lesion lowing local anesthetic injection. For pain that is resistant to
and thrower age, years pitched , or innings pitched. Conversely, conservative treatment for longer than 3 months, the authors
a more recent study (19) found that patients with Bennett le- recommend arthroscopic lesion removal via Bennett-plasty
sions had played baseball longer (10.6 years) than those with- (16,21). Meister (2) showed successful return to play in 10 of
out Bennett lesions (8.8 years). 18 players when resection, along with débridement of the ro-
The association between the exostosis and other PSI find- tator cuff and labral tears, was performed. The investigation
ings, including undersurface rotator cuff tears and posterior of Yoneda et al (16), involving baseball players with concom-
labral tears, is also controversial (16,19). Park et al (19) con- itant rotator cuff and labral disease, concluded with 11 of 16
tend that the lesion tends to form parallel to and not toward the players resuming competitive activity.
inner aspect of the glenoid and emphasize that patients expe-
rience pain mostly during follow-through rather than during Posterosuperior Internal Impingement
cocking. While the exostosis may represent an advanced form PSI refers to abnormal contact of the undersurface of the pos-
of the posterior capsular thickening seen in GIRD, there is no terior supraspinatus and/or anterior infraspinatus tendons
definite established relationship. An investigation involving between the greater tuberosity and the posterosuperior gle-
388 baseball players found no significant difference in inter- noid and labrum during late cocking (Fig 5). Walch et al (22)
nal rotation deficit between patients with and those without first attributed pathologic and symptomatic impingement,
Bennett lesions (19). Given variable evidence in the literature initially considered to be physiologic and asymptomatic in
to support an association with signs and symptoms of PSI and throwers, to repetitive microtrauma from the throwing mo-
GIRD, the finding of a Bennett lesion must be correlated with tion. The clinical diagnosis is established by the presence of
the clinical history and physical examination findings. pain without apprehension in the ABER position and relief
The ossification can be visualized on axillary, Stryker on application of a posteriorly directed force (Jobe relocation
notch, or modified Bennett radiographs. CT can be used to as- test), eliminating the impingement (22).
sess for fragmented lesions or posterior glenoid dysplasia (19). Various theories regarding the causes of PSI exist. Sev-
Sagittal and axial T2-weighted or proton-density–weighted eral investigators (9,11,12,15) believe it represents a conse-
MR images obtained parallel to the glenoid fossa depict the quence of altered biomechanics from a stiff posteroinferior
Bennett lesion as a low-signal-intensity crescentic bump with capsule (ie, GIRD). Myers et al (12) showed significantly
an elevated periosteum along the posteroinferior glenoid (19). greater GIRD and posterior shoulder tightness in 11 throw-
While CT remains the reference standard for diagnosing Ben- ing athletes with impingement compared to controls, with
nett lesions with a sensitivity and specificity of 98% and 97%, an average internal rotation loss of 19.7°. Others postulate
respectively, T1-weighted MR images can depict early thick- that there is an association of impingement with anterior
ened subperiosteal tissue before mature mineralization (19). instability. The excessive external rotation during throwing

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Figure 6. Humeral head cysts and

an undersurface rotator cuff tear in
a 26-year-old female elite volleyball
player, with concern for a labral
tear. Coronal (A) and sagittal (B)
T2-weighted fat-suppressed MR im-
ages show fluid signal intensity on
the undersurface of the infraspina-
tus tendon at the footprint, consis-
tent with a partial-thickness tear (be-
tween the white bars). The overlying
bursal-sided fibers (arrowheads in
A) are intact. There are also a few
cysts with surrounding edema-like
changes (arrows) in the osseous
footprint of the infraspinatus ten-
don; these cysts are more optimally
visualized in B. These findings are
commonly seen with PSI.

elongates the inferior glenohumeral ligament complex, al- ula syndrome, is a fatigue condition that disrupts the normal
lowing significant increases in anterior translation (23). The humeral and scapular alignment during acceleration, con-
consequent anterior capsular laxity and microinstability ex- tributing to symptoms of PSI (23). The characteristic clini-
acerbate the entrapment of the posterosuperior labrum and cal manifestation is asymmetric malposition of the scapula
capsule between the humeral head and glenoid (23). in the dominant throwing shoulder; this frequently appears
The posterosuperior shift in contact point between the with one shoulder lower than the other (30). Types I (inferior
glenoid and the humeral head may contribute to pathologic medial scapular border prominence) and II (medial scapular
shearing forces on the rotator cuff and labrum predisposing border prominence) scapulothoracic muscle dysfunction are
to tears. MRI features include humeral head cysts, articu- associated with labral disease, and type III (superomedial bor-
lar-sided partial-thickness tears of the posterior supraspinatus der prominence) is associated with rotator cuff lesions (30). In
and anterior infraspinatus tendons (Fig 6) and posterosuperior a cadaveric study (31) involving simulation of the throwing
labrum tear (24). An investigation involving 10 asymptomatic motion, greater internal scapular rotation and less upward
college baseball players with physical examination signs of scapular rotation significantly increased the glenohumeral
PSI (25) revealed cuff tears in two of the 10 cases, superior la- contact pressure and impingement of the rotator cuff tendon
brum anterior-posterior (SLAP) lesions with paralabral cysts between the greater tuberosity and the glenoid.
in three cases, and humeral head cysts in two cases, as well
as bony contact. The contralateral nonthrowing shoulder in SLAP Tears and Pseudolaxity
the same patients all showed contact without other associated The shift in glenohumeral contact point predisposes an indi-
findings (25). vidual to labral tearing, specifically the “peel-back” injury of
Cysts in the absence of clinical or other MRI features of the biceps-labral complex. In the ABER position, the postero-
impingement can be mistaken for marrow and cortical abnor- inferior glenohumeral ligament is positioned beneath the hu-
malities of Hill-Sachs lesions and should be carefully scruti- meral head. A contracted posteroinferior capsule levers and
nized on sequential axial images. While the cortical irregu- pushes the humeral head posterosuperiorly (Fig 9). In this
larities, defects, and/or cysts of PSI are seen in the posterior position, the biceps tendon twists upon its base, forcing the
humeral head, the Hill-Sachs lesion affects the posterosupe- posterosuperior labrum and the biceps root to rotate medial
rior humeral head—specifically the three superiormost axial to the glenoid, predisposing to biceps anchor and labral de-
images (26) or the superior 4–5 mm of the humeral head (Fig tachment from bone (Fig 10). The associated labral injury is
7) (7,27). Caution must also be exercised with articular-sided a SLAP tear, classified as type II (Fig 11) (32). While GIRD is
partial-thickness tears presenting in asymptomatic throwers considered the remote or chronic cause of dead arm, a SLAP
(25,28). MRI studies of 20 asymptomatic shoulders in elite II tear is considered the immediate or acute cause (9). Among
overhead athletes showed rotator cuff tears in up to 40% of the the SLAP tear subtypes, it is the posterior lesion (thrower’s
players (29). MR arthrography with ABER positioning is espe- SLAP) and combined anterior and posterior lesions that are
cially useful for confirming undersurface cuff tears by lifting frequently observed in overhead throwers (33).
the tendon from the humeral head (Figs 8, S2) (24). The peel-back injury may be visualized in the ABER posi-
tion (Fig 11) with MR arthrography (34). The following grades
Scapulothoracic Muscle Dysfunction have been proposed for assessment of the posterosuperior
Scapulothoracic muscle dysfunction, or SICK (scapular mal- labral position relative to the glenoid articular plane: grade 0,
position, inferior medial border prominence, coracoid pain whereby the labrum is lateral and cranial to the glenoid tan-
and malposition, and dyskinesis of scapular movement) scap- gent line; grade 1, whereby the labrum remains flush but not
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Figure 7. Hill-Sachs lesion versus PSI

in two patients. (A, B) Axial T2-weighted
fat-suppressed (A) and coronal T1-
weighted (B) MR images in a 34-year-old
woman who sustained a shoulder disloca-
tion a week earlier show a prominent bony
concavity (arrows) on the posterosuperior
humeral head, at the top or superior
aspect of the humeral head, consistent
with a Hill-Sachs lesion. (C, D) Axial T2-
weighted fat-suppressed (C) and coronal
T1-weighted (D) MR images in a 36-year-
old right-handed baseball pitcher with-
out any history of instability show bony
concavities (arrowheads) in a lower axial
section at the level of the glenoid. These
findings favor sequelae of PSI.

Figure 9. Drawing
superimposed on a
sagittal T1-weighted
MR arthrogram shows
the shift in position
that occurs in the
major tendon and
capsuloligamentous
structures of the
glenohumeral joint
between the resting
position (all graphics
in yellow) and ABER
position (all graphics
in blue). AIGHL =
anterior band of the
inferior glenohumeral
ligament, MGHL =
middle glenohumeral
ligament, PIGHL =
posterior band of the
inferior glenohumeral
ligament, SGHL = su-
Figure 8. Undersurface rotator cuff tear in a 28-year-old perior glenohumeral
male elite beach volleyball player with persistent shoulder ligament.
discomfort. T1-weighted fat-suppressed ABER MR arthrogram
shows contrast imbibition through the torn undersurface of the
infraspinatus tendon (arrow), undercutting the detached pos-
terior labrum (arrowhead).

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Figure 10. Graphic illustrations demonstrate the

mechanism of peel-back injury. The normal position of the
biceps tendon is highlighted in blue. In the ABER position,
the new position of the humerus forces the biceps
tendon to twist (black arrow) and change position (* in A),
stripping the biceps anchor and posterosuperior labrum
(white arrow in B) from the osseous attachment.

Figure 11. Peel-back lesion in a 28-year-old male elite beach volleyball player (same patient as in Fig 8). (A, B) Axial (A) and ABER (B) T1-weighted fat-sup-
pressed MR arthrograms show contrast material extending through the superior labrum, from the anterior to posterior aspects (arrowheads), consistent with
a thrower’s SLAP or peel-back lesion. (C) Subsequent arthroscopic findings confirmed the tear (arrowheads).

medial and caudal to the glenoid tangent line; and grade 2, more common superior insertional tendon tears (Fig 13)
whereby the labral apex is clearly positioned medial and cau- (7,35). Excessive external rotation and cross-body abduction
dal to the glenoid tangent line (34). during late cocking stretch the inferior fibers across the an-
In the ABER position, the anteroinferior capsule is taut terior glenohumeral joint to their limit, predisposing to sub-
across the humeral articular surface; this is the so-called cam scapularis muscle failure. As the humerus continues to ex-
effect (9). According to Burkhart’s circle concept, stresses on ternally rotate between late cocking to early acceleration, the
the posterosuperior labrum allow laxity to be channeled on subscapularis begins internal rotation and forward accelera-
the opposite side of the labral ring or anteroinferior labrum tion (7). Lesser tuberosity avulsions also may occur but are
(9). In throwers, the shift in glenohumeral contact dimin- more common in adolescent throwers (36). Avulsions are best
ishes the cam or tightening effect of the anteroinferior cap- depicted with axillary radiography or CT, while MRI can be
sule, resulting in capsular redundancy and thereby permitting used to evaluate the integrity of the subscapularis, degree of
greater external rotation (Fig 12) (9). retraction, and presence of muscle atrophy (7).

Anterior Shoulder Injuries Latissimus Dorsi and Teres Major Injuries

In professional baseball pitchers, subscapularis tears tend to Latissimus dorsi and teres major injuries occur during late
occur within the inferior half of the muscle, instead of the cocking and acceleration. The latissimus dorsi muscle adducts

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Figure 12. Graphic illustration of anterior

pseudolaxity. When the shoulder is in the ABER
position, the anteroinferior capsule is tightly draped
across the inferior articular surface of the humerus
(curved arrows); this condition is also termed the
cam effect against the proximal humerus. With
the posterosuperior shift of the humeral head on
the glenoid (straight arrow), the cam effect is re-
duced, leading to anterior capsular redundancy or
pseudolaxity (arrowheads).

the elevated arm against resistance to pull down on the hu- valgus resistance increases to 54%, the anterior joint capsule’s
merus and compresses the inferior scapula when the arm is contribution decreases to 10%, and the osseous contribution re-
elevated (37). The teres major muscle acts to adduct, extend, mains nearly the same at 36% (40). The UCL is subdivided into
and internally rotate the humerus. Injuries to these muscles anterior, posterior, and transverse bundles. The anterior bundle
can occur together by virtue of their confluent humeral inser- arises from the anteroinferior medial epicondyle and inserts on
tion, synergistic muscle action, and similar muscle vectors (37). the sublime tubercle of the ulna. It is the strongest bundle, pro-
In a study of 12 cadaveric specimens, all shoulder specimens viding valgus restraint at 30°–120° elbow flexion that predomi-
demonstrated fascial connections between the two muscle bel- nates during the throwing motion, and is subjected to up to 260
lies, while the tendon insertions were most commonly sepa- N of tensile force during acceleration (40).
rate in two-thirds of specimens, or loosely bound or completely The anterior bundle is further subdivided into anterior
joined in the remaining one-third (38). Most acute injuries in- and posterior bands, which exhibit different strain and injury
volving one or both tendons have been reported in professional patterns depending on the elbow position (41). The anterior
baseball pitchers (Fig 14) (37) and less commonly in basketball band exhibits an isometric strain pattern throughout the elbow
and volleyball players (39). range of motion, while the posterior band strain pattern in-
The diagnosis may be challenging in the setting of non- creases at higher degrees of elbow flexion. The posterior bun-
specific pain in the axilla at ball release and pain with re- dle contributes to stability at flexion angles greater than 120°,
sisted pull-downs. The clinical history must be considered, and the transverse bundle provides minimal stability to valgus
as standard shoulder MRI protocols do not routinely include forces at all angles (Fig 15) (42,43).
the latissimus dorsi, which requires larger field-of-view T2- An abnormal UCL can be thickened, attenuated, ossified,
weighted fat-suppressed sequences for assessment (37). and/or partially or completely torn. Most injuries involve the
anterior bundle and occur in its midsubstance but can involve
Throwing Elbow Injuries other locations or more than one location (40,41). The anterior
Abundant valgus loads during acceleration generate large band of the anterior bundle is more vulnerable in distal tears,
tensile forces at the medial elbow, resulting in ligament tears, whereas the posterior band is more frequently affected in prox-
tendon injuries, ulnar nerve damage, and osseous abnormal- imal tears (41). A popping sensation, or “pop” sign, is more
ities (6). frequent among patients with single tears than among those
with attenuated functionally incompetent ligaments without
UCL Injuries discrete tears (41).
The UCL is the primary static restraint to valgus stress on the Radiographs depict heterotopic ossification within the
elbow and thereby the most commonly injured structure in UCL in the setting of a chronic tear. Sublime tubercle avulsion
overhead throwers. The ulnohumeral articulation, anterior fractures may occur and are more likely to require surgical in-
joint capsule, and UCL each contribute approximately one- tervention (44). Dynamic valgus stress radiographs depict ul-
third of the resistance against valgus stress at full elbow ex- nohumeral gapping, although there is no generally accepted
tension (40). At 90° elbow flexion, the UCL contribution to reference value. The ligament is well depicted on US images

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December 2023 Goes et al

Figure 13. Subscapularis tear in a 24-year-

old male professional pitcher with soreness
in the shoulder for 1 week and a previous
teres major strain. Sagittal (A) and axial (B)
T2-weighted fat-suppressed MR images
show a high-grade injury of the subscapu-
laris muscle involving the lower myotendi-
nous units (straight arrows in A). The upper-
most portion of the subscapularis muscle is
relatively spared (curved arrow in A). There
is fluid surrounding the injured myotendi-
nous units and the latissimus dorsi–teres
major muscle-tendon complex (arrowheads
in A). There is marked retraction of the torn
muscle bellies (arrows in B).

Figure 14. Normal latissimus dorsi (LD)

and teres major (TMa) anatomy versus
latissimus dorsi and teres major injuries.
CB = coracobrachialis muscle, LH-tr =
long head of the triceps muscle, SH-b =
short head of the biceps muscle, SSc =
subscapularis muscle, TMi = teres minor
muscle. (A, B) Axial (A) and sagittal (B)
proton-density–weighted fat-suppressed
(PDFS) MR images in an asymptomatic
healthy volunteer demonstrate the normal
anatomy of the latissimus dorsi and teres
major in comparison to the injured pa-
tient. (C, D) Axial (C) and sagittal (D) PDFS
MR images in a 28-year-old professional
baseball player show a moderate-grade
partial-thickness tear involving the distal
insertion of the combined tendon of the
latissimus dorsi and teres major (arrow-
heads in A, C, and D). Arrow in A and C
points to the pectoralis major tendon.

due to its superficial location. In pitchers, ligament thickening Other reported measurements exclude the deep underlying
may be adaptive rather than pathologic and can demonstrate echogenic fat, with mean thicknesses of 1.86 mm (46) and 1.38
hypoechoic foci and/or calcifications (45). Nazarian et al (45) mm (47). Valgus stress US can be used to distinguish true lax-
measured the anterior band of the UCL at its midportion, from ity from adaptive laxity while directly assessing the ligament.
its superficial surface down to the bone on coronal sections, A study of 26 asymptomatic pitchers (45) showed a significant
and reported a mean thickness (± 1 standard deviation) of 6.3 difference in ulnohumeral gapping on valgus stress compared
mm ± 1.1 in pitching arms versus 5.3 mm ± 1.0 in nonpitching to at rest, with mean differences of 1.4 mm compared to 0.5
arms. mm on the nonthrowing side. A cutoff of 1.5 mm for relative

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December 2023 Goes et al

Figure 15. Graphic illustration of the bundles and bands of the UCL: the
anterior bundle (yellow), transverse bundle (red), posterior bundle (purple), Figure 17. Partial tear at the distal attachment of the UCL in a
and annular ligament (AL). 21-year-old male pitcher with soreness along his medial fore-
arm while throwing. Coronal T1-weighted fat-suppressed MR
arthrogram shows interposition of intra-articular contrast mate-
rial between the ulnar attachment of the UCL and the sublime
tubercle, consistent with a partial undersurface tear of the dis-
tal anterior bundle of the ligament, or the T sign (arrowheads).

ulnohumeral gapping has been proposed, yielding 81% sensi-

tivity and 91% specificity for UCL injury (Fig 16) (48).
MRI has high specificity (approaching 100%) but only 57%
sensitivity for UCL tears, lower than the sensitivity of CT ar-
thrography (86%) (49). MR arthrography is superior to con-
ventional MRI and CT arthrography, with reported sensitivity
and specificity of 100% (50). Similar to other imaging findings
in throwers, an abnormal-appearing UCL is not necessarily
pathologic. A study of 21 asymptomatic baseball pitchers (28)
showed a higher prevalence of increased intrasubstance signal
and partial tears in pitching elbows compared to nonpitching
elbows.
On coronal MR images, a partial tear at the distal attach-
ment of the anterior bundle appears as a characteristic “T”
sign due to fluid or contrast material interposed between the
ligament and sublime tubercle (Fig 17). This sign must be dif-
ferentiated from the normal 3–4-mm separation between the
distal insertion of the anterior bundle and the sublime tuber-
cle that is seen in up to 50% of the general population (51).
Figure 16. Normal and reconstructed UCLs in two pitchers. ME = me- The flexed elbow valgus external rotation (FEVER) view is a
dial epicondyle, U = ulna. (A) Longitudinal US image in a 22-year-old more recently described MRI position in which valgus stress is
asymptomatic right-handed pitcher shows fine homogeneous echogenic applied to the ulnotrochlear joint (Fig S3) and that yields long-
striations (arrowheads), indicating an intact ligament; the ulnohumeral gap
is also normal, measuring less than 1.5 mm (bracket). (B) Longitudinal US
axis images parallel to the UCL (Fig 18) (52). An investigation
image in another asymptomatic 22-year-old right-handed pitcher after involving 44 professional baseball pitchers (52) showed high
UCL reconstruction shows a markedly thickened and heterogeneous but intraobserver agreement on ulnotrochlear joint space mea-
contiguous reconstructed ligament (arrowheads); there is no gapping with surements and confidence in assessing the UCL with FEVER
stress (bracket), further supporting an intact ligament.
views, as compared with standard views (Fig 19). The authors

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December 2023 Goes et al

Figure 18. Complete distal UCL tear seen on FEVER MRI view in a 24-year-old professional pitcher with medial elbow pain. (A, B) Standard coronal (A) and
FEVER (B) T2-weighted fat-suppressed MR images show a high-grade tear of the distal sublime tubercle attachment of the anterior bundle of the UCL, with
focal abnormal signal intensity (arrowhead in A). This is more apparent on the FEVER view, which shows an abrupt change in signal intensity (arrowhead in
B). The ulnohumeral gap is normal at rest on the standard coronal view, measuring approximately 3.0 mm between the subchondral bone plates (between
arrows on A). On the FEVER view, there is approximately 5.7 mm of gapping between the subchondral bone plates (between arrows on B) of the humeral
trochlea and the trochlear groove of the ulna, or a difference of approximately 2.7 mm between the two positions. (C) Intraoperative imaging during surgical
exploration and UCL reconstruction confirmed the gapping (straight arrows); the surgically split flexor tendon (curved arrows) is also shown.

Figure 19. Intact postoperative UCL in

a 31-year-old left-hand–dominant relief
pitcher 13 months after flexor tendon re-
pair and concern for repeat flexor tendon
injury. Standard coronal (A) and FEVER (B)
T2-weighted fat-suppressed MR images
show an intact common flexor tendon with
susceptibility artifacts (curved arrow) in the
origin, representing a prior flexor tendon
repair. There is increased T2 signal inten-
sity in the humeral attachment of the UCL
(arrowhead); this is a nonspecific finding
that can be seen in intact grafts. Notably,
there are no areas of graft discontinuity.
The joint width increased from 2.7 mm on
the standard view to 4.1 mm on the FEVER
view (between straight arrows on B), or a
difference of 1.4 mm.

found a mean relative increase of 1.80 mm in the ulnotroch- and colleagues, involving bone tunnels and a figure-of-8 graft,
lear joint space between the standard and stress FEVER views has evolved into advanced methods, including the docking
but found no significant difference between symptomatic and technique (Fig 20), use of interference screws and suspensory
asymptomatic pitchers (52). cortical buttons, and hybrid procedures.
Reconstruction of an injured UCL has become increasingly At MRI, an intact graft has low or intermediate signal in-
frequent among elite overhead throwing athletes. UCL injury tensity on T1- and T2-weighted images and may be thickened,
was once considered to be career ending for professional pitch- especially at its proximal attachment. Less commonly, 25%
ers until Dr Frank Jobe performed the first successful UCL of intact grafts demonstrate intermediate T1 signal intensity
reconstruction on the pitcher Tommy John in 1974. Between and intermediate to high T2 signal intensity. Graft degenera-
1974 and 2012, a total of 147 pitchers underwent a single re- tion has diffuse intermediate signal intensity on T1-weighted
construction procedure, with 80% of them returning to pitch images, mild hyperintensity on T2-weighted images, and fi-
in at least one Major League Baseball game and more than bers that cannot be clearly delineated (54). A normal graft
two-thirds of them returning to the same level of competition may be irregular but should not be wavy (54). In the setting
postoperatively (53). The original fixation described by Jobe of UCL reconstruction, contrast material extending between

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December 2023 Goes et al

Figure 20. UCL reconstruction performed by using the docking technique in a 21-year-old male pitcher
with soreness along the medial forearm while throwing (same patient as in Fig 17). Intraoperative pho-
tograph showing a flexor-pronator muscle splitting approach (A) and three-dimensional reconstructed
CT image (B) show UCL reconstruction performed by using the docking technique. With this method,
the UCL is reconstructed by looping a single continuous graft loop (straight arrows, yellow outline in B)
through converging ulnar bone tunnels (arrowheads in B), “docking” the sutured graft ends through a
single humeral tunnel (curved arrow in B) and tying the two ends of the UCL graft with a suture over a
bone bridge (* in B). Note the position of the ulnar tunnels: distal to the joint line and sublime tubercle.
The docking technique has become popular, as it minimizes injury to the flexor-pronator mass, avoids
the ulnar nerve, and prevents excessive bone resection from the medial epicondyle.

the distal reconstructed UCL and the sublime tubercle does Radiographs are often normal, although 25%–53% of ra-
not have the same significance (ie, false T sign) because of diographs may depict calcifications typically at the humeral
the tunnel locations approximately 3–4 mm distal to the ar- origin of the common flexor tendon (33%), pronator teres
ticular surface (54). (18%), and UCL attachment (10%) (56). US has demonstrated
sensitivity, specificity, and positive predictive and negative
Medial Epicondylitis predictive values of greater than 90% for ME (57). It shows hy-
Medial epicondylitis (ME), or epicondylosis, colloquially re- poechoic areas without fiber discontinuity or intratendinous
ferred to as “golfer’s elbow,” occurs frequently in overhead calcifications (tendinosis), a partial tear (focal anechoic area
throwing athletes. The term epicondylitis, which is widely with partial-thickness fiber discontinuity), or a complete tear
cited in the clinical and imaging literature, is somewhat of a (full-width tendon gap or tendon nonvisualization) (57). MRI
misnomer, as this condition is a noninflammatory process of findings include common flexor tendon thickening, increased
the tendon rather than the bone and is characterized by tendi- T1 and T2 signal intensity, peritendinous edema, tendon tear,
nosis or degeneration of the flexor-pronator mass. It is due to partial UCL tear, and medial epicondyle marrow edema (58).
a repetitive eccentric load of the muscles responsible for wrist An MRI case-control study found T2-hyperintense signal of a
flexion and forearm pronation, combined with valgus over- thickened common flexor tendon and peritendinous edema to
load at the elbow during late cocking and early acceleration. be the most specific imaging features (Fig 21) (58).
The flexor-pronator mass can be hypertrophied in overhead
throwing athletes, and it can be accompanied by partial UCL Ulnar Neuropathy
tears, ulnar neuropathy (UN), and lateral-sided impaction At the cubital tunnel, the ulnar nerve is bordered by the medial
injuries (55). Imaging helps to differentiate flexor-pronator epicondyle anteriorly, cubital retinaculum laterally, and flexor
mass injuries from other sources of medial elbow pain, given carpi ulnaris posteromedially. UN can occur owing to entrap-
the considerable clinical overlap among these entities. ment, trauma, chronic irritation, and/or compression. During

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December 2023 Goes et al

Figure 21. Medial epicondylitis in a 31-year-old professional

baseball pitcher with medial-sided elbow pain. Coronal T2-
weighted fat-suppressed MR image shows a high-grade par-
tial-thickness tear of the common flexor tendon at the origin
(arrow), with peritendinous edema and chronic adaptive thick-
ening of the UCL (arrowheads).

the throwing motion itself, the rapid shift from elbow extension
to flexion during acceleration compresses the nerve at the cu-
bital tunnel, with pressures increasing up to 20-fold (40). The
nerve can also be irritated by adjacent anterior capsular inflam-
mation, the flexor-pronator muscle mass, injury to the UCL
(Fig S4), osteophytes, or avulsed medial epicondyle fragments.
US and MRI are the primary imaging tools for evaluating
UN or cubital tunnel syndrome. Commonly described US
findings are a swollen hypoechoic nerve and loss of fascicu-
lar architecture. There are limited data on the sensitivity and
specificity of these findings, although investigators found
that combining them with cross-sectional nerve area mea-
surements could yield a sensitivity of 53.7% and a specificity
of 95.6% for the diagnosis of cubital tunnel syndrome (59).
MRI depicts increased nerve signal intensity on T2-weighted
fat-suppressed images, with 83% sensitivity and 85% specificity
for diagnosing UN (Fig 22) (60). However, increased nerve
signal intensity occurs in 60% of asymptomatic elbows (61) Figure 22. UN in a 20-year-old male college
and thus must be correlated with clinical signs or other imag- javelin thrower with a UCL tear and clinical symp-
ing features of UN. toms consistent with ulnar neuritis. Axial (A)
Increased cross-sectional nerve area measured 2–3 cm and sagittal (B) T2-weighted fat-suppressed
MR images show increased signal intensity (ar-
proximal and distal to the cubital tunnel is the most widely ac- rowheads) within the ulnar nerve at the cubital
cepted imaging feature of the UN cross-sectional area (62,63). tunnel and proximal forearm, suggesting neu-
Roedl et al (48) proposed different nerve size cutoff values ropathy or neuritis. Compare the signal intensity
with US and MRI, using 9 mm2 and 10 mm2, respectively, within the ulnar nerve with the signal intensity of
the normal median nerve (arrow in A). The pa-
while Terayama et al (63) proposed a nerve size cutoff value tient underwent subsequent UCL reconstruction
of 11 mm2 with both US and MRI. In baseball pitchers, an and ulnar nerve transposition, with subsequent
increase in cross-sectional area was shown to be significantly resolution of the UN symptoms.
associated with number of pitches, innings pitched, and
games pitched (64). While authors have demonstrated that

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December 2023 Goes et al

forces from late cocking through deceleration. These val-

gus stresses result in olecranon wedging into the olecranon
fossa, leading to posteromedial impingement. Ahmad and
colleagues (67) suggest that UCL insufficiency alters the
contact area between the posteromedial trochlea and olecra-
non, thereby serving as the main stimulus in posteromedial
osteophyte formation. Valgus extension overload syndrome
represents a combination of elbow extension and varus
torque that counter these valgus stresses. Also termed pitch-
er’s elbow, valgus extension overload syndrome manifests
with clinical symptoms secondary to a triad of excessive
tension on the medial side, enormous compressive forces on
the lateral side, and shear forces along the olecranon on the
posterior side (Fig 23). Concurrent injury to the UCL or flex-
or-pronator mass transfers stress from the insufficient val-
gus restraints to the posteromedial olecranon, thereby exac-
erbating posteromedial impingement and valgus extension
overload syndrome (40).
Radiographs and CT images show osteophytes at the pos-
terior olecranon tip and posteromedial olecranon; a frac-
tured osteophyte or intra-articular body may lodge at the
olecranon fossa (Fig 24). Chronic mechanical loading due
to throwing also results in other adaptive osseous changes.
Kooima et al (68) found a significant correlation between
Figure 23. Graphic illustration of the pathomechanics subclinical UCL thickening and subchondral sclerosis. In a
of valgus extension overload syndrome. This syndrome quantitative CT study, Neil and Schweitzer (69) found sig-
is characterized by abundant tension on the medial
side (black arrows), excessive compression on the lat- nificant differences in humeral diaphyseal cortical thickness
eral side (arrowheads), and shear forces along the head between throwing versus nonthrowing arms. Apart from
of the olecranon on the posterior side (white arrows), showing “kissing” osteochondral lesions of the posterome-
resulting in bone-on-bone contact in the posteromedial dial olecranon and trochlea, MRI depicts UCL injuries, olec-
aspect of the olecranon (*).
ranon fat pad scarring, medial triceps insertional tendinosis,
posteromedial recess synovitis, and olecranon chondral and
the cross-sectional area measurements at MRI and US are not subchondral abnormalities (28,68,70). MRI findings must be
significantly different (63), US has the important advantage interpreted cautiously, with awareness of the clinical pre-
of dynamic examination. A recent consensus of 15 experts sentation, as 13 of 16 professional baseball players without
agreed that all investigations of UN should include nerve con- impingement symptoms had UCL abnormalities and imag-
duction studies and US assessment of nerve mobility at the ing signs of posteromedial impingement in the Kooima et al
elbow, along with cross-sectional area measurements and im- investigation (68).
aging of the entire nerve (65). Olecranon stress fractures may be seen following postero-
Dynamic examination is performed at the cubital tunnel medial impingement and are thought to be the result of re-
with passive flexion to approximately 135° from full exten- petitive triceps contraction during follow-through or from
sion to assess for nerve subluxation or dislocation. During repetitive olecranon impingement. These fractures manifest
this maneuver, alterations in the bone contours should be as transverse or oblique high signal intensity through the af-
avoided, and the nerve should remain posterior to the medial fected bone marrow on T2-weighted MR images (Fig 25) (71).
epicondyle. Nerve motion superficial and anterior to the me-
dial epicondyle apex with elbow flexion is often considered Imaging Recommendations in Throwing
abnormal, although this finding can be seen in up to 20% of Athletes
asymptomatic individuals (66). At dedicated sports medicine Because most abnormalities in overhead throwing ath-
facilities and referral centers, use of a combination of modal- letes affect the soft-tissue structures of the shoulder, MRI
ities is prudent. Concurrent nerve size assessment with US is preferred for comprehensive evaluation after initial ra-
(with a 9-mm2 cutoff value) and either subluxation at US or diographic assessment. MR arthrography may be indicated
increased signal intensity at MRI have 90% sensitivity, 100% over conventional MRI, given the greater sensitivity of this
specificity, and 98% accuracy (48). modality for partial-thickness articular-sided rotator cuff
tears and posterosuperior labral disease (72,73). In throwing
Posteromedial Impingement and Valgus Extension athletes, MR arthrography may also assist in characterizing
Overload Syndrome GIRD and PSI (15). It should be noted that most of the ex-
Posteromedial impingement and valgus extension overload isting MR arthrography data on throwing injuries were from
syndrome are related entities that follow abundant valgus studies performed on 1.5-T systems, and recommendations

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December 2023 Goes et al

Figure 24. Posteromedial impingement with a symptomatic intra-articular body in a 23-year-old professional baseball pitcher with elbow pain mainly with
extension. Preoperative sagittal reconstructed (A) and three-dimensional (B) CT images and postoperative three-dimensional CT image (C) show an intra-ar-
ticular body (arrowhead in A and B) within the olecranon fossa, adjacent sclerosis and cystic changes at the interface of the intra-articular body with the
olecranon (curved arrow in A), thickening of the cortical bone in the humeral diaphysis (straight arrows in A), and posteromedial compartment joint space
narrowing (between arrows in B and C). CT image after resection of the intra-articular body (C) shows an empty olecranon fossa (arrowhead in C).

Figure 25. Olecranon stress fracture in a

21-year-old right-handed pitcher, with con-
cern for olecranon stress reaction.
(A) Sagittal T2-weighted fat-suppressed
MR image shows a faint line with a hy-
perintense signal (arrow) across the olec-
ranon, with subtle surrounding marrow
edema. (B) Sagittal reconstructed CT
image confirms the presence of an in-
complete stress fracture of the olecranon
(arrow). Also note the thickening of the
cortical bone in the humeral diaphysis
(arrowheads in A and B), which is more
readily discernible on the CT image.

will probably evolve with increased accessibility of 3.0-T Conclusion

systems. Overhead throwing subjects the shoulder and elbow to ex-
In the elbow, MR arthrography also has higher sensitivity treme stresses, predisposing them to various osseous and
and specificity than conventional MRI for evaluation of UCL soft-tissue injuries. Knowledge of the anatomy, biomechanics,
tears (49,74). Although no comparison between MR arthrog- and imaging findings of pertinent throwing injuries enables
raphy and conventional MRI has been performed in the post- precise diagnosis and timely management.
operative setting, Wear et al (54) suggest that MR arthrography
delineates the thickening and intermediate graft signal inten- Author affiliations.—From the Division of Musculoskeletal Radiology, Lab-
oratorio Delboni Auriemo, DASA Diagnostic Imaging, São Paulo, Brazil
sity associated with recurrent tears. However, the prediction (P.K.G.); Department of Radiology, Radiation Oncology and Medical Phys-
of valgus laxity is inaccurate with use of both conventional ics, Faculty of Medicine, University of Ottawa, Ottowa, Ontario, Canada
MRI and MR arthrography and requires dynamic stress ex- (D.V.F., A.D.); Department of Medical Imaging, The Ottawa Hospital, 501
Smyth Rd, Ottawa, ON, Canada K1H 8L6 (D.V.F.); Ottawa Hospital Research
amination. In addition to using the FEVER MRI view, which Institute, Ottawa, Ontario, Canada (D.V.F.); and Department of Radiology,
increases diagnostic confidence (52), combining MR arthrog- Division of Musculoskeletal Imaging and Intervention, University of Cal-
raphy with stress US may prove to be useful (49). ifornia San Diego Medical Center, San Diego, Calif (B.K.H.). Presented as

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December 2023 Goes et al

an education exhibit at the 2022 RSNA Annual Meeting. Received April 30, 24. Tirman PF, Bost FW, Garvin GJ, et al. Posterosuperior glenoid impinge-
2023; revision requested May 20 and received June 22; accepted June 28. ment of the shoulder: findings at MR imaging and MR arthrography with
Address correspondence to D.V.F. (email: [email protected]). arthroscopic correlation. Radiology 1994;193(2):431–436.
25. Halbrecht JL, Tirman P, Atkin D. Internal impingement of the shoulder:
Acknowledgments.—The illustrations in Figures 1, 5A, 5B, 10A, 10B, 12, comparison of findings between the throwing and nonthrowing shoulders
and 15 were created by Ilija Visnjic, Belgrade, Serbia. of college baseball players. Arthroscopy 1999;15(3):253–258.
26. Herring A, Davis DL. Mimickers of Hill-Sachs Lesions. Can Assoc Radiol
J 2021;72(2):258–270.
Disclosures of conflicts of interest.—The authors, editor, and reviewers have 27. Sandstrom CK, Kennedy SA, Gross JA. Acute shoulder trauma: what the
disclosed no relevant relationships. surgeon wants to know. RadioGraphics 2015;35(2):475–492.
28. Del Grande F, Aro M, Farahani SJ, Wilckens J, Cosgarea A, Carrino JA.
References Three-tesla MR imaging of the elbow in non-symptomatic professional
1. Laudner K, Sipes R. The Incidence of Shoulder Injury among Collegiate baseball pitchers. Skeletal Radiol 2015;44(1):115–123.
Overhead Athletes. J Intercoll Sport 2009;2(2):260–268. 29. Connor PM, Banks DM, Tyson AB, Coumas JS, D’Alessandro DF. Magnetic
2. Meister K. Injuries to the shoulder in the throwing athlete. I. Biome- resonance imaging of the asymptomatic shoulder of overhead athletes: a
chanics/pathophysiology/classification of injury. Am J Sports Med 5-year follow-up study. Am J Sports Med 2003;31(5):724–727.
2000;28(2):265–275. 30. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder:
3. Fares MY, Fares J, Baydoun H, Fares Y. Prevalence and patterns of shoul- spectrum of pathology. III. The SICK scapula, scapular dyskinesis, the
der injuries in major league baseball. Phys Sportsmed 2020;48(1):63–67. kinetic chain, and rehabilitation. Arthroscopy 2003;19(6):641–661.
4. Ciccotti MG, Pollack KM, Ciccotti MC, et al. Elbow Injuries in Profes- 31. Mihata T, Gates J, McGarry MH, Neo M, Lee TQ. Effect of posterior shoulder
sional Baseball: Epidemiological Findings From the Major League Base- tightness on internal impingement in a cadaveric model of throwing. Knee
ball Injury Surveillance System. Am J Sports Med 2017;45(10):2319–2328. Surg Sports Traumatol Arthrosc 2015;23(2):548–554.
5. Weber AE, Kontaxis A, O’Brien SJ, Bedi A. The biomechanics of throw- 32. Burkhart SS, Morgan CD. The peel-back mechanism: its role in producing
ing: simplified and cogent. Sports Med Arthrosc Rev 2014;22(2):72–79. and extending posterior type II SLAP lesions and its effect on SLAP repair
6. Fleisig GS, Escamilla RF. Biomechanics of the elbow in the throwing rehabilitation. Arthroscopy 1998;14(6):637–640.
athlete. Oper Tech Sports Med 1996;4(2):62–68. 33. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions:
7. Lin DJ, Wong TT, Kazam JK. Shoulder injuries in the overhead-throwing three subtypes and their relationships to superior instability and rotator
athlete: epidemiology, mechanisms of injury, and imaging findings. cuff tears. Arthroscopy 1998;14(6):553–565.
Radiology 2018;286(2):370–387. 34. Borrero CG, Casagranda BU, Towers JD, Bradley JP. Magnetic resonance
8. Kancherla VK, Caggiano NM, Matullo KS. Elbow injuries in the throwing appearance of posterosuperior labral peel back during humeral abduction
athlete. Orthop Clin North Am 2014;45(4):571–585. and external rotation. Skeletal Radiol 2010;39(1):19–26.
9. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: 35. Polster JM, Lynch TS, Bullen JA, et al. Throwing-related injuries of the sub-
spectrum of pathology. I. Pathoanatomy and biomechanics. Arthroscopy scapularis in professional baseball players. Skeletal Radiol 2016;45(1):41–47.
2003;19(4):404–420. 36. Vavken P, Bae DS, Waters PM, Flutie B, Kramer DE. Treating Subscapularis
10. Werner SL, Fleisig GS, Dillman CJ, Andrews JR. Biomechanics and Lesser Tuberosity Avulsion Injuries in Skeletally Immature Patients:
of the elbow during baseball pitching. J Orthop Sports Phys Ther A Systematic Review. Arthroscopy 2016;32(5):919–928.
1993;17(6):274–278. 37. Schickendantz MS, Kaar SG, Meister K, Lund P, Beverley L. Latissimus
11. Kibler WB, Sciascia A, Thomas SJ. Glenohumeral internal rotation dorsi and teres major tears in professional baseball pitchers: a case series.
deficit: pathogenesis and response to acute throwing. Sports Med Ar- Am J Sports Med 2009;37(10):2016–2020.
throsc Rev 2012;20(1):34–38. 38. Goldberg BA, Elhassan B, Marciniak S, Dunn JH. Surgical anatomy of
12. Myers JB, Laudner KG, Pasquale MR, Bradley JP, Lephart SM. Glenohu- latissimus dorsi muscle in transfers about the shoulder. Am J Orthop
meral range of motion deficits and posterior shoulder tightness in throwers 2009;38(3):E64–E67.
with pathologic internal impingement. Am J Sports Med 2006;34(3):385–391. 39. Anderson SE, Hertel R, Johnston JO, Stauffer E, Leinweber E, Steinbach LS.
13. Cools AM, Johansson FR, Cagnie B, Cambier DC, Witvrouw EE. Stretch- Latissimus dorsi tendinosis and tear: imaging features of a pseudotumor of
ing the Posterior Shoulder Structures in Subjects with Internal Rotation the upper limb in five patients. AJR Am J Roentgenol 2005;185(5):1145–1151.
Deficit: Comparison of Two Stretching Techniques. Shoulder Elbow 40. Wo S, Mulcahy H, Richardson ML, et al. Pathologies of the shoulder
2012;4(1):56–63. and elbow affecting the overhead throwing athlete. Skeletal Radiol
14. Tehranzadeh AD, Fronek J, Resnick D. Posterior capsular fibrosis in 2017;46(7):873–888.
professional baseball pitchers: case series of MR arthrographic findings 41. Molenaars RJ, van den Bekerom MPJ, Eygendaal D, Oh LS. The patho-
in six patients with glenohumeral internal rotational deficit. Clin Imaging anatomy of the anterior bundle of the medial ulnar collateral ligament. J
2007;31(5):343–348. Shoulder Elbow Surg 2019;28(8):1497–1504.
15. Tuite MJ, Petersen BD, Wise SM, Fine JP, Kaplan LD, Orwin JF. Shoulder 42. Edama M, Matsuzawa K, Yokota H, et al. Elbow valgus stability of the
MR arthrography of the posterior labrocapsular complex in overhead transverse bundle of the ulnar collateral ligament. BMC Musculoskelet
throwers with pathologic internal impingement and internal rotation Disord 2021;22(1):873.
deficit. Skeletal Radiol 2007;36(6):495–502. 43. Ciccotti MC, Hammoud S, Dodson CC, Cohen SB, Nazarian LN, Ciccotti
16. Yoneda M, Nakagawa S, Hayashida K, Fukushima S, Wakitani S. Ar- MG. Stress ultrasound evaluation of medial elbow instability in a cadaveric
throscopic removal of symptomatic Bennett lesions in the shoulders model. Am J Sports Med 2014;42(10):2463–2469.
of baseball players: arthroscopic Bennett-plasty. Am J Sports Med 44. Salvo JP, Rizio L 3rd, Zvijac JE, Uribe JW, Hechtman KS. Avulsion fracture
2002;30(5):728–736. of the ulnar sublime tubercle in overhead throwing athletes. Am J Sports
17. Bautista JM, Fernández-Jara J, Bautista SM, et al. Infraspinatus atrophy Med 2002;30(3):426–431.
due to Bennett lesion causing suprascapular nerve palsy. J Ultrason 45. Nazarian LN, McShane JM, Ciccotti MG, O’Kane PL, Harwood MI. Dynamic
2021;21(85):e177–e181. US of the anterior band of the ulnar collateral ligament of the elbow in a­symp-
18. Cummins CA, Messer TM, Schafer MF. Infraspinatus muscle atrophy in tomatic major league baseball pitchers. Radiology 2003;227(1):149–154.
professional baseball players. Am J Sports Med 2004;32(1):116–120. 46. Jacobson JA, Propeck T, Jamadar DA, Jebson PJL, Hayes CW. US of the
19. Park JY, Noh YM, Chung SW, et al. Bennett lesions in baseball players anterior bundle of the ulnar collateral ligament: findings in five cadaver
detected by magnetic resonance imaging: assessment of association factors. elbows with MR arthrographic and anatomic comparison: initial obser-
J Shoulder Elbow Surg 2016;25(5):730–738. vations. Radiology 2003;227(2):561–566.
20. Wright RW, Paletta GA Jr. Prevalence of the Bennett lesion of the shoulder 47. Shukla M, Keller R, Marshall N, et al. Ultrasound evaluation of the ulnar
in major league pitchers. Am J Sports Med 2004;32(1):121–124. collateral ligament of the elbow: which method is most reproducible?
21. Nakagawa S, Yoneda M, Hayashida K, Mizuno N, Yamada S. Posterior Skeletal Radiol 2017;46(8):1081–1085.
shoulder pain in throwing athletes with a Bennett lesion: factors that 48. Roedl JB, Gonzalez FM, Zoga AC, et al. Potential Utility of a Combined
influence throwing pain. J Shoulder Elbow Surg 2006;15(1):72–77. Approach with US and MR Arthrography to Image Medial Elbow Pain
22. Walch G, Boileau P, Noel E, Donell ST. Impingement of the deep surface in Baseball Players. Radiology 2016;280(1):328.
of the supraspinatus tendon on the posterosuperior glenoid rim: an ar- 49. Timmerman LA, Schwartz ML, Andrews JR. Preoperative evaluation of
throscopic study. J Shoulder Elbow Surg 1992;1(5):238–245. the ulnar collateral ligament by magnetic resonance imaging and com-
23. Mistry A, Campbell RSD. Microinstability and internal impingement of puted tomography arthrography: evaluation in 25 baseball players with
the shoulder. Semin Musculoskelet Radiol 2015;19(3):277–283. surgical confirmation. Am J Sports Med 1994;22(1):26–32.

Volume 43 Number 12 17 radiographics.rsna.org

December 2023 Goes et al

50. Magee T. Accuracy of 3-T MR arthrography versus conventional 3-T 63. Terayama Y, Uchiyama S, Ueda K, et al. Optimal Measurement Level
MRI of elbow tendons and ligaments compared with surgery. AJR Am and Ulnar Nerve Cross-Sectional Area Cutoff Threshold for Identifying
J Roentgenol 2015;204(1):W70–W75. Ulnar Neuropathy at the Elbow by MRI and Ultrasonography. J Hand
51. Munshi M, Pretterklieber ML, Chung CB, et al. Anterior bundle of ulnar Surg Am 2018;43(6):529–536.
collateral ligament: evaluation of anatomic relationships by using MR 64. Keller RA, Marshall NE, Bey MJ, et al. Pre- and Postseason Dynamic Ul-
imaging, MR arthrography, and gross anatomic and histologic analysis. trasound Evaluation of the Pitching Elbow. Arthroscopy 2015;31(9):1708–
Radiology 2004;231(3):797–803. 1715.
52. Lund P, Waslewski GL, Crenshaw K, et al. FEVER: The Flexed Elbow 65. Pelosi L, Arányi Z, Beekman R, et al. Expert consensus on the combined
Valgus External Rotation View for MRI Evaluation of the Ulnar Collateral investigation of ulnar neuropathy at the elbow using electrodiagnostic
Ligament in Throwing Athletes—A Pilot Study in Major League Baseball tests and nerve ultrasound. Clin Neurophysiol 2021;132(9):2274–2281.
Pitchers. AJR Am J Roentgenol 2021;217(5):1176–1183. 66. Jacobson JA, Wilson TJ, Yang LJS. Sonography of common peripheral nerve
53. Makhni EC, Lee RW, Morrow ZS, Gualtieri AP, Gorroochurn P, Ahmad disorders with clinical correlation. J Ultrasound Med 2016;35(4):683–693.
CS. Performance, return to competition, and reinjury after Tommy John 67. Ahmad CS, Park MC, Elattrache NS. Elbow medial ulnar collateral liga-
surgery in major league baseball pitchers: a review of 147 cases. Am J ment insufficiency alters posteromedial olecranon contact. Am J Sports
Sports Med 2014;42(6):1323–1332. Med 2004;32(7):1607–1612.
54. Wear SA, Thornton DD, Schwartz ML, Weissmann RC 3rd, Cain EL, 68. Kooima CL, Anderson K, Craig JV, Teeter DM, van Holsbeeck M.
Andrews JR. MRI of the reconstructed ulnar collateral ligament. AJR Evidence of subclinical medial collateral ligament injury and postero-
Am J Roentgenol 2011;197(5):1198–1204. medial impingement in professional baseball players. Am J Sports Med
55. Hsu JE, Peng Q, Schafer DA, Koh JL, Nuber GW, Zhang LQ. In vivo 2004;32(7):1602–1606.
three-dimensional mechanical actions of individual. J Appl Biomech 69. Neil JM, Schweitzer ME. Humeral cortical and trabecular changes in the
2008;24(4):325–332. throwing athlete: a quantitative computed tomography study of male
56. Kang KB, Cheon SH, Lee HD. Radiologic evaluation and clinical college baseball players. J Comput Assist Tomogr 2008;32(3):492–496.
effect of calcification in medial epicondylitis. J Shoulder Elbow Surg 70. Cohen SB, Valko C, Zoga A, Dodson CC, Ciccotti MG. Posteromedial
2022;31(2):375–381. elbow impingement: magnetic resonance imaging findings in overhead
57. Park GY, Lee SM, Lee MY. Diagnostic value of ultrasonography for clin- throwing athletes and results of arthroscopic treatment. Arthroscopy
ical medial epicondylitis. Arch Phys Med Rehabil 2008;89(4):738–742. 2011;27(10):1364–1370.
58. Kijowski R, De Smet AA. Magnetic resonance imaging findings in patients 71. Ciccotti MC, Stull JD, Buckley PS, Cohen SB. Correlation of MRI to Ar-
with medial epicondylitis. Skeletal Radiol 2005;34(4):196–202. throscopy in the Elbow: Thrower’s Elbow and Ulnar Collateral Ligament
59. Gruber H, Glodny B, Peer S. The validity of ultrasonographic assessment Injury. Sports Med Arthrosc Rev 2017;25(4):191–198.
in cubital tunnel syndrome: the value of a cubital-to-humeral nerve area 72. Magee T, Williams D, Mani N. Shoulder MR arthrography: which patient
ratio (CHR) combined with morphologic features. Ultrasound Med Biol group benefits most? AJR Am J Roentgenol 2004;183(4):969–974.
2010;36(3):376–382. 73. Samet JD, Alizai H, Chalian M, et al. Society of skeletal radiology position
60. Bäumer P, Dombert T, Staub F, et al. Ulnar neuropathy at the elbow: paper: recommendations for contrast use in musculoskeletal MRI—when
MR neurography—nerve T2 signal increase and caliber. Radiology is non-contrast imaging enough? Skeletal Radiol doi: 10.1007/s00256-023-
2011;260(1):199–206. 04367-8. Published online June 10, 2023.
61. Husarik DB, Saupe N, Pfirrmann CWA, Jost B, Hodler J, Zanetti M. 74. Campbell RE, McGhee AN, Freedman KB, Tjoumakaris FP. Diagnostic
Ligaments and plicae of the elbow: normal MR imaging variability in 60 Imaging of Ulnar Collateral Ligament Injury: A Systematic Review. Am J
asymptomatic subjects. Radiology 2010;257(1):185–194. Sports Med 2020;48(11):2819–2827.
62. Wiesler ER, Chloros GD, Cartwright MS, Shin HW, Walker FO. Ultrasound
in the diagnosis of ulnar neuropathy at the cubital tunnel. J Hand Surg
Am 2006;31(7):1088–1093.

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