Sport Sci Health (2013) 9:81–88
DOI 10.1007/s11332-013-0151-z
REVIEW
Imaging of shoulder pain in overhead throwing athletes
Alberto Aliprandi • Silvana Sdao • Paola Maria Cannaò
Yasir Jamil Khattak • Stefano Longo •
Luca Maria Sconfienza • Francesco Sardanelli
Received: 1 April 2013 / Accepted: 2 July 2013 / Published online: 13 August 2013
Ó Springer-Verlag Italia 2013
Abstract Overhead sports are widely practiced around
the world and overhead athletes can present with pain and
dysfunction in the throwing shoulder, generally due to
degenerative changes secondary to overuse. Numerous
etiologies can be taken into account, including rotator cuff
and glenoid labrum tears, biceps pathologies, internal
impingement, and gleno-humeral instability. In this setting,
imaging plays a central role in early diagnosis, thus
allowing for a prompt management, correct rehabilitation,
and quick return to competition. This review is aimed to
discuss the role of imaging to diagnose the most common
types of overhead-related shoulder injuries.
Keywords Overhead sports
Shoulder
Rotator
cuff
Imaging
Magnetic resonance
A. Aliprandi
L. M. Sconfienza (&)
F. Sardanelli
Servizio di Radiologia, IRCCS Policlinico San Donato,
Piazza Malan 2, San Donato Milanese, 20097 Milan, Italy
e-mail: io@lucasconfienza.it
S. Sdao
P. M. Cannaò
Scuola di Specializzazione in Radiodiagnostica, Università
degli Studi di Milano, Milan, Italy
Y. J. Khattak
Department of Radiology, Aga Khan University Hospital,
Karachi, Pakistan
S. Longo
L. M. Sconfienza
F. Sardanelli
Dipartimento di Scienze Biomediche Per La Salute,
Università degli Studi di Milano, Milan, Italy
•
Introduction
Overhead sports are widely practiced around the world.
They include a large variety of activities, such as basketball,
volleyball, water polo, baseball, tennis or swimming [1].
Overhead throwing needs highly coordinated and skilled
movements. Also, it represents one of the most stressful
maneuvers a joint can be subjected to, as remarkable forces
are applied to shoulder structures at angular velocities [2].
When these forces are applied repeatedly, the throwing
athlete is prone to a number of shoulder injuries.
Overhead athletes can present with pain and dysfunction
in the throwing shoulder, generally due to degenerative
changes secondary to overuse. Numerous etiologies can be
taken into account, including rotator cuff (RC) or glenoid
labrum (GL) tears, internal impingement, gleno-humeral
(GH) instability, as well as neurovascular abnormalities
[3]. As one of the challenges of sports medicine is treat-
ment of players involved in injuries related to overhead
throwing, understanding the mechanism underlying these
injuries and performing a correct differential diagnosis are
crucial for a correct management [4]. In this setting, ima-
ging plays a central role in early diagnosis, thus allowing
for a prompt management, correct rehabilitation, and quick
return to competition [5].
This review discusses the role of imaging to diagnose
the most common types of overhead-related shoulder
injuries.
Important changes in the thrower shoulder
The ability to throw a ball with accuracy at high velocity is
the upper goal of athletic achievement [6]. The loss of that
ability is the so-called ‘‘dead arm’’ and is a condition in
which the athlete is unable to throw with his original power
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and control as a result of a combination of pain and sub-
jective unease in the shoulder [7]. Throwers with a ‘‘dead
arm’’ typically have difficulty in describing the uneasy
sensations they feel as they attempt to throw a ball. They
relate the discomfort to the late cocking phase of the
throwing sequences, when the arm begins to accelerate
forward and the shoulder is maximally abducted and
externally rotated. In early 1970s, the ‘‘dead arm’’ was
something treated as a psychological disorder, but Jobe
et al. [8] postulated that repetitive throwing gradually
stretches out the anterior capsulo-ligamentous complex,
allowing for antero-superior migration of the humeral head
during throwing, thus causing both subacromial impinge-
ment and shoulder instability symptoms. The next step in
the evolution of understanding the ‘‘dead arm’’ came when
Jobe described postero-superior impingement [9], which
occurs when the arm is in abducted and external rotated
position.
The shoulder of an overhead athlete generally presents
pain, loss of performance, deficit in strength or reduced
range of motion (ROM) [10]. To understand the phenom-
enon of ‘‘dead arm’’ and assess throwers shoulder, several
adaptive changes, due to repetitive movements and high
forces produced, should be taken into account:
– ROM: in the past, researchers reported that the
throwing shoulder acquires increased external rotation
in abduction over time compared with the non-throw-
ing shoulder [9]. Modifications in tissue structures of
the anterior capsule of GH joint, due to repetitive
microtrauma produced in the cocking phase of throw-
ing, are thought to be the greatest contributors to
shoulder external rotation increase. Other pathologic
condition that occurs in throwers is a loss of internal
rotation in abduction maybe caused by postero-inferior
capsular fibrosis and thickening [6]. The decrease of
internal rotation can be defined as GH internal rotation
deficit (GIRD) [11, 12]. Other factors involved in
modifications of ROM are increase of humeral head
and glenoid retroversion, frequently found in throwing
shoulders [13]. Chronic and repetitive injuries to
posterior shoulder capsule and proximal enthesis of
the long head of the triceps brachii typically lead to
bony adaptations, the most common of them being the
so-called Bennett lesion [14]. This is an ossification
typically located at the postero-inferior glenoid rim.
– Muscle strength: usually, overhead athletes have weak
external rotator muscles and strong internal rotator and
adductor muscles. These muscle groups contribute to
mobility and stability of both the humerus and the
scapula. Asymmetric ROM, repetitive movements, or
secondary deficit of innervations of these muscles can
determine loss of physiological shoulder balance [15].
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– Scapular position: the function of the scapula is to
provide a stable platform for the humeral head during
rotation and elevation as well as to transfer kinetic
energy from the lower limbs and the trunk to the upper
extremity [16]. Scapular dyskinesis, an alteration in
motion of the scapula during coupled scapula-humeral
movement, is a common issue in overhead athletes.
The kinetic chain
All throwing motions involve sequential activation of
muscles that allow athletes for propelling the hand at
optimum or maximum velocity [7]. This kinetic chain
activation starts at ground and proceeds through the legs to
the trunk and shoulder and then to the arm and hand. In
normal subjects the ground, legs, and trunk act as the force
generator; the shoulder acts as a funnel and force regulator;
and the arm acts as the force-delivery mechanism [7].
Shoulder structures may be injured by excessive or
imbalanced forces if regional or distant areas of the kinetic
chain are abnormal. Conversely, abnormalities around
shoulder acquired for whatever reason may lead to
impairment of the physiological kinetic chain, further
increasing a pre-existing imbalance.
Overhead shoulder pathology
As reported, overhead shoulders are usually affected with
instability, due to the increased anterior capsular laxity.
Also, postero-superior impingement may occur in the late
cocking or early acceleration phase of throwing, due to
abnormal contact between the RC and the posterior aspect
of the glenoid.
Shoulder instability
The wide ROM of the shoulder can be achieved thanks to a
delicate balance between stability and mobility that
depends both on static and dynamic stabilizers. Static sta-
bilizers are GH bone morphology, GH version, capsule and
ligamentous structures and intra-articular negative pres-
sure. The muscles of the RC are the dynamic stabilizers of
the shoulder [17].
A certain degree of joint laxity may be normal. How-
ever, at extreme ROM, laxity may predispose to instability,
reported by the subject as the sensation of excessive
humeral head mobility and usually associated with pain
and discomfort [18, 19].
Shoulder instability is typically distinct in macro- and
micro-instability. Macro-instability can be subdivided into
Sport Sci Health (2013) 9:81–88 83

traumatic (traumatic etiology, unidirectional instability,

Bankart lesion, surgery is required; TUBS), mostly
occurring in younger subjects, and non-traumatic (atrau-
matic or minor trauma, multidirectional instability,
bilateral, rehabilitation, inferior capsular shift; AMBRI).
Micro-instability is a condition that lies between the two
abovementioned categories. It has been postulated as a kind
of acquired instability due to microtrauma, further subdi-
vided into acquired instability overstress syndrome (AIOS)
or atraumatic minor shoulder instability (AMSI). [20].
Micro-instability is the most common condition in throw-
ing athletes.
Shoulder instability usually results in subluxation or
dislocation of the humeral head, mostly occurring antero-
inferiorly, thus causing GL, capsule and bony injuries [21].

Internal impingement

Internal impingement refers to the impaction of the greater

tuberosity of the humerus against the postero-superior
aspect of the glenoid as the arm is abducted and externally
rotated. A portion of the RC may be entrapped between the
bones [9].
This contact can be present in normal asymptomatic
throwers but can become symptomatic and result in a
constellation of typical injuries, like partial cuff tears,
greater tuberosity bony changes and labral tears, that are
typically located over the postero-superior region of the
glenoid rim [22].
Imaging techniques
Despite the availability of more sophisticated imaging
modalities, shoulder is usually imaged with radiography
first, especially in a post-traumatic setting. Radiographic
evaluation in thrower’s shoulder can show anomalous
morphology of GH bones, dislocation of the humeral head
(Fig. 1), fractures, or subchondral cysts.
Ultrasonography (US) is a non-invasive and cost-effec-
tive imaging modality that can be used to assess shoulder
tendons, especially RC tears (Fig. 2) [23]. US can also be
performed with dynamic maneuvers and has the main
advantage of not providing ionizing radiations [24]. One
drawback of US is a suboptimal evaluation of intra-artic-
ular pathology.
Computed tomography (CT) has high sensitivity and
specificity in bone evaluation, also quantifying bone loss in
case of anterior luxation with glenoid fracture [25]. How-
ever, CT is rarely used to evaluate thrower’s shoulder due
to radiation exposure and the inability to correctly assess
soft-tissue lesions.
Fig. 1 Radiography of acute anterior dislocation. Arrow shows
engagement of the humeral head (H) with the anterior inferior
glenoid (G) profile. Some bony fragments can also be seen
(arrowhead)
Magnetic resonance imaging (MRI) is considered the
imaging modality of choice to evaluate thrower’s shoulder
[26] thanks to its high contrast resolution and the possibility
to obtain images in different planes. MRI has high sensi-
tivity and specificity for the detection of labral and RC tears
[27], also evaluating glenoid cartilage and soft-tissue
lesions. Moreover, MRI allows for detecting inflammation
and edema. For conventional MRI, anatomical (i.e., T1-
weighted) and fluid-sensitive (i.e., T2-weighted) sequences
are generally used. Another diagnostic option is MR
arthrography, which implies the intra-articular injection of
gadolinium-based diluted contrast agent. This technique
allows for distending the joint space thus increasing accu-
racy in detecting labral and capsular abnormalities, as well
as undersurface RC tears [28]. MR arthrography is usually
performed using particular T1-weighted sequences, in
which signal obtained from fat tissue is electronically sub-
tracted (i.e., fat saturation) [29]. MR arthrography allows
for more confident distinction of pathologic conditions from
anatomic variations of labral morphology or GH ligaments,
which are encountered in 1.5–27 % of shoulders [30].
Shoulder-specific injuries
As reported, lesions in thrower’s shoulders can involve
more than one anatomical structure.

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Fig. 2 Ultrasound of the shoulder. a Normal appearance of supra-
spinatus tendon (arrows) showing normal fibrillar echotexture. b Thin
full-thickness perforation of the supraspinatus tendon (arrows). Note
that the tear is predominantly articular (arrowheads) with a very thin
full-thickness perforation of tendon matrix (circle). D deltoid,
H humerus
RC tears
In throwing athletes, tears are typically partial-thickness
and occur on the articular side of RC tendons. They are
usually seen at the postero-superior aspect of the cuff, at
the junction of the infraspinatus and supraspinatus tendon
insertions. Occasionally, tear of the cranial fibers of the
subscapularis tendon can be seen, possibly resulting in
subtle instability of the long head of biceps tendon (LHBT)
in the humeral groove, which may lead to anterior pain
[31].
US is a quick and cheap imaging modality to assess RC
tears. Diagnostic accuracy of US in detecting RC tendon
disruptions varies according to the size of the lesion. On
US, partial RC tears appear as small, localized hypoechoic
areas affecting only a side of the tendon thickness. US has
been reported to have 93 % sensitivity and 94 % specificity
[32], although performance may be lower in detecting
small undersurface tears. Full-thickness tears are typically
seen as hypoechoic areas involving the full thickness of the
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tendon. In acute traumatic lesions, the tendon is usually not
retracted and still detectable by US. In chronic ruptures, the
tendon stump is retracted and is usually undetectable, as it
disappears under the acromion. US has been demonstrated
to be non inferior to MRI in diagnosing full-thickness tears,
with 93–97 % sensitivity and 91–100 % specificity [33,
34]. US is also able to detect a series of additional findings
around the shoulder, such as thickening or effusion of
subacromial-subdeltoid bursa, and pathological findings of
LHBT, such as tenosynovitis, dislocation, partial or com-
plete rupture [34].
On MRI, partial-thickness tears appear as focal defects
along the articular or bursal surface of the tendons. Of note,
detection of small undersurface cuff tears is often extre-
mely subtle. Tears are usually seen as areas of fluid-
equivalent signal intensity on fluid-sensitive images. Inju-
ries of the subscapularis tendon are less common than those
involving the supraspinatus and infraspinatus tendons [35].
Conventional MRI has been reported to have 69 %
sensitivity and 94 % specificity in the diagnosis of partial-
thickness tears [36]. MR arthrography has been reported to
be more useful in detecting partial RC tears detecting tears
involving\25 % of the cuff with 85 % sensitivity [37, 38].
Full-thickness tears are seen as fluid extending across
the tendon (Fig. 3). In this case, the dimension of the tear,
the degree of the tendon retraction, and the possible asso-
ciate muscular atrophy can be accurately assessed. To
diagnose full-thickness tears, MRI and MR arthrography
have been demonstrated to have similar sensitivity
(92–95 %) and specificity (93–98 %) [39]. MR arthrogra-
phy can also be performed positioning the patient into the
MR scanner with the arm in abduction and extra rotation
(ABER position) (Fig. 3b). This approach is helpful to
increase diagnostic accuracy of undersurface tears, as dis-
tance between RC tendons and humeral head increase and
contrast agent infiltration can be more effectively detected.
GL tears and biceps pathology
A wide range of different tears can affect the GL. However,
in an overhead setting, degenerative tears are much more
common than traumatic ones. The most commonly
encountered type of degenerative GL tear affects the
superior GL from anterior to posterior (SLAP lesions). In
thrower’s athletes, SLAP tears are commonly seen over the
postero-superior portion of the GL, occasionally involving
the apex (i.e., the biceps anchor), and can be quite debili-
tating (Fig. 4) [39]. Extreme external rotation of the
shoulder may be a cause of increased strain at the biceps
anchor during the late cocking phase. A dynamic peel-back
phenomenon involving biceps tendon in throwers with
posterior and combined antero-posterior SLAP lesions has
been demonstrated arthroscopically [6]. This phenomenon
Sport Sci Health (2013) 9:81–88 85

addition, the biceps root will shift medial to the supragle-

noid tubercle [6, 7]. This peel-back phenomenon is a
consistent finding in patients with posterior SLAP lesions
and it is absent in normal shoulder and in some anterior
SLAP lesions. This mechanism is enhanced in subjects
with GIRD, in whom the thickened postero-inferior capsule
acts as a fulcrum that contributes to further dislocate the
humeral head.
Chronic traction on the LHBT during the deceleration
phase has been also implicated as a causative factor [40].
The GL usually has a low signal, triangular shape on
cross-sectional imaging. Findings that may help to confirm
a diagnosis of SLAP lesion include abnormal signal
intensity within the GL, irregularity of GL margins, and
signal abnormality extending into the bicipital anchor
(Fig. 5). Diagnostic performance of conventional MRI in
detecting GL tears has been reported to be extremely
valuable, with 44–100 % sensitivity and 66–95 % speci-
ficity [27, 28]. Conversely, MR arthrography has been
demonstrated to have higher sensitivity (86–91 %) and
specificity (86–98 %). This is due to contrast agent injected
in the capsule that allows for detecting possible contrast
leakage between the GL and the bony glenoid [41]. ABER
position may further helps to improve the diagnosis
(Fig. 3b) [42].

Bony changes

Some authors theorized that osteochondral lesions seen in

the humeral head of thrower’s shoulders (Fig. 6) are due to
repetitive avulsive trauma caused by deceleration during
motion of throwing [43]. Recently, it has been suggested

Fig. 3 MR arthrography in a 28-year-old waterpolo player. a Neutral

position, coronal T1-weighted image. Full-thickness tear (arrow-
heads) of the supraspinatus tendon (SSPt). SSPm supraspinatus
muscle, C clavicle. b Abduction and extrarotation (ABER) position,
fat-saturated T1-weighted image. Arrowheads show complete tear of
the supraspinatus tendon. The infraspinatus tendon (ISPt) is pre-
served. SS scapular spine H humerus, G glenoid, D deltoid

occurs with the arm abducted and extra-rotated and is due

to the effect of the biceps tendon as its vector shifts to a
more posterior position in the late cocking. At arthroscopy,
when the arm is removed from traction and brought into
abduction and external rotation the biceps tendon can be
seen to assume a more vertical and posterior angle. This
dynamic angle change produces a posterior shift in the
biceps vector as well as a twist at the base of the biceps,
which then transmits a torsional force to the posterior
superior labrum. If the superior labrum is not well- Fig. 4 MR arthrography in a 29-year-old basketball player. Axial fat-
saturated T1-weighted image. Black arrows show a cleft at the base of
anchored to the glenoid, this posteriorly directed torsional
the bicipital anchor (i.e., the superior labrum), indicating a SLAP
force will cause it to rotate medially over the corner of the lesion. LHBT long head of biceps tendon, G glenoid, SS scapular
glenoid onto the postero-superior scapular neck. In spine

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Fig. 5 MR arthrography in a 24-year-old volleyball player. Axial fat-
saturated T1-weighted image. Black arrows show detachment of the
anterior labrum. H humerus, G glenoid, C coracoid
Fig. 6 Conventional MR in a 27-year-old volleyball player. Coronal
fat-saturated T2-weighted image. White arrows show subcortical
changes over the greater tuberosity due to repetitive microtrauma.
H humerus, SSPt supraspinatus tendon, SSPm supraspinatus muscle,
A acromion
that the reiterated impact of the greater tuberosity onto the
glenoid in abduction and external rotation results in an
inflammatory process, which increases vascularity, in turn
resulting in bony changes [44]. Subcortical marrow edema
and cysts in the greater tuberosity or in the postero-superior
glenoid are also secondary signs of shoulder instability and
impingement and are more conspicuous on fluid-sensitive
images. Subchondral sclerosis is also a sign of overload.
When present, sclerosis is best identified on T1-weighted
images, as low signal intensity contrasts sharply with the
high intensity of the adjacent marrow fat [45].
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Sport Sci Health (2013) 9:81–88
Discussion
The performance of overhead athletes is frequently limited
by overuse shoulder injuries. These may occur as a result
of a combination of muscle fatigue imbalances, anterior
capsular laxity, posterior capsular contractures, abnormal
mechanics, and repetitive microtrauma from compressive,
tensile, and torsional forces. Burkhart et al. [6] proposed
that the primary insult in throwers with painful shoulder is
a tight postero-inferior capsule originated by repetitive
microtrauma, causing the postero-inferior capsule and
posterior band of the IGL to thicken and contract. They
hypothesized that the tight posterior capsule combined
with anterior capsular stretching is a more likely expla-
nation for the abrasion injury seen in the posterior superior
labrum and RC. These structural changes to the capsule
could also create shear stresses to the posterior supraspi-
natus and infraspinatus tendon, leading to an articular
surface partial-thickness cuff tear and allowing excessive
twisting of the biceps tendon, thus explaining the peel-
back mechanism over the posterior superior labrum [46].
As a result, lesions that involve the postero-superior aspect
of the GL, RC tendons, and the chondral surfaces are
commonly seen in throwing athletes. Clinical history and
physical examination can be inadequate to establish an
accurate diagnosis.
Based on the accurate recognition of the lesion and
underlying cause of the pathology, a successful non-oper-
ative or in some cases operative treatment plan can be
implemented. The main goal in treatment is to return ath-
letes to their previous activity level. Overhead shoulder
pathologies are treatable if prompt diagnosis is undertaken.
Diagnostic imaging, in particular MR arthrography, has
been demonstrated to be able to detect most abnormalities
around the shoulder, being also helpful in ruling out those
cases in which clinical diagnosis is inconclusive. Thanks to
multi-planar evaluation and high contrast resolution, MR
arthrography can provide excellent depiction of intra-
articular structures of GH joint. Furthermore, imaging
plays a crucial role in selecting patients who can be treated
conservatively and those who need surgical repair.
However, a thorough understanding of the biomechanics
of thrower’s shoulder and of the pathogenetic mechanisms
is necessary to establish a correct diagnosis on images.
Conflict of interest Authors have no conflict of interest to disclose
in regard to the present paper.
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