Clinical Note
MR Imaging of Shoulder Injuries
in Professional Baseball Players'
D. Lawrence Burk, Jr, MD Jorge L. Torres, MD
Donald G. Mitchell, MD Matthew D. Rifkin, MD
Magnetic resonance (MR)im-
aging was used to evaluate the
shoulders of 10 symptomatic
professional baseball players
and one asymptomatic player,
with surgical correlation in six
cases and arthrographiccorre-
lation in two cases. Seven
small rotator cuff tears mea-
suring 0.6-1 cm were identi-
fied on MR images. with ar-
thrographic and surgical con-
firmation of these findings in
two patients and surgical con-
firmation only in three pa-
tients. Cortical irregularity
and/or subchondral cyst for-
mation at the posterior aspect
of the greater tuberosity near
the insertion site of the infra-
spinatus tendon was found in
five of the seven players with
rotator cuff tears. Similar
findings were noted in the
asymptomaticvolunteer and
in one of the three players
without cuff tear. who also had
irregular thickening of the
posterior capsule. These find-
ings are believed to represent
chronic avulsive changes re-
sulting from the deceleration
stresses of the follow-through
motion.
Index terms: Athletic injuries,
41.4813. Shoulder. injuries. 41.4813
Shoulder, MR studies. 41.1214 Ten-
dons, Injuries. 41 4813 * Tendons, MR
studles. 41.121 4
JMRI 1991; 1:385-389
From the Departments of Radiology
(D.L.B..D.G.M.,M.D.R., D.K.)andOr-
thopedics (P.J.M.),Thomas Jefferson
University Hospital. Rm 1033. Main
Bldg, 132 S 10th St. Philadelphia, PA
19107: and the Hospital Damas, Ponce.
Puerto Rlco (J.L.T.).From the 1990
SMRI annual meeting. Received No-
vember 12. 1990: revision requested
December 19: revision received Janu-
ary 3. 199 1: accepted January 7. Ad-
dress reprint request6 to D.L.B.
OSMRI, 1991
Phillip J. Marone, MD
David Karasick, MD
MAGNETIC RESONANCE (MR) imag-
ing is rapidly gaining acceptance as
an important technique for evaluating
the shoulder (1).Rotator cuff tears
can be detected with an accuracy
equal to or exceeding that of arthrog-
raphy, and the size of tears and the
degree of cuff atrophy can be quanti-
tated. In cases in which arthrographic
findings may be normal, MR imaging
can enable detection of tendinitis,
static impingement, or bursitis [2).
Other causes of shoulder pain such as
labral and capsular tears, muscle
tears, loose bodies, and ganglion cysts
can also be evaluated (3).
Athletes who throw, such as base-
ball players, create tremendous
stresses on the rotator cuff and other
components of the shoulder joint that
result in a variety of acute and chron-
ic injuries (4).In the high-pressure at-
mosphere of professional sports,
where there is significant incentive
for rapid rehabilitation of these in-
jured athletes, arthroscopy is becom-
ing increasingly popular as the next
step in diagnosis after plain radiogra-
phy. This invasive approach requires
general anesthesia and is not without
morbidity (5).In addition, treatment
capabilities through the arthroscope
are limited, and open surgery may be
required. As a noninvasive study that
can enable a comprehensive evalua-
tion of the shoulder, MR imaging
should have a more significant impact
on the workup of these players than
either arthrography or sonography. In
this preliminary study, we have at-
tempted to determine the potential
role for MR imaging in baseball
throwing injuries by examining 10
symptomatic players and one asymp-
tomatic player.
0 METHODS
Ten professional baseball players
were referred for MR imaging to eval-
uate shoulder pain in the throwing
arm. There were seven pitchers, two
third basemen, and one outfielder. In
addition, one asymptomatic pitcher
with no history of significant shoulder
pain was recruited as a healthy vol-
unteer. The average age of the players
was 30 years, with a range of 23-39
years. Their average weight was 192
pounds (87 kg) with a range of 175-
207 pounds (79-94 kg). Imaging was
performed on a 1.5-T magnet with ei-
ther a prototype loop-gap resonator
coil pair (Medical Advances, Milwau-
kee) or a n anteriorly positioned sin-
gle-loop coil (Medrad, Pittsburgh, for
GE Medical Systems, Milwaukee). The
players were imaged in the supine po-
sition, with the arm at the side and
the thumb in a neutral position. The
coil position in these broad-shoul-
dered individuals was usually near
the periphery of the magnet bore,
where the field was less homoge-
neous, but image quality was ade-
quate for diagnosis in all cases. Respi-
ratory compensation and even-echo
rephasing were used to combat occa-
sional respiratory motion artifacts,
and oversampling was used routinely
in the phase- and frequency-encoding
axes to prevent aliasing artifacts.
All pulse sequences were performed
with two excitations, a 128 X 256 ac-
quisition matrix, a 5-mm section
thickness, and a 1-mm intersection
gap. A spin-echo (SE)600/20 (TR
msec/TE msec) axial localizer se-
quence with a 16-cm field of view was
used to prescribe 14-cm-field-of-view
oblique coronal and sagittal SE 2,0001
40.80 sequences and an oblique coro-
nal SE 600/25 sequence. In patients
in whom there was a question of
shoulder instability, a n axial SE
2,000/20,80 sequence was also per-
formed, although the quality of the
initial images obtained with the proto-
type loop-gap resonator coil pair was
limited by respiratory motion artifact
in most cases. Image quality in the ax-
ial plane improved at the end of the
study, when the anteriorly positioned
single-loop coil was used, allowing ad-
equate visualization of the glenoid la-
385
 Figure 1. Full-thickness su-
praspinatus tendon tear. SE
2,000/80oblique coronal im-
age. Fluid-filled defect in the
supraspinatus tendon [arrow)
demonstrates high signal in-
tensity.

a. b.
Figure 2. Partial-thickness supraspinatus tendon tear. (a)SE 2,000/80 oblique coronal image. Small tear at the distal
insertion of the supraspinatus tendon (arrow]. (b)Arthrogram shows that a small amount of contrast material has passed
from the glenohumeral joint into the rotator cuff near the greater tuberosity [arrow),without filling of the subdeltoid bursa.

brum and capsular structures.
Tears were prospectively seen as
fluid-filled gaps in the rotator cuff ten-
dons on T2-weighted images [Fig 1).
Definite differentiation between small
full-thickness tears and large partial-
thickness tears could not be made
with certainty on the basis of the MR
images. Correlation with the findings
at surgery was obtained in six pa-
tients. Four patients underwent clini-
cal follow-up only. Correlation with
arthrography after interpretation of
the MR images was obtained in two of
these patients.
0 RESULTS
Seven tears confined to the distal
insertion of the supraspinatus tendon
were detected on MR images, and
tears were confirmed in all five of
these patients who went to surgery.
The tears varied in size at surgery
from 0.5 to 1 cm. Despite the relative-
ly small size of these tears, none of
the players treated surgically was
able to return to his previous level of
performance and all subsequently re-
tired. The first two of these patients
underwent arthrography before sur-
gery, and the findings on MR images
were confirmed (Fig 2). After these
initial cases and on the basis of exten-
sive experience in other patients, it
was concluded that arthrographic
correlation would not be required for
subsequent cases. Of the three pa-
tients who did not have rotator cuff
tears on MR images, the only patient
who underwent surgery was discov-
ered to have a small, superficial un-
dersurface tear that was treated with
minor debridement and that was not
seen on the MR study even in retro-
spect. The asymptomatic volunteer
had a normal cuff.

386 0 JMRl May/June 1991

a.
Figure 3. Subchondral defect at the posterior aspect of the greater tuberosity in asymptomatic volunteer. I = infraspina-
tus muscle. (a) SE 600/25 oblique coronal image. Low-signal-intensity focal lesion (arrow) at the insertion of the infraspi-
natus tendon. (b)SE 2.000/80oblique coronal image. Persistent low-signal-intensity central area with high-signal-inten-
sity rim [arrows)consistent with fibrosis surrounded by granulation tissue.
Seven patients were found to have
irregularity of the cortex and/or sub-
chondral cyst formation at the poste-
rior aspect of the greater tuberosity on
the MR images. This finding was
present in five of the seven patients
with rotator cuff tears, as well as in
the asymptomatic volunteer (Fig 3)
and in one of the three symptomatic
patients without cuff tear (Fig 4). The
lesion was consistently related to the
distal insertion of the infraspinatus
tendon (Fig 4c) and was usually
slightly posterior to the site of the su-
praspinatus tear when this finding
was present.
Additional findings were noted in
three of the patients who did not un-
dergo surgery. In the symptomatic pa-
tient without cuff tear described
above, irregular thickening of the pos-
terior capsule was noted on axial im-
ages [Fig 4c) near the triceps inser-
tion. In one patient with a small cuff
tear, a 0.5-cm ossicle was detected
within the substance of the supra-
spinatus tendon, which was visible
because of the presence of marrow
fat. This finding was thought to be a
loose body at plain radiography (Fig
5).In a pitcher with a normal rotator
cuff and pain only on adduction of the
shoulder during delivery of a curve
ball, tears of the latissimus dorsi and
teres major muscles were identified
(Fig 6). This finding correlated exactly
with the finding of posterior axillary
b.
pain at physical examination and was
useful in determining a definite cause
for this patient’s unusual symptoms.
After a rest of several months, this
player was able to return to active
participation at his previous level of
performance.
0 DISCUSSION
Throwing a baseball is a complex
motion that places a variety of stress-
e s on the shoulder that may lead to in-
jury when performed in a repetitive
fashion (6). A starting professional
baseball pitcher may throw up to 150
pitches a game and perform in as
many as 30 games in a season. A cy-
cle of combinations of contraction, re-
laxation, and stretch occurs in the
musculotendinous units, with local-
ization of forces at the tendon attach-
ment. The cocking and acceleration
phases of throwing place significant
stress on the anterior aspect of the ro-
tator cuff and may result in impinge-
ment of the supraspinatus tendon,
with tendinitis and eventual cuff tear.
The infraspinatus and teres minor
musculotendinousjunctions are fre-
quently inflamed due to the decelera-
tion stress of follow-through, which
may also produce a pull on the poste-
rior capsule and triceps tendon (7).
MR imaging is a noninvasive method
for evaluating many of the potential
injuries that may result from throw-
ing.
Volume 1
The utility of MR imaging in the
evaluation of the rotator cuff for tears
is well established, and the results of
our small series are in agreement
with those of previous larger studies
(8).The detection of a fluid-filled gap
in the rotator cuff tendons is a highly
sensitive and specific criterion for the
diagnosis of a cuff tear. Secondary cri-
teria such as absence of the normal
low signal intensity within the tendon
or distortion of tendon morphology
can also be helpful in the diagnosis of
tears and tendinitis. Agreement with
arthrography regarding the presence
of a tear is usually the case, as in our
two patients, although MR imaging
may show bursa1 side tears and tears
at the distal insertion site more effec-
tively. The one tear that was missed
at MR imaging was a very small, su-
perficial, joint-side lesion that was not
clinically significant. Differentiation
between full- and partial-thickness
tears is difficult in the case of small
tears because some fibers of the ten-
don may remain intact in full-thick-
ness tears and pinhole tears may be
interpreted as partial-thickness tears.
Even though the tears in our patients
were relatively small, measuring less
than 1 cm, the degree of disability in
these high-performance athletes was
significant and usually represented a
career-threatening injury.
Cortical irregularity and/or sub-
chondral cystic changes of the poste-
Number3 JMRl 387
a. b.
Figure 4. Subchondral cyst and posterior capsular
thickening in symptomatic patient without cuff tear. I =
infraspinatus muscle. (a) SE 600/25oblique coronal im-
age. Low-signal-intensity focal subchondral defect (arrow)
at the insertion of the infraspinatus tendon. @) SE 2,000/
80 oblique coronal image. High-signal-intensity cyst in
the posterior aspect of the greater tuberosity (arrow].
(0) SE 2,000/20 axial image. Focal cortical defect (black
arrow) at the insertion site of the infraspinatus tendon.
Low-signal-intensity irregular thickening of the posterior
capsule (white arrow) is also present.

rior aspect of the greater tuberosity

were present in a large proportion of
the players with and without rotator
cuff tears, including the asymptomat-
ic pitcher. These findings most likely
are the result of stress on the infraspi-
natus tendon during the deceleration
phase of the throwing motion. Irregu-
lar posterior capsular thickening near
the triceps insertion, which was seen
in one patient, is also probably related
to the deceleration forces of the fol-
low-through. These lesions may re-
sult in posterior shoulder pain, which
is different from the typical anterior
pain of the impingement syndrome.
Other causes of shoulder pain in the
throwing athlete that may be difficult
to adequately evaluate with other mo-
dalities can be diagnosed with MR im-
aging. One player with a possible
loose body a t plain radiography was
found to have a n intratendinous ossi-
cle at MR imaging. Mature osteochon-
dral fragments containing fatty mar-
row will demonstrate high signal in-
tensity on T1-weighted images, while
densely sclerotic lesions may have
low signal intensity at all pulse se-
quences. Cartilaginous loose bodies
may be invisible on T1-weighted im-
ages and only detectable on T2-
C.
weighted images. Muscle tears can be
suspected at clinical examination but
are difficult to confirm with conven-
tional imaging studies. In the patient
who presented with the unusual com-
plaint of having pain only when
throwing a curve ball, MR imaging
was useful in confirming the clinical
suspicion of tears of the teres major
and latissimus dorsi muscles. Biceps
tendon lesions and labral tears can
potentially also be evaluated with MR
imaging. The examination of these ar-
eas depends on high-quality axial im-
ages that are becoming increasingly
easy to obtain with recent improve-
ments in surface-coil technology.
MR imaging can be a valuable inter-
mediate diagnostic step between plain
radiography and arthroscopy in the
evaluation of shoulder pain in base-
ball players. Supraspinatus disorders
can be visualized with a great degree
of accuracy. Avulsive lesions associ-
ated with chronic stress at the inser-
tions of the infraspinatus and triceps
tendons can be identified posteriorly.
Other problems such as muscle tears
and loose bodies can be successfully
demonstrated. MR imaging also lends
itself to the performance of longitudi-
nal studies of professional athletes.
Such studies may be of benefit in de-
termining the natural history of these
career-threatening shoulder injuries
and in guiding management. 0

388 JMRl May/June 1991

a. b.
Figure 6. Marrow-containing intratendinous ossicle. (a) Anteroposterior radiograph shows well-corticated bone frag-
ment (arrow] adjacent to the greater tuberosity. @] SE 600/25coronal oblique image. High-signal-intensity fatty marrow of
ossicle [arrow) is contained within tendon of the supraspinatus muscle (S).

a. b.
Figure 6. Teres major and latissimus dorsi muscle tears. (a) SE 600/25coronal oblique image. Poorly defined muscles
(arrow)with obliterated fat planes inferior to glenoid. (b)SE 2.000/80coronal oblique image. High-signal-intensity hemor-
rhage and edema (arrow] within teres major and latissimus dorsi muscles, consistent with tears.

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Volume 1 Number3 JMRl 389