Postoperative Imaging in the Throwing Athlete

Abstract

Overhead throwing subjects the shoulder and elbow to substantial stresses, resulting in unique injury patterns that need to be recognized to allow appropriate treatment and return to sport. At the elbow, the ulnar collateral ligament (UCL) is the primary static restraint to valgus stress and the most commonly injured structure. UCL reconstruction is the most frequent surgical procedure in throwers and may be performed along with ulnar nerve transposition and flexor-pronator mass procedures. Posteromedial impingement and valgus extension overload syndrome are related entities that result in intra-articular pathology, such as osteophytes or bodies lodged within the olecranon fossa, also warranting excision at the time of UCL reconstruction. Shoulder injuries involve the rotator cuff (partial-thickness articular-sided tear), labrum (superior anteroposterior labral tear), and capsule (glenohumeral internal rotation deficit). Surgical options such as cuff repair, labral debridement or repair, and capsular release or tightening therefore target these structures.

Keywords

throwing - labral tear - rotator cuff tear - ulnar collateral ligament reconstruction

Publication History

Article published online:
11 February 2025

• References

• 1 Makhni EC, Lee RW, Morrow ZS, Gualtieri AP, Gorroochurn P, Ahmad CS. Performance, return to competition, and reinjury after Tommy John surgery in major league baseball pitchers: a review of 147 cases. Am J Sports Med 2014; 42 (06) 1323-1332
• 2 Chalmers PN, Erickson BJ, D'Angelo J, Ma K, Romeo AA. Epidemiology of shoulder surgery among professional baseball players. Am J Sports Med 2019; 47 (05) 1068-1073
• 3 Goes PK, Flores DV, Damer A, Huang BK. Shoulder and elbow injuries in adult overhead throwers: imaging review. Radiographics 2023; 43 (12) e230094
• 4 Fleisig GS, Escamilla RF. Biomechanics of the elbow in the throwing athlete. Oper Tech Sports Med 1996; 4 (02) 62-68
• 5 Meister K. Injuries to the shoulder in the throwing athlete: Part one: Biomechanics/Pathophysiology/Classification of injury. Am J Sports Med 2005; 33 (01) 3-7
• 6 Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy 2003; 19 (04) 404-420
• 7 Wo S, Mulcahy H, Richardson ML. et al. Pathologies of the shoulder and elbow affecting the overhead throwing athlete. Skeletal Radiol 2017; 46 (07) 873-888
• 8 Molenaars RJ, van den Bekerom MPJ, Eygendaal D, Oh LS. The pathoanatomy of the anterior bundle of the medial ulnar collateral ligament. J Shoulder Elbow Surg 2019; 28 (08) 1497-1504
• 9 Ciccotti MC, Hammoud S, Dodson CC, Cohen SB, Nazarian LN, Ciccotti MG. Stress ultrasound evaluation of medial elbow instability in a cadaveric model. Am J Sports Med 2014; 42 (10) 2463-2469
• 10 Nazarian LN, McShane JM, Ciccotti MG, O'Kane PL, Harwood MI. Dynamic US of the anterior band of the ulnar collateral ligament of the elbow in asymptomatic major league baseball pitchers. Radiology 2003; 227 (01) 149-154
• 11 Roedl JB, Gonzalez FM, Zoga AC. et al. Potential utility of a combined approach with US and MR arthrography to image medial elbow pain in baseball players. Radiology 2016; 280 (01) 328-328
• 12 Timmerman LA, Schwartz ML, Andrews JR. Preoperative evaluation of the ulnar collateral ligament by magnetic resonance imaging and computed tomography arthrography. Evaluation in 25 baseball players with surgical confirmation. Am J Sports Med 1994; 22 (01) 26-31 ; discussion 32
• 13 Magee T. Accuracy of 3-T MR arthrography versus conventional 3-T MRI of elbow tendons and ligaments compared with surgery. AJR Am J Roentgenol 2015; 204 (01) W70-W75
• 14 Lund P, Waslewski GL, Crenshaw K. et al. FEVER: The flexed elbow valgus external rotation view for MRI evaluation of the ulnar collateral ligament in throwing athletes—a pilot study in major league baseball pitchers. AJR Am J Roentgenol 2021; 217 (05) 1176-1183
• 15 Wong TT, Lin DJ, Ayyala RS, Kazam JK. Elbow injuries in adult overhead athletes. AJR Am J Roentgenol 2017; 208 (03) W110-W120
• 16 Savoie III FH, Trenhaile SW, Roberts J, Field LD, Ramsey JR. Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: a case series of injuries to the proximal and distal ends of the ligament. Am J Sports Med 2008; 36 (06) 1066-1072
• 17 Vitale MA, Ahmad CS. The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes: a systematic review. Am J Sports Med 2008; 36 (06) 1193-1205
• 18 Deely DM, Morrison WB. Imaging the postoperative elbow. Semin Musculoskelet Radiol 2021; 25 (04) 628-636
• 19 Wear SA, Thornton DD, Schwartz ML, Weissmann III RC, Cain EL, Andrews JR. MRI of the reconstructed ulnar collateral ligament. AJR Am J Roentgenol 2011; 197 (05) 1198-1204
• 20 Daniels SP, Mintz DN, Endo Y, Dines JS, Sneag DB. Imaging of the post-operative medial elbow in the overhead thrower: common and abnormal findings after ulnar collateral ligament reconstruction and ulnar nerve transposition. Skeletal Radiol 2019; 48 (12) 1843-1860
• 21 Gruber H, Glodny B, Peer S. The validity of ultrasonographic assessment in cubital tunnel syndrome: the value of a cubital-to-humeral nerve area ratio (CHR) combined with morphologic features. Ultrasound Med Biol 2010; 36 (03) 376-382
• 22 Bäumer P, Dombert T, Staub F. et al. Ulnar neuropathy at the elbow: MR neurography—nerve T2 signal increase and caliber. Radiology 2011; 260 (01) 199-206
• 23 Terayama Y, Uchiyama S, Ueda K. et al. Optimal measurement level and ulnar nerve cross-sectional area cutoff threshold for identifying ulnar neuropathy at the elbow by MRI and ultrasonography. J Hand Surg Am 2018; 43 (06) 529-536
• 24 Keller RA, Marshall NE, Bey MJ. et al. Pre- and postseason dynamic ultrasound evaluation of the pitching elbow. Arthroscopy 2015; 31 (09) 1708-1715
• 25 Wei SH, Jong YJ, Chang YJ. Ulnar nerve conduction velocity in injured baseball pitchers. Arch Phys Med Rehabil 2005; 86 (01) 21-25 ; quiz 180
• 26 Clain JB, Vitale MA, Ahmad CS, Ruchelsman DE. Ulnar nerve complications after ulnar collateral ligament reconstruction of the elbow: a systematic review. Am J Sports Med 2019; 47 (05) 1263-1269
• 27 Hodgins JL, Trofa DP, Donohue S, Littlefield M, Schuk M, Ahmad CS. Forearm flexor injuries among major league baseball players: epidemiology, performance, and associated injuries. Am J Sports Med 2018; 46 (09) 2154-2160
• 28 Kijowski R, De Smet AA. Magnetic resonance imaging findings in patients with medial epicondylitis. Skeletal Radiol 2005; 34 (04) 196-202
• 29 Han SH, Lee JK, Kim HJ, Lee SH, Kim JW, Kim TS. The result of surgical treatment of medial epicondylitis: analysis with more than a 5-year follow-up. J Shoulder Elbow Surg 2016; 25 (10) 1704-1709
• 30 Paci JM, Dugas JR, Guy JA. et al. Cannulated screw fixation of refractory olecranon stress fractures with and without associated injuries allows a return to baseball. Am J Sports Med 2013; 41 (02) 306-312
• 31 Walch G, Boileau P, Noel E, Donell ST. Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: an arthroscopic study. J Shoulder Elbow Surg 1992; 1 (05) 238-245
• 32 Kibler WB, Sciascia A, Thomas SJ. Glenohumeral internal rotation deficit: pathogenesis and response to acute throwing. Sports Med Arthrosc Rev 2012; 20 (01) 34-38
• 33 Myers JB, Laudner KG, Pasquale MR, Bradley JP, Lephart SM. Glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med 2006; 34 (03) 385-391
• 34 Tuite MJ, Petersen BD, Wise SM, Fine JP, Kaplan LD, Orwin JF. Shoulder MR arthrography of the posterior labrocapsular complex in overhead throwers with pathologic internal impingement and internal rotation deficit. Skeletal Radiol 2007; 36 (06) 495-502
• 35 Mistry A, Campbell RSD. Microinstability and internal impingement of the shoulder. Semin Musculoskelet Radiol 2015; 19 (03) 277-283
• 36 Tirman PF, Bost FW, Garvin GJ. et al. Posterosuperior glenoid impingement of the shoulder: findings at MR imaging and MR arthrography with arthroscopic correlation. Radiology 1994; 193 (02) 431-436
• 37 Halbrecht JL, Tirman P, Atkin D. Internal impingement of the shoulder: comparison of findings between the throwing and nonthrowing shoulders of college baseball players. Arthroscopy 1999; 15 (03) 253-258
• 38 Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy 2003; 19 (06) 641-661
• 39 Liem D, Lichtenberg S, Magosch P, Habermeyer P. Arthroscopic rotator cuff repair in overhead-throwing athletes. Am J Sports Med 2008; 36 (07) 1317-1322
• 40 Mazoué CG, Andrews JR. Repair of full-thickness rotator cuff tears in professional baseball players. Am J Sports Med 2006; 34 (02) 182-189
• 41 Roy JS, Braën C, Leblond J. et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a systematic review and meta-analysis. Br J Sports Med 2015; 49 (20) 1316-1328
• 42 Gulotta LV, Nho SJ, Dodson CC, Adler RS, Altchek DW, MacGillivray JD. HSS Arthroscopic Rotator Cuff Registry. Prospective evaluation of arthroscopic rotator cuff repairs at 5 years: part II—prognostic factors for clinical and radiographic outcomes. J Shoulder Elbow Surg 2011; 20 (06) 941-946
• 43 Pierce JL, Nacey NC, Jones S. et al. Postoperative shoulder imaging: rotator cuff, labrum, and biceps tendon. Radiographics 2016; 36 (06) 1648-1671
• 44 Yoo HJ, Choi JY, Hong SH. et al. Assessment of the postoperative appearance of the rotator cuff tendon using serial sonography after arthroscopic repair of a rotator cuff tear. J Ultrasound Med 2015; 34 (07) 1183-1190
• 45 Crim J, Burks R, Manaster BJ, Hanrahan C, Hung M, Greis P. Temporal evolution of MRI findings after arthroscopic rotator cuff repair. AJR Am J Roentgenol 2010; 195 (06) 1361-1366
• 46 Zanetti M, Jost B, Hodler J, Gerber C. MR imaging after rotator cuff repair: full-thickness defects and bursitis-like subacromial abnormalities in asymptomatic subjects. Skeletal Radiol 2000; 29 (06) 314-319
• 47 Spielmann AL, Forster BB, Kokan P, Hawkins RH, Janzen DL. Shoulder after rotator cuff repair: MR imaging findings in asymptomatic individuals—initial experience. Radiology 1999; 213 (03) 705-708
• 48 Magee T, Shapiro M, Hewell G, Williams D. Complications of rotator cuff surgery in which bioabsorbable anchors are used. AJR Am J Roentgenol 2003; 181 (05) 1227-1231
• 49 Chang EY, Bencardino JT, French CN. et al. SSR white paper: guidelines for utilization and performance of direct MR arthrography. Skeletal Radiol 2024; 53 (02) 209-244
• 50 Duc SR, Mengiardi B, Pfirrmann CWA, Jost B, Hodler J, Zanetti M. Diagnostic performance of MR arthrography after rotator cuff repair. AJR Am J Roentgenol 2006; 186 (01) 237-241
• 51 Burkhart SS, Morgan CD. The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy 1998; 14 (06) 637-640
• 52 Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy 1998; 14 (06) 553-565
• 53 Borrero CG, Casagranda BU, Towers JD, Bradley JP. Magnetic resonance appearance of posterosuperior labral peel back during humeral abduction and external rotation. Skeletal Radiol 2010; 39 (01) 19-26
• 54 Popp D, Schöffl V. Superior labral anterior posterior lesions of the shoulder: current diagnostic and therapeutic standards. World J Orthop 2015; 6 (09) 660-671
• 55 Rand T, Trattnig S, Breitenseher M, Wurnig C, Marschner B, Imhof H. The postoperative shoulder. Top Magn Reson Imaging 1999; 10 (04) 203-213
• 56 Wagner SC, Schweitzer ME, Morrison WB, Fenlin Jr JM, Bartolozzi AR. Shoulder instability: accuracy of MR imaging performed after surgery in depicting recurrent injury—initial findings. Radiology 2002; 222 (01) 196-203
• 57 Sugimoto H, Suzuki K, Mihara K, Kubota H, Tsutsui H. MR arthrography of shoulders after suture-anchor Bankart repair. Radiology 2002; 224 (01) 105-111
• 58 Tehranzadeh AD, Fronek J, Resnick D. Posterior capsular fibrosis in professional baseball pitchers: case series of MR arthrographic findings in six patients with glenohumeral internal rotational deficit. Clin Imaging 2007; 31 (05) 343-348
• 59 Cools AM, Johansson FR, Cagnie B, Cambier DC, Witvrouw EE. Stretching the posterior shoulder structures in subjects with internal rotation deficit: comparison of two stretching techniques. Shoulder Elbow 2012; 4 (01) 56-63
• 60 Yoneda M, Nakagawa S, Mizuno N. et al. Arthroscopic capsular release for painful throwing shoulder with posterior capsular tightness. Arthroscopy 2006; 22 (07) 801.e1-801.e5
• 61 Codding J, Dahm DL, McCarty III LP, May JH, Tucker LH, Buss DD. Arthroscopic posterior-inferior capsular release in the treatment of overhead athletes. Am J Orthop 2015; 44 (05) 223-227