CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 434, pp. 130–137
© 2005 Lippincott Williams & Wilkins
MRI Findings in Throwing Shoulders
Abnormalities in Professional Handball Players
Bernhard Jost, MD*; Matthias Zumstein, MD*; Christian W. A. Pfirrmann, MD†;
Marco Zanetti, MD†; and Christian Gerber, MD*
Magnetic resonance imaging (MRI) is one of the most
important imaging methods for evaluation of clinical
shoulder abnormalities. It is known from previous studies
that abnormalities seen on MRI scans frequently are present in shoulders of asymptomatic volunteers with average
overhead use of the arm.9,11,12,14,16
In overhead athletes with repetitive shoulder activity
MRI abnormalities have been reported even more frequently, but these studies included either only asymptomatic1,6,7,10,15 or only symptomatic shoulders.3,5 However,
these studies compared only the prevalence of MRI abnormalities of the repetitively overhead stressed shoulders
with the contralateral shoulders. A comparison of repetitively overhead stressed shoulders with shoulders of a normal population is lacking.1,3,5–7,10,15 Because none of
these reports have included symptomatic and asymptomatic shoulders, no reliable information regarding correlation between MRI findings and clinical tests is available.
Frequently seen MRI abnormalities in the overhead athlete’s shoulder involve the rotator cuff tendons, but the
reported prevalence of tendinopathies, partial tears, and
full-thickness tears are somewhat contradictory.1,10 Magnetic resonance imaging abnormalities of the humeral head
in the overhead athlete’s shoulder are described in a few
studies, but they are not specified.1,5,13
We wanted to assess the prevalence and the type of
abnormal MRI findings in the throwing shoulder compared with the athletic but nonthrowing contralateral
shoulder, and with shoulders of volunteers engaged only in
recreational sports activity. We were particularly interested in MRI abnormalities of the rotator cuff tendons;
especially in differentiating between tendinopathies, partial tears, and full-thickness tears, the superolateral aspect
of the humeral head in terms of edema, cysts, and osteochondral defects. Furthermore, we sought to correlate
symptoms with abnormal MRI findings in the throwing
shoulder.
Shoulders of throwing athletes are highly stressed joints and
likely to have more structural abnormalities seen on magnetic resonance imaging scans. Prevalence and type of structural abnormalities, especially abnormalities of the rotator
cuff tendons and the superolateral humeral head, and correlation of magnetic resonance imaging findings with symptoms and clinical tests, are not well known. Throwing and
nonthrowing (symptomatic and asymptomatic) shoulders of
30 fully competitive professional handball players and 20
dominant shoulders of randomly selected volunteers were
evaluated for comparison clinically and with magnetic resonance imaging. An average of seven abnormal magnetic resonance imaging findings was observed in the throwing shoulders; more than in the nonthrowing and the control shoulders. Although 93% of the throwing shoulders had abnormal
magnetic resonance imaging findings, only 37% were symptomatic. Partial rotator cuff tears and mainly superolateral
osteochondral defects of the humeral head were identified as
typical throwing lesions. Symptoms correlated poorly with
abnormalities seen on magnetic resonance imaging scans and
findings from clinical tests. This suggests that the evaluation
of an athlete’s throwing shoulder should be done very thoroughly and should not be based mainly on abnormalities seen
on magnetic resonance imaging scans.
Level of Evidence: Diagnostic study, Level III-1 (study of
nonconsecutive patients—no consistently applied reference
“gold” standard)
Received: May 13, 2004
Revised: October 18, 2004
Accepted: December 1, 2004
From the *Department of Orthopedics; and the †Department of Radiology,
University of Zurich, Balgrist, Zurich, Switzerland.
Each author certifies that he has no commercial associations (consultancies,
stock ownership, equity interest, patent/licensing arrangements, etc) that
might pose a conflict of interest in connection with the submitted article.
Each author certifies that his institution has approved the human protocol for
this investigation and that all investigations were conducted in conformity
with ethical principles of research, and that informed consent was obtained.
Correspondence to: Bernhard Jost, MD, Department of Orthopedics, University of Zurich, Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland.
Phone: 41-1-386-1111; Fax: 41-1-386-1609; E-mail: bernhard.jost@
balgrist.ch.
DOI: 10.1097/01.blo.0000154009.43568.8d
MATERIALS AND METHODS
We elected to study shoulders of elite handball (team handball in
the United States) players. Handball is a fast-moving indoor
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May 2005
contact sport mainly played in Europe resulting in a substantial
number of acute and chronic upper extremity injuries. A team
consists of six field players and one goalkeeper. The aim of the
team in possession of the ball is to move the ball down the court
to score by throwing (almost always overhead) the ball into the
goal. The handball is round, made of leather, has a diameter of
approximately19 cm (circumference of approximately 60 cm),
and a weight of approximately 450 g. Overhead throws will yield
ball speeds of 130 km/hour, and a player will perform at least
48,000 throwing motion per season.8 The shoulder of handball
players therefore are subjected to high repetitive stresses, mostly
caused by an overhead throwing movement, comparable to that
of baseball pitchers (Fig 1).
Thirty selected fully competitive professional handball players from the top four teams of the Swiss Handball League 2001
including all Swiss National Team players were evaluated in this
study. Asymptomatic and symptomatic or painful throwing
shoulders were included. None of the players with symptoms had
limitations in his throwing activity. Excluded were players with
prior shoulder surgery and goalkeepers who have no repetitive
throwing activity.
The mean duration of competition on a professional level was
9 years (range, 2–24 years), with an average practice per week
including games of 20 hours. Both shoulders of the players with
an average age of 27 years (range, 20–39 years) were examined.
In addition, the dominant shoulder of 20 randomly selected volunteers with average recreational overhead activity and an average age of 29 years (range, 24–34 years) were examined as a
control group. This resulted in three groups: Group 1, the athlete’s throwing shoulder; Group 2, the athlete’s nonthrowing
shoulder; and Group 3, the dominant shoulder of volunteers. All
shoulders were examined clinically and with MRI. The study
was approved by the local institutional review board.
All shoulders had MRI according to the following standard
protocol. In the coronal oblique plane, T2-weighted and inter-
Fig 1. A typical handball overhead throwing movement is
shown.
MRI Findings in Throwing Shoulders
131
mediate-weighted fast spin-echo images with fat saturation
(3300/95 and 14 [repetition time ms/echo time ms]) were obtained (4 mm section thickness, 160 × 100 mm field of view, 256
× 512 matrix). In the transverse plane, T2-weighted and intermediate-weighted fast spin-echo images with fat saturation
(3300/95 and 14) were obtained (4 mm section thickness, 160 ×
160 mm field of view, 256 × 512 matrix). In the sagittal oblique
plane, T1-weighted spin-echo images were obtained (600/12, 4
mm section thickness, 160 × 100 mm field of view, 512 × 320
matrix). Two experienced musculoskeletal radiologists evaluated the MRI in consensus and were blinded for all shoulders of
the three groups. Rotator cuff abnormalities were divided into
tendinopathies: partial and complete tears of the supraspinatus,
infraspinatus, and subscapularis tendons. Posterosuperior glenoid impingement was identified when an articular partial tear in
the posterior aspect of the supraspinatus tendon was visible.17
Anterior glenoid rim impingement was assessed according to
Weishaupt et al.18 Abnormalities of the anterior, posterior, and
cranial labrum were characterized as normal (uniform low signal
intensity compared with muscle with a triangular or round configuration of the labrum) or pathologic (degenerated ⳱ globular
or diffuse high signal intensity within the labrum or irregular
contours; and torn ⳱ linear high signal intensity extending
through the labrum to both surfaces, cleft in the labrum, separation of the labrum from the surface of the glenoid cavity, or
absent labrum). Ganglion cysts around the glenohumeral shoulder were assessed and localization was determined (anterior,
posterior, cranial, and caudal) and divided into small (< 5 mm),
medium (5–15 mm), and large (> 15 mm) cysts.
Osseous abnormalities in the glenoid and the humeral head
were divided into edema, cyst formation, and osteochondral defects. The long biceps tendon was categorized as normal (no
caliber changes, smooth contours, and low signal intensity) or
abnormal (thickened or attenuated with an abrupt change of caliber, irregular contours, and increased signal intensity). Degenerative changes in the glenoid and humeral head cartilage were
graded as either subtle (signal alterations or irregular surface of
the cartilage and superficial cartilage defects) or marked (defects
of greater than 50% of the cartilage thickness and defects reaching the subchondral bone). Acromioclavicular joint changes
were graded as mild (small osteophytes < 3 mm, contour irregularities, acromioclavicular joint effusion, thickening of the acromioclavicular joint capsule < 3 mm) or severe (large osteophytes
> 3 mm, thickening of the acromioclavicular joint capsule > 3
mm, presence of subchondral cysts, and bone marrow edema).
The presence or absence of edema of the lateral part of the
clavicle was noted. Finally, MRI signal abnormalities in the
subacromial bursa were assessed.
Clinical assessment was done by two examiners (BJ, MZ) in
a standardized fashion including a structured interview and a
detailed physical examination including all elements requested
for shoulder function according to Constant and Murley.2 The
total score obtained in points (absolute Constant score) also was
related to the age- and gender-matched normal values, and the
respective value in percent was called the relative Constant
score.4 The two examiners did the clinical examinations of each
player and volunteer in consensus.
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Clinical Orthopaedics
and Related Research
In addition, shoulders were tested in detail for shoulder instability (anterior and posterior apprehension test and hyperabduction test), laxity (sulcus sign in neutral and external rotation,
anterior and posterior drawer test), rotator cuff lesions (Jobe test,
external rotation strength, lift-off test, and lag signs), subacromial impingement (Neer test and modified Hawkins test), posterosuperior glenoid impingement (Walch test), and biceps abnormalities (palm-up test and O’Brien test).
The Mann-Whitney test was used for unpaired groups and the
Wilcoxon test was used for paired groups. For the frequency
between two groups the McNemar test was used for paired
groups and the chi square test was used for unpaired groups. The
level of significance was set at p < 0.05. Spearman’s correlation
coefficient was used to test relationships between variables.
RESULTS
Overall, abnormal MRI findings according to the above
criteria were identified in 93% (28 of 30 patients) of the
shoulders in Group 1, in 83% (25 of 30 patients) of the
shoulders in Group 2 and in 80% (16 of 20 patients) of
shoulders in Group 3. In the 30 shoulders in Group 1, an
average of seven (range, 0–13) abnormal MRI findings per
shoulder was identified, in the 30 shoulders in Group 2, an
average of four abnormal findings was identified (range,
0–15), and in the 20 shoulders of Group 3, an average of
two (range, 0-5) abnormal findings was identified. The
number of abnormal findings was more frequent in Group
1 compared with Group 2 (p ⳱ 0.0004), in Group 1 compared with Group 3 (p < 0.0001), and in Group 2 compared
with Group 3 (p ⳱ 0.0097).
There were no complete rotator cuff tears in the 80
shoulders. A supraspinatus abnormality (tendinopathy or
partial tear) was identified in 83% of shoulders in Group 1
with partial tears in 43% (Fig 2). Whereas supraspinatus
abnormalities were more frequent compared with abnormalities in Group 2 (43%; p ⳱ 0.01) and Group 3 (35%;
p ⳱ 001), there was no difference between Groups 2 and
3. An infraspinatus abnormality was found in 60% of
shoulders in Group 1 (partial tears in 27%), more frequent
than in shoulders in Group 2 (p ⳱ 0.0005) and Group 3 (p
⳱ 0.0004), but there was no difference between Groups 2
and 3. The subscapularis was abnormal in 50% of shoulders in Group 1 (partial tears in 17%) (Table 1).
Abnormalities of the superolateral aspect of the humeral head adjacent to the supraspinatus insertion on the
greater tuberosity were consistent and frequent MRI findings of the throwing shoulder. Edema (37%) and bony
cysts (60%) were more frequent in shoulders in Group 1
than in shoulders in Group 2 (edema, p ⳱ 0.05; cysts, p ⳱
0.01) or Group 3 (edema, p ⳱ 0.002; cysts, p ⳱ 0.008).
Superolateral osteochondral defects of the humeral head
(Fig 3) were identified in 57% of shoulders in Group 1.
This was more frequent than in shoulders in Group 2 (p ⳱
0.001) and Group 3 (p < 0.0001) (Table 1).
Fig 2. A coronal oblique T2-weighted fat-saturated MRI scan
shows the right throwing shoulder of a 28-year-old professional handball player. An extensive partial tear of the supraspinatus (arrow heads) is visible. The player had slight diffuse
pain in the throwing shoulder at the time of examination, but he
had 12 abnormal MRI findings.
Posterior labral abnormalities were more frequent in
shoulders in Group 1 and Group 2 compared with shoulders in Group 3 (p ⳱ 0.05 and p ⳱ 0.01). Anterior labral
abnormalities were more frequent only in Group 1 compared with Group 3 (p ⳱ 0.05). The frequency of ganglion
cysts was not different among groups, but large cysts (> 15
mm) (Fig 4) were observed only in throwing shoulders
(three of nine). A posterosuperior glenoid impingement
was detected more frequently in shoulders in Group 1
(37%) than in shoulders in Group 2 (0%; p ⳱ 0.001) or
Group 3 (5%; p ⳱ 0.01). The frequency of acromioclavicular joint abnormalities was not different between
Group 1 (33%) and Group 2 (30%), but was less frequent
in Group 3 (5%; p ⳱ 0.01 and p ⳱ 0.02).
There was no difference of frequencies in terms of subacromial bursal, long biceps tendon, glenohumeral joint
cartilage, and anterior glenoid rim impingement among the
three groups.
The Constant and Murley scores of all subjects were
within normal values with no difference among the three
groups (Table 2). Although shoulders in Group 1 were nire
painful than shoulders in Group 2 or Group 3, the difference was not significant (p > 0.05). External rotation at
90° abduction was greater (p ⳱ 0.003) and internal rota-
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May 2005
MRI Findings in Throwing Shoulders
133
TABLE 1. Frequency of Abnormal MRI Findings: Comparison of Throwing, Nonthrowing, and
Control Shoulders
Magnetic Resonance
Imaging Findings
Group 1
(n = 30)
Throwing
Shoulder
Percent (n)
Supraspinatus abnormality
Tendinopathy
Partial tear
Infraspinatus abnormality
Tendinopathy
Partial tear
Subscapularis abnormality
Tendinopathy
Partial tear
Superolateral humeral head edema
Superolateral humeral head cyst
Superolateral humeral head defect
Anterior labrum abnormality
Posterior labrum abnormality
Posterosuperior glenoid impingement
Ganglion cyst
Acromioclavicular joint
83 (25)
40 (12)
43 (13)
60 (18)
33 (10)
27 (8)
50 (15)
33 (10)
17 (5)
37 (11)
60 (18)
57 (17)
40 (12)
30 (9)
37 (11)
30 (9)
40 (12)
p Value*
0.01
0.0005
0.09
0.05
0.01
0.001
0.5
0.2
0.001
0.3
1.0
Group 2
(n = 30)
Nonthrowing
Shoulder
Percent (n)
43 (13)
20 (6)
23 (7)
13 (4)
10 (3)
3 (1)
23 (7)
10 (3)
13 (4)
10 (3)
33 (10)
13 (4)
30 (9)
17 (5)
0 (0)
20 (6)
37 (11)
p Value†
0.3
0.6
0.2
0.1
0.3
0.8
0.2
0.05
0.1
1.0
0.02
Group 3
(n = 20)
Control
Percent (n)
Group 1
versus
Group 3
p Value†
35 (7)
25 (5)
10 (2)
5 (1)
5 (1)
0 (0)
10 (2)
10 (2)
0 (0)
0 (0)
25 (5)
0 (0)
15 (3)
0 (0)
5 (1)
20 (4)
5 (1)
0.001
0.0004
0.01
0.002
0.008
<0.0001
0.05
0.01
0.01
0.4
0.01
* = paired signed test McNemar (level of significance < 0.05); †= chi square test (level of significance < 0.05)
tion was less (p ⳱ 0.01) in shoulders in Group 1 compared
with shoulders in Group 2. Thirty-seven percent of the
shoulders in Group 1 were painful or symptomatic at the
time of examination, but all 11 players were fully competitive and reported no restriction in their throwing activity. Pain in symptomatic shoulders averaged 10 points
(range, 5–14 points) on the visual analog scale (VAS)
scale of the Constant and Murley score. Pain correlated
poorly with abnormal MRI findings and clinical tests;
weak correlations could be found only for the Jobe, Neer,
and Hawkins tests (Table 3).
Pain was not associated with any of the identified typical MRI abnormalities of the shoulders in Group 1. A
supraspinatus abnormality was found in all of the 11
symptomatic shoulders (seven partial tears and four tendinopathies), and in 14 of the 19 asymptomatic shoulders
(six partial tears and eight tendinopathies). Similar observations were made for the other rotator cuff tendons in the
symptomatic shoulders in Group 1 shoulders in which 10
MRI abnormalities were found in the infraspinatus (three
partial tears and seven tendinopathies) and subscapularis
(two partial tears and eight tendinopathies) each. In the 19
asymptomatic shoulders in Group 1, eight also had MRI
abnormalities of the infraspinatus (five partial tears and
three tendinopathies) and five of the subscapularis (three
partial tears and two tendinopathies). Therefore, pain did
not seem to be associated with an abnormality of a single
rotator cuff tendon, but ten of the 11 painful shoulders had
an abnormality in all three tendons. This was almost not
observed in asymptomatic shoulders (one of 19 asymptomatic shoulders; p ⳱ 0.003).
Superolateral osteochondral defects of the humeral
head also were not associated with pain, as in five of the
11 symptomatic and in 12 of the 19 asymptomatic shoulders in Group 1, such an MRI abnormality was found.
Posterosuperior glenoid impingement was observed in
symptomatic (six of 11) and asymptomatic (five of 19)
throwing shoulders and therefore was not associated with
pain.
DISCUSSION
Highly repetitively stressed joints like throwing shoulders
of overhead athletes are likely to have more structural
abnormality and therefore more abnormal findings on
MRI. Few studies have been published in which abnormal
MRI findings were analyzed, and these studies were done
either in athletes who were asymptomatic or with a limited
number of throwers,7,10 only in a heterogeneous group of
overhead athletes, who were asymptomatic, with mixed
hitting (tennis players) and throwing (baseball pitchers)
activities,1 or only in throwing athletes who were symptomatic.5 The only study investigating symptomatic and
asymptomatic shoulders included marathon kayakers with
equal stresses on both shoulders.6 To our knowledge, our
series with the assessment of 30 fully competitive profes-
134
Jost et al
Clinical Orthopaedics
and Related Research
Fig 4. An axial proton density fat-saturated MRI scan of the
right throwing shoulder of a 26-year-old handball player shows
a large posterior ganglion cyst (arrowhead). There is an associated posterior labral tear (arrow). The player was asymptomatic.
Fig 3A–B. A (A) coronal oblique proton density fat-saturated
MRI scan and an (B) axial proton density fat-saturated MRI
scan of the right throwing shoulder of a 27-year-old professional handball player show a large superolateral osteochondral defect (arrowhead) on the humeral head close to the supraspinatus insertion. There is surrounding edema in the humeral head and the greater tuberosity (arrow), and an
additional partial tear of the supraspinatus (curved arrow). The
player was asymptomatic.
sional handball players is the largest homogeneous MRI
study of throwing athletes which compares throwing with
contralateral nonthrowing shoulders, and with shoulders of
volunteers with normal recreational overhead sports activities. The specific focus of our investigation was to
determine the prevalence and type of abnormal MRI findings, especially in terms of abnormalities of the rotator
cuff and the superolateral aspect of the humeral head. Including asymptomatic and symptomatic throwing shoulders allowed us to determine the correlation of MRI abnormalities with symptoms and clinical tests.
This study has limitations. Although this is the largest
series in the literature, the number of subjects is still small.
However, this group of high level throwing athletes is
homogenous with a substantial number. Furthermore, the
players were examined together in consensus by two examiners (BJ, MZ) who had been elite handball players.
Therefore they were familiar with shoulder abnormalities
and symptoms encountered in this sport. Second, evaluation was done with MRI without arthrography which did
not allow making substantial conclusions in terms of labral
or biceps tendon and glenohumeral cartilage conditions.
This study revealed a high prevalence of abnormal MRI
findings in the throwing shoulders of elite handball players
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May 2005
TABLE 2.
MRI Findings in Throwing Shoulders
135
Comparison Constant and Murley Score between Different Groups
Component
Group 1
Throwing
Shoulder
(n = 30)
p Value*
Group 2
Nonthrowing
Shoulder
(n = 30)
Subjective shoulder value (percent)‡
Constant and Murley absolute score (points)§
Constant and Murley relative score (percent)㛳
Pain (points, VAS 0–15)¶
External rotation in 90° abduction (degrees)
Internal rotation in 90° abduction (degrees)
Strength for abduction (kg)#
94
104
13.5
100
65
11
ns
ns
ns
ns
0.003
0.01
ns
96
93
105
14.5
92
70
11
p Value†
ns
ns
ns
ns
Group 3
Control
(n = 20)
93
103
15
98
79
9.2
p Value†
ns
ns
ns
ns
* = Wilcoxon test (level of significance < 0.05); † = Mann-Whitney (level of significance < 0.05); ‡ = Patients estimation of the shoulder in percent compared with a
normal shoulder; § = Constant and Murley score in points; 㛳 = Relative Constant and Murley score in percent of an age- and gender-related normal value; ¶ = According
to Constant and Murley with VAS (visual analog scale); # = Strength in kilograms measured with an Isobex姞 dynamometer; ns = not significant.
compared with the contralateral nonthrowing shoulder,
and with the shoulders of the volunteers. Although MRI
abnormalities were observed in 93% of the throwing
shoulders and an average of seven abnormalities per shoulder was identified, only 37% of the handball players were
symptomatic. Correlation of pain with MRI findings was
poor and might be explained by the high number of different abnormal findings per throwing shoulder. Shoulders
of handball players or overhead throwing athletes in general seem to occur in a special category of patients with
shoulder disorders in whom the discrepancy of imaging
findings and clinical symptoms make diagnosis and treatment challenging. Therefore, shoulder surgery in the overhead athlete should be evaluated thoroughly and should
not be based predominantly on imaging findings.
Furthermore, our study allowed us to identify typical
MRI abnormalities of throwing shoulders which are likely
to be relevant for throwing athletes in general. The most
impressive and typical MRI findings of the throwing
shoulders were rotator cuff tendon abnormalities, posteroTABLE 3.
superior glenoid impingement, and especially superolateral osteochondral lesions of the humeral head. The high
prevalence of rotator cuff abnormalities (83%) in throwing
shoulders is similar to the prevalence in other reported
studies.1,7,10 Miniaci et al10 observed, in 14 throwing
shoulders of baseball pitchers, MRI signal abnormalities
consistent with tendinopathy in the supraspinatus and infraspinatus in as much as 86% of shoulders, but the subscapularis tendon always was normal. No partial or fullthickness tears were found, which is in contrast to our
study where partial tears were identified frequently in all
three tendons (supraspinatus, 43%; infraspinatus, 27%;
and subscapularis, 17%). Connor et al1 observed a similar
frequency of rotator cuff tears (40%) in the dominant
shoulder in their series of 20 athletes with mixed overhead
activities (tennis players and baseball pitchers), but partial
and full-thickness tears were not differentiated. In our series, no full-thickness tear was observed in the 80 examined shoulders. These observations suggest that tendinopathies and partial rotator cuff tears are well tolerated in fully
Correlations between Selected Clinical Tests and Imaging Data
Component 1
Jobe test
Jobe test
Jobe test
Jobe test
Neer test
Neer test
Neer test
Neer test
Hawkins test
Hawkins test
Hawkins test
Hawkins test
Throwing shoulders (n = 30)
Spearman Rank
Correlation (r)
Component 2
MRI
MRI
MRI
MRI
MRI
MRI
MRI
MRI
MRI
MRI
MRI
MRI
supraspinatus abnormality
infraspinatus abnormality
superolateral humeral head
superolateral humeral head
supraspinatus abnormality
infraspinatus abnormality
subscapularis abnormality
superolateral humeral head
supraspinatus abnormality
infraspinatus abnormality
subscapularis abnormality
superolateral humeral head
cysts
defect
defect
defect
0.43
0.45
0.56
0.58
0.47
0.58
0.56
0.50
0.43
0.38
0.61
0.45
136
Clinical Orthopaedics
and Related Research
Jost et al
competitive high-level throwing athletes and do not seem
to have a substantial influence on their throwing ability.
Consistent with the report of Connor et al,1 but not with
the study Miniaci et al,10 our data showed that MRI abnormalities of the supraspinatus and infraspinatus were
more frequent in elite throwing shoulders compared with
the contralateral nonthrowing shoulders. In addition to
data in the literature, our data also revealed that symptomatic throwing shoulders did not have more rotator cuff
abnormalities than pain-free asymptomatic shoulders.
Forty-six percent of the supraspinatus partial tears were
asymptomatic, even 63% of the infraspinatus and 60% of
the subscapularis partial tears. Only players with simultaneous MRI abnormalities of all three tendons were more
symptomatic, which may suggest the beginning decompensation of a highly stressed shoulder.
Posterosuperior glenoid impingement, first described
by Walch et al,17 is a mechanical conflict of the deep
surface of the posterior supraspinatus with the posterosuperior glenoid in greater than 90° abduction and maximal
external rotation, typically found in throwing athletes. It
has been a consistent finding in overhead throwing athletes.5,7,13 In our study, a posterosuperior glenoid impingement was confirmed as a typical throwing lesion and identified on MRI in approximately 1⁄3 of the throwing shoulders. But like rotator cuff abnormalities, it was not a
predictor for pain as 45% of the throwing shoulders with
a posterosuperior glenoid impingement were completely
asymptomatic.
The most impressive abnormal MRI findings in this
series were osteochondral defects of the humeral head.
The observed lesions were clear osteochondral defects
which could be well differentiated from humeral head
cysts and were consistently located superolateral on the
humeral head adjacent to the supraspinatus insertion on the
greater tuberosity. On MRI scans, shape and configuration
of these osteochondral lesions were similar to Hill-Sachs
lesions found after anterior shoulder dislocation, but were
situated clearly more superiorly on the humeral head, and
furthermore, none of the handball players had a history of
shoulder dislocation. Superolateral osteochondral defects
of the humeral head were typical throwing abnormalities
found in 57% of the throwing shoulders.
Abnormalities which might be similar to our findings
have been observed in the greater tuberosity (cystic
changes)1 or in the posterior aspect of the humeral head
(osteochondral defects)5,15,17 of throwing shoulders, but
were not further specified. In an arthroscopic study (without preoperative MRI) by Paley et al,13 osteochondral lesions similar to our defects were identified in 17% of
overhead throwing athletes (mainly baseball pitchers) and
were interpreted as impingement of the humeral head with
the glenoid rim. We agree with this hypothesis that these
superolateral osteochondral defects of the humeral head
are the consequence of a repetitive mechanical conflict of
the humeral head with the posterosuperior glenoid rim at
the end of the late cocking phase of the throwing motion
in abduction and maximal external rotation. However,
there was no association of this often impressive MRI
abnormality with pain, as 71% of the throwing shoulders
with such a defect were asymptomatic.
In professional handball players abnormal MRI findings were found in 93% of the throwing shoulders, but
only 37% of the shoulders were symptomatic. There is a
discrepancy between a large number of impressive abnormal MRI findings, absent or moderate clinical symptoms,
and poor correlation with physical examination. Therefore,
abnormal MRI findings are of limited value in assessing
the athlete’s throwing shoulder, and indications for shoulder surgery should be determined carefully. Tendinopathies and partial tears of the rotator cuff, posterosuperior
glenoid impingement, and mainly impressive superolateral
osteochondral defects of the humeral head were typical
asymptomatic MRI findings of throwing shoulders.
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3. Ferrari JD, Ferrari DA, Coumas J, Pappas AM: Posterior ossification of the shoulder: The Bennett lesion: Etiology, diagnosis, and
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