Advertisement

MR imaging of the shoulder in youth baseball players: Anatomy, pathophysiology, and treatment

      Highlights

      • Many of the shoulder injuries in youth baseball players are the result of repetitive overuse.
      • Injury patterns depend on the stage of skeletal maturation.
      • MR imaging assessment of the shoulder provides superior soft tissue, cartilage and physeal detail.
      • Injuries to the physis, osteochondral junction, labrum, capsule, and cuff can occur in adolescents.

      Abstract

      With an increasing participation in youth sports and a growing popularity of overhead sports, shoulder pain and injuries are common in pediatric baseball players. In contrast to traumatic and collision injuries, which are more frequent with high-impact sports, many of the shoulder injuries are the result of repetitive overuse. Undiagnosed and untreated injury to the growth plates of skeletally immature athletes can lead to remodeling, which can negatively impact the biomechanics of the shoulder and produce long-term morbidity. Recently, there is an increasing emphasis on the association between skeletal maturation and injury patterns. The increasing use of magnetic resonance (MR) imaging has led to a better characterization of the traditionally radiographically-diagnosed growth plate injuries and awareness of other soft tissue and cartilaginous injuries that were previously thought to predominately occur in adult baseball players. The goal of this review is to: 1) highlight the normal anatomic changes that occur in the shoulder girdle during development and maturation; 2) discuss the biomechanical forces that are applied to the shoulder during a pitch; and 3) highlight the various injury patterns and adaptive remodeling that can occur in the shoulders of youth baseball athletes along with the current treatment options. These topics include growth plate injury, osteochondral injury, labral tear, capsular remodeling and rotator cuff tendinopathy.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Clinical Imaging
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Sports NCoY
        Report on trends and participation in organized youth sports.
        NCYS, 2008
        • Conte S.
        • Requa R.K.
        • Garrick J.G.
        Disability days in major league baseball.
        Am J Sports Med. 2001; 29: 431-436
        • Robinson T.W.
        • Corlette J.
        • Collins C.L.
        • Comstock R.D.
        Shoulder injuries among US high school athletes, 2005/2006–2011/2012.
        Pediatrics. 2014; 133 ([peds. 2013-279]): 272-279
        • Leonard J.
        • Hutchinson M.R.
        Shoulder injuries in skeletally immature throwers: review and current thoughts.
        Br J Sports Med. 2010; 44: 306-310
        • O'Brien S.J.
        • Neves M.C.
        • Arnoczky S.P.
        • Rozbruck S.R.
        • Dicarlo E.F.
        • Warren R.F.
        • et al.
        The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder.
        Am J Sports Med. 1990; 18: 449-456
        • Long F.
        • Ornitz D.M.
        Development of the endochondral skeleton.
        Cold Spring Harb Perspect Biol. 2013; 5: a008334
        • Zember J.S.
        • Rosenberg Z.S.
        • Kwong S.
        • Kothary S.P.
        • Bedoya M.A.
        Normal skeletal maturation and imaging pitfalls in the pediatric shoulder.
        Radiographics. 2015; 35: 1108-1122
        • Matsen F.
        Rockwood C.A. Matsen F.A. Wirth M.A. Lippit S.B. Glenohumeral instability. The shoulder. fourt ed. Elsevier, 2009
        • Flecker H.
        Roentgenographic observations of the times of appearance of epiphyses and their fusion with the diaphyses.
        J Anat. 1932; 67 (Pt 1): 118-64.3
        • Kwong S.
        • Kothary S.
        • Poncinelli L.L.
        Skeletal development of the proximal humerus in the pediatric population: MRI features.
        AJR Am J Roentgenol. 2014; 202: 418-425
        • Gardner E.
        The embryology of the clavicle.
        Clin Orthop Relat Res. 1968; 58: 9-16
        • Moyer J.E.
        • Brey J.M.
        Shoulder injuries in pediatric athletes.
        Orthop Clin North Am. 2016; 47: 749-762
        • Kocher M.S.
        • Waters P.M.
        • Micheli L.J.
        Upper extremity injuries in the paediatric athlete.
        Sports Med. 2000; 30: 117-135
        • Ogden J.A.
        • Phillips S.B.
        Radiology of postnatal skeletal development. VII. The scapula.
        Skeletal Radiol. 1983; 9: 157-169
        • Boyle S.
        • Haag M.
        • Limb D.
        • Lafosse L.
        Shoulder arthroscopy, anatomy and variants - part 2.
        Orthopaedics and Trauma. 2009; 23: 365-376
        • Munshi M.
        • Davidson J.M.
        Unilateral glenoid hypoplasia: unusual findings on MR arthrography.
        AJR Am J Roentgenol. 2000; 175: 646-648
        • Owen R.
        Bilateral glenoid hypoplasia; report of five cases.
        J Bone Joint Surg Br. 1953; 35-b: 262-267
        • Kothary S.
        • Rosenberg Z.S.
        • Poncinelli L.L.
        • Kwong S.
        Skeletal development of the glenoid and glenoid-coracoid interface in the pediatric population: MRI features.
        Skeletal Radiol. 2014; 43: 1281-1288
        • Monk A.P.
        • Berry E.
        • Limb D.
        • Soames R.W.
        Laser morphometric analysis of the glenoid fossa of the scapula.
        Clin Anat. 2001; 14: 320-323
        • Roedl J.B.
        • Morrison W.B.
        • Ciccotti M.G.
        • Zoga A.C.
        Acromial apophysiolysis: superior shoulder pain and acromial nonfusion in the young throwing athlete.
        Radiology. 2015; 274: 201-209
        • Jones K.J.
        • Kahlenberg C.A.
        • Dodson C.C.
        • Nam D.
        • Williams R.J.
        • Altchek D.W.
        Arthroscopic capsular plication for microtraumatic anterior shoulder instability in overhead athletes.
        Am J Sports Med. 2012; 40: 2009-2014
        • Chen F.S.
        • Diaz V.A.
        • Loebenberg M.
        • Rosen J.E.
        Shoulder and elbow injuries in the skeletally immature athlete.
        J Am Acad Orthop Surg. 2005; 13: 172-185
        • Weber A.E.
        • Kontaxis A.
        • O'Brien S.J.
        • Bedi A.
        The biomechanics of throwing: simplified and cogent.
        Sports Med Arthrosc Rev. 2014; 22: 72-79
        • Dillman C.J.
        • Fleisig G.S.
        • Andrews J.R.
        Biomechanics of pitching with emphasis upon shoulder kinematics.
        J Orthop Sports Phys Ther. 1993; 18: 402-408
        • Lin D.J.
        • Wong T.T.
        • Kazam J.K.
        Shoulder injuries in the overhead-throwing athlete: epidemiology, mechanisms of injury, and imaging findings.
        Radiology. 2018; 286: 370-387
        • Lintner D.
        • Noonan T.J.
        • Kibler W.B.
        Injury patterns and biomechanics of the athlete's shoulder.
        Clin Sports Med. 2008; 27: 527-551
        • Zaremski J.L.
        • Krabak B.J.
        Shoulder injuries in the skeletally immature baseball pitcher and recommendations for the prevention of injury.
        PM R. 2012; 4: 509-516
        • Seroyer S.T.
        • Nho S.J.
        • Bach B.R.
        • Bush-Joseph C.A.
        • Nicholson G.P.
        • Romeo A.A.
        Shoulder pain in the overhead throwing athlete.
        Sports Health. 2009; 1: 108-120
        • Braun S.
        • Kokmeyer D.
        • Millett P.J.
        Shoulder injuries in the throwing athlete.
        J Bone Joint Surg Am. 2009; 91: 966-978
        • Kuhn J.E.
        • Lindholm S.R.
        • Huston L.J.
        • Soslowsky L.J.
        • Blasier R.B.
        Failure of the biceps superior labral complex: a cadaveric biomechanical investigation comparing the late cocking and early deceleration positions of throwing.
        Arthroscopy. 2003; 19: 373-379
        • Nishii T.
        • Tanaka H.
        • Sugano N.
        • Miki H.
        • Takao M.
        • Yoshikawa H.
        Disorders of acetabular labrum and articular cartilage in hip dysplasia: evaluation using isotropic high-resolutional CT arthrography with sequential radial reformation.
        Osteoarthr Cartil. 2007; 15: 251-257
        • Mosher T.J.
        Musculoskeletal imaging at 3T: current techniques and future applications.
        Magn Reson Imaging Clin N Am. 2006; 14: 63-76
      1. Kuo R, Panchal M, Tanenbaum L, Crues JV, 3rd. 3.0 Tesla imaging of the musculoskeletal system. Journal of magnetic resonance imaging : JMRI 2007;25(2):245–61.

        • Magee T.
        3-T MRI of the shoulder: is MR arthrography necessary?.
        AJR Am J Roentgenol. 2009; 192: 86-92
        • de Jesus J.O.
        • Parker L.
        • Frangos A.J.
        • Nazarian L.N.
        Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis.
        AJR Am J Roentgenol. 2009; 192: 1701-1707
        • Connell D.A.
        • Potter H.G.
        • Wickiewicz T.L.
        • Altchek D.W.
        • Warren R.F.
        Noncontrast magnetic resonance imaging of superior labral lesions. 102 cases confirmed at arthroscopic surgery.
        Am J Sports Med. 1999; 27: 208-213
        • Cochet H.
        • Couderc S.
        • Pele E.
        • Amoretti N.
        • Moreau-Durieux M.H.
        • Hauger O.
        Rotator cuff tears: should abduction and external rotation (ABER) positioning be performed before image acquisition? A CT arthrography study.
        Eur Radiol. 2010; 20: 1234-1241
        • Jung J.Y.
        • Jee W.H.
        • Chun H.J.
        • Ahn M.I.
        • Kim Y.S.
        Magnetic resonance arthrography including ABER view in diagnosing partial-thickness tears of the rotator cuff: accuracy, and inter- and intra-observer agreements.
        Acta Radiol. 2010; 51: 194-201
        • Magee T.
        Usefulness of unenhanced MRI and MR arthrography of the shoulder in detection of unstable labral tears.
        AJR Am J Roentgenol. 2015; 205: 1056-1060
        • Nguyen J.C.
        • Lin B.
        • Potter H.G.
        Maturation-dependent findings in the shoulders of pediatric baseball players on magnetic resonance imaging.
        Skeletal Radiol. 2019; ([Epub ahead of print])https://doi.org/10.1007/s00256-018-3130-2
        • Pennock A.T.
        • Dwek J.
        • Levy E.
        • Stearns P.
        • Manning J.
        • Dennis M.M.
        • et al.
        Shoulder MRI abnormalities in asymptomatic little league baseball players.
        Orthop J Sports Med. 2018; 62325967118756825
        • Carter S.R.
        • Aldridge M.J.
        • Fitzgerald R.
        • Davies A.M.
        Stress changes of the wrist in adolescent gymnasts.
        Br J Radiol. 1988; 61: 109-112
        • Nguyen J.C.
        • Markhardt B.K.
        • Merrow A.C.
        • Dwek J.R.
        Imaging of pediatric growth plate disturbances.
        Radiographics. 2017; 37: 1791-1812
        • Wu M.
        • Fallon R.
        • Heyworth B.E.M.
        Overuse injuries in the pediatric population.
        Sports Medicine & Arthroscopy Review. 2016; 24: 150-158
        • Mizuta T.
        • Benson W.M.
        • Foster B.K.
        • Paterson D.C.
        • Morris L.L.
        Statistical analysis of the incidence of physeal injuries.
        J Pediatr Orthop. 1987; 7: 518-523
        • Caine D.
        • DiFiori J.
        • Maffulli N.
        Physeal injuries in children's and youth sports: reasons for concern?.
        Br J Sports Med. 2006; 40: 749-760
        • Shapiro F.
        Epiphyseal growth plate fracture-separations: a pathophysiologic approach.
        Orthopedics. 1982; 5: 720-736
        • Salter R.B.
        • Harris W.R.
        Injuries involving the epiphyseal plate.
        JBJS. 1963; 45: 587-622
        • Ecklund K.
        • Jaramillo D.
        Patterns of premature physeal arrest: MR imaging of 111 children.
        AJR Am J Roentgenol. 2002; 178: 967-972
        • Khoshhal K.I.
        • Kiefer G.N.
        Physeal bridge resection.
        J Am Acad Orthop Surg. 2005; 13: 47-58
        • Dotter W.E.
        Little leaguer's shoulder: a fracture of the proximal epiphysial cartilage of the humerus due to baseball pitching.
        Guthrie Clin Bull. 1953; 23: 68-72
        • Heyworth B.E.
        • Kramer D.E.
        • Martin D.J.
        • Micheli L.J.
        • Kocher M.S.
        • Bae D.S.
        Trends in the presentation, management, and outcomes of little league shoulder.
        Am J Sports Med. 2016; 44: 1431-1438
        • Sabick M.B.
        • Kim Y.K.
        • Torry M.R.
        • Keirns M.A.
        • Hawkins R.J.
        Biomechanics of the shoulder in youth baseball pitchers: implications for the development of proximal humeral epiphysiolysis and humeral retrotorsion.
        Am J Sports Med. 2005; 33: 1716-1722
        • Osbahr D.C.
        • Kim H.J.
        • Dugas J.R.
        Little league shoulder.
        Curr Opin Pediatr. 2010; 22: 35-40
        • Axe M.
        • Hurd W.
        • Snyder-Mackler L.
        Data-based interval throwing programs for baseball players.
        Sports health. 2009; 1: 145-153
        • Committee UBMSA
        Youth baseball pitching injuries.
        • Patel D.R.
        • Breisach S.
        Evaluation and management of shoulder pain in skeletally immature athletes.
        Transl Pediatr. 2017; 6: 181-189
        • Hatem S.F.
        • Recht M.P.
        • Profitt B.
        MRI of Little Leaguer's shoulder.
        Skeletal Radiol. 2006; 35: 103-106
        • Song J.C.
        • Lazarus M.L.
        • Song A.P.
        MRI findings in Little Leaguer's shoulder.
        Skeletal Radiol. 2006; 35: 107-109
        • Seidl A.J.
        • Kraeutler M.J.
        Management of articular cartilage defects in the glenohumeral joint.
        J Am Acad Orthop Surg. 2018; 26: e230-e237
        • Chu P.J.
        • Shih J.T.
        • Hou Y.T.
        • Hung S.T.
        • Chen J.K.
        • Lee H.M.
        Osteochondritis dissecans of the glenoid: a rare injury secondary to repetitive microtrauma.
        J Trauma. 2009; 67: E62-E64
        • Fujisawa M.
        • Hara M.
        • Ogimoto S.
        • Araki G.
        Osteochondritis dissecans of the glenoid in two school baseball players.
        Katakansetsu. 2009; 37: 1335-1338
        • Koike Y.
        • Komatsuda T.
        • Sato K.
        Osteochondritis dissecans of the glenoid associated with the nontraumatic, painful throwing shoulder in a professional baseball player: a case report.
        J Shoulder Elbow Surg. 2008; 17: e9-12
        • Rossi F.
        • Dragoni S.
        Osteochondrosis dissecans of the shoulder glenoid fossa diagnosed in four throwing athletes.
        J Sports Med Phys Fitness. 2006; 46: 111-115
        • Nishinaka N.
        • Tsutsui H.
        • Mihara K.
        • Hokari S.
        A case report: painful throwing shoulder accompanied by a peculiar glenoid osteochondral injury.
        Shoulder Joint. 2002; 26: 419-422
        • Suzuki K.
        • Hiroaki T.
        • Kenichi M.
        • Shigeru H.
        • Tomoyoshi U.
        • Katsuhiro O.
        • et al.
        Painful throwing shoulder of a baseball player accompanied by an osteochondritis dissecans of the glenoid fossa: a case report.
        Shoulder Joint. 2003; 27: 295-299
        • Grossman M.G.
        • Tibone J.E.
        • McGarry M.H.
        • Schneider D.J.
        • Veneziani S.
        • Lee T.Q.
        A cadaveric model of the throwing shoulder: a possible etiology of superior labrum anterior-to-posterior lesions.
        J Bone Joint Surg Am. 2005; 87: 824-831
        • Yu J.S.
        • Greenway G.
        • Resnick D.
        Osteochondral defect of the glenoid fossa: cross-sectional imaging features.
        Radiology. 1998; 206: 35-40
        • Walch G.
        • Boileau P.
        • Noel E.
        • Donell S.T.
        Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: an arthroscopic study.
        J Shoulder Elbow Surg. 1992; 1: 238-245
        • Tirman P.F.
        • Bost F.W.
        • Garvin G.J.
        • Peterfy C.G.
        • Mall J.C.
        • Steinbach L.S.
        • et al.
        Posterosuperior glenoid impingement of the shoulder: findings at MR imaging and MR arthrography with arthroscopic correlation.
        Radiology. 1994; 193: 431-436
        • Pham T.T.
        • Kany J.
        • Lakhal W.
        • Sales de Gauzy J.
        • Accadbled F.
        Arthroscopic osteochondral autograft transfer for juvenile osteochondritis dissecans of the humeral head: a case report.
        JBJS Case Connect. 2017; 7: e63
        • Pydisetty R.V.
        • Prasad S.S.
        • Kaye J.C.
        Osteochondritis dissecans of the humeral head in an amateur boxer.
        J Shoulder Elbow Surg. 2002; 11: 630-632
        • Giaroli E.L.
        • Major N.M.
        • Higgins L.D.
        MRI of internal impingement of the shoulder.
        AJR Am J Roentgenol. 2005; 185: 925-929
        • Burkhart S.S.
        • Morgan C.D.
        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: 637-640
        • Snyder S.J.
        • Karzel R.P.
        • Del Pizzo W.
        • Ferkel R.D.
        • Friedman M.J.
        SLAP lesions of the shoulder.
        Arthroscopy. 1990; 6: 274-279
        • Burkhart S.S.
        • Morgan C.D.
        • Kibler W.B.
        The disabled throwing shoulder: spectrum of pathology part I: pathoanatomy and biomechanics.
        Arthroscopy. 2003; 19: 404-420
        • Connolly K.P.
        • Schwartzberg R.S.
        • Reuss B.
        • Crumbie D.
        • Homan B.M.
        Sensitivity and specificity of noncontrast magnetic resonance imaging reports in the diagnosis of type-II superior labral anterior-posterior lesions in the community setting.
        J Bone Joint Surg Am. 2013; 95: 308-313
        • Gusmer P.B.
        • Potter H.G.
        • Schatz J.A.
        • Wickiewicz T.L.
        • Altchek D.W.
        • O'Brien S.J.
        • et al.
        Labral injuries: accuracy of detection with unenhanced MR imaging of the shoulder.
        Radiology. 1996; 200: 519-524
        • Dinauer P.A.
        • Flemming D.J.
        • Murphy K.P.
        • Doukas W.C.
        Diagnosis of superior labral lesions: comparison of noncontrast MRI with indirect MR arthrography in unexercised shoulders.
        Skeletal Radiol. 2007; 36: 195-202
        • Trofa D.P.
        C.S. A. The management of superior labrum anterior-posterior tears in the throwers' shoulder.
        Oper Tech Sports med. 2016; 24: 181-188
        • Edwards S.L.
        • Lee J.A.
        • Bell J.E.
        • Packer J.D.
        • Ahmad C.S.
        • Levine W.N.
        • et al.
        Nonoperative treatment of superior labrum anterior posterior tears: improvements in pain, function, and quality of life.
        Am J Sports Med. 2010; 38: 1456-1461
        • Sayde W.M.
        • Cohen S.B.
        • Ciccotti M.G.
        • Dodson C.C.
        Return to play after type II superior labral anterior-posterior lesion repairs in athletes: a systematic review.
        Clin Orthop Relat Res. 2012; 470: 1595-1600
        • Brockmeier S.F.
        • Voos J.E.
        • Williams R.J.
        • Altchek D.W.
        • Cordasco F.A.
        • Allen A.A.
        • et al.
        Outcomes after arthroscopic repair of type-II SLAP lesions.
        J Bone Joint Surg Am. 2009; 91: 1595-1603
        • Galano G.J.
        • Ahmad C.S.
        • Bigliani L.
        • Levine W.
        Percutaneous SLAP lesion repair technique is an effective alternative to portal of Wilmington.
        Orthopedics. 2010; 33: 803
        • Park J.Y.
        • Chung S.W.
        • Jeon S.H.
        • Lee J.G.
        • Oh K.S.
        Clinical and radiological outcomes of type 2 superior labral anterior posterior repairs in elite overhead athletes.
        Am J Sports Med. 2013; 41: 1372-1379
        • Sethi P.M.
        • Tibone J.E.
        • Lee T.Q.
        Quantitative assessment of glenohumeral translation in baseball players: a comparison of pitchers versus nonpitching athletes.
        Am J Sports Med. 2004; 32: 1711-1715
        • Hibberd E.E.
        • Oyama S.
        • Myers J.B.
        Increase in humeral retrotorsion accounts for age-related increase in glenohumeral internal rotation deficit in youth and adolescent baseball players.
        Am J Sports Med. 2014; 42: 851-858
        • Major N.
        • Morrison W.B.
        • Coker D.
        The shoulder.
        Top Magn Reson Imaging. 2015; 24: 83-92
        • Ferrari J.D.
        • Ferrari D.A.
        • Coumas J.
        • Pappas A.M.
        Posterior ossification of the shoulder: the Bennett lesion. Etiology, diagnosis, and treatment.
        Am J Sports Med. 1994; 22 ([discussion 5-6]): 171-175
        • Miniaci A.
        • Mascia A.T.
        • Salonen D.C.
        • Becker E.J.
        Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers.
        Am J Sports Med. 2002; 30: 66-73
      2. Lombardo SJ, Jobe FW, Kerlan RK, Carter VS, Shields CL, Jr. Posterior shoulder lesions in throwing athletes. Am J Sports Med 1977;5(3):106–10.

        • Edmonds E.W.
        • Eisner E.A.
        • Kruk P.G.
        • Roocroft J.H.
        • Dwek J.D.
        Diagnostic shortcomings of magnetic resonance arthrography to evaluate partial rotator cuff tears in adolescents.
        J Pediatr Orthop. 2015; 35: 407-411
        • Yoneda M.
        • Nakagawa S.
        • Hayashida K.
        • Fukushima S.
        • Wakitani S.
        Arthroscopic removal of symptomatic Bennett lesions in the shoulders of baseball players: arthroscopic Bennett-plasty.
        Am J Sports Med. 2002; 30: 728-736
        • BENNETT G.E.
        Elbow and shoulder lesions of baseball players.
        Am J Surg. 1959; 98: 484-492
        • Bennett G.E.
        Shoulder and elbow lesions distinctive of baseball players. 1947.
        Clin Orthop Relat Res. 2012; 470: 1531-1533
        • Wright R.W.
        • Paletta G.A.
        Prevalence of the Bennett lesion of the shoulder in major league pitchers.
        Am J Sports Med. 2004; 32: 121-124
        • Bennett G.E.
        Shoulder and elbow lesions of the professional baseball pitcher.
        JAMA. 1941; 117: 510-514
      3. Connor PM, Banks DM, Tyson AB, Coumas JS, D'Alessandro DF. Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study. Am J Sports Med 2003;31(5):724–7.

        • Mazoue C.G.
        • Andrews J.R.
        Repair of full-thickness rotator cuff tears in professional baseball players.
        Am J Sports Med. 2006; 34: 182-189
        • Conway J.E.
        Arthroscopic repair of partial-thickness rotator cuff tears and SLAP lesions in professional baseball players.
        Orthop Clin North Am. 2001; 32: 443-456
        • Matava M.J.
        • Purcell D.B.
        • Rudzki J.R.
        Partial-thickness rotator cuff tears.
        Am J Sports Med. 2005; 33: 1405-1417
        • Shaffer B.
        • Huttman D.
        Rotator cuff tears in the throwing athlete.
        Sports Med Arthrosc Rev. 2014; 22: 101-109
        • Reinus W.R.
        • Shady K.L.
        • Mirowitz S.A.
        • Totty W.G.
        MR diagnosis of rotator cuff tears of the shoulder: value of using T2-weighted fat-saturated images.
        AJR Am J Roentgenol. 1995; 164: 1451-1455
        • Herold T.
        • Bachthaler M.
        • Hamer O.W.
        • Hente R.
        • Feuerbach S.
        • Fellner C.
        • et al.
        Indirect MR arthrography of the shoulder: use of abduction and external rotation to detect full- and partial-thickness tears of the supraspinatus tendon.
        Radiology. 2006; 240: 152-160
        • Lee S.Y.
        • Lee J.K.
        Horizontal component of partial-thickness tears of rotator cuff: imaging characteristics and comparison of ABER view with oblique coronal view at MR arthrography initial results.
        Radiology. 2002; 224: 470-476
        • Tirman P.F.
        • Bost F.W.
        • Steinbach L.S.
        • Mall J.C.
        • Peterfy C.G.
        • Sampson T.G.
        • et al.
        MR arthrographic depiction of tears of the rotator cuff: benefit of abduction and external rotation of the arm.
        Radiology. 1994; 192: 851-856
        • Polster J.M.
        • Schickendantz M.S.
        Shoulder MRI: what do we miss?.
        AJR Am J Roentgenol. 2010; 195: 577-584
        • Edelson G.
        • Teitz C.
        Internal impingement in the shoulder.
        J Shoulder Elbow Surg. 2000; 9: 308-315
        • Paley K.J.
        • Jobe F.W.
        • Pink M.M.
        • Kvitne R.S.
        • ElAttrache N.S.
        Arthroscopic findings in the overhand throwing athlete: evidence for posterior internal impingement of the rotator cuff.
        Arthroscopy. 2000; 16: 35-40
        • Perry J.
        Anatomy and biomechanics of the shoulder in throwing, swimming, gymnastics, and tennis.
        Clin Sports Med. 1983; 2: 247-270
        • Klouche S.
        • Lefevre N.
        • Herman S.
        • Gerometta A.
        • Bohu Y.
        Return to sport after rotator cuff tear repair: a systematic review and meta-analysis.
        Am J Sports Med. 2016; 44: 1877-1887
      4. Azzam MG, Dugas JR, Andrews JR, Goldstein SR, Emblom BA, Cain EL, Jr. Rotator cuff repair in adolescent athletes. Am J Sports Med 2018;46(5):1084–90.

        • Oliva F.
        • Piccirilli E.
        • Bossa M.
        • Via A.G.
        • Colombo A.
        • Chillemi C.
        • et al.
        I.S.Mu.L.T - rotator cuff tears guidelines.
        Muscles Ligaments Tendons J. 2015; 5: 227-263