Have you ever been in your doctor's office and they pull up your X-Ray or MRI to show you what’s going on, and you nod along even though you have no idea what you are looking at? Well, you are not alone. In fact, most clients I have worked with have had this exact experience. In this week’s edition of “The Overhead Athlete’s Edge,” I would like to share some basic anatomy and pointers to look for when analyzing your scan, so you can be an informed participant in that room with your doctor. So let’s dive in to the first edition of our Imaging 101 Series, as we take a look at the shoulder.

An Athlete’s Guide to Interpreting X-Rays

X-rays are like shadows of your bones. Think of them as taking a flashlight to shine through your skin – dense structures like bones appear white, while soft tissues appear in various shades of gray. Air appears black.

Key Landmarks on Shoulder X-Rays

The Glenohumeral Joint: The Ball and Socket
- The round "ball" at the top of your arm bone (humeral head)
- The shallow "socket" of your shoulder blade (glenoid)
- The space between them should be smooth and even
The Acromion: The “Roof” of Your Shoulder
- Appears as a horizontal white line above the ball
- Important because that is where many rotator cuff problems occur
The Clavicle: The “Collarbone”
- Appears as a long horizontal bone at the top of the x-ray
- The ONLY (really, it is) bone that connects your shoulder to your skeleton
The Scapula: The “Shoulder Blade”
- Appears as a triangular shape behind the shoulder joint
- Contains the socket portion of the joint and the acromion, and acts as an attachment site for ALL of the rotator cuff muscles

What We are Looking For on X-Ray

Narrowing of joint space and/or breaks in the smooth contouring of a joint (for example in arthritis)
Bone spurs or other atypical bony shapes
Obvious breaks or fractures

Check out this X-Ray of an AC Joint Sprain, notice the space between the acromion and the clavicle at the top of the shoulder.

Understanding Your MRI: A Deeper Look

An MRI shows the soft tissues that X-Rays don’t quite capture. When looking through your MRI slides, think of it like slicing through a loaf of bread – each image is a "slice" through your shoulder. A T2-Weighted Image is the more common type of MRI seen in orthopedics due to the fact that it highlights fluid and pathology.

Here is an axial image, meaning we are looking down at the shoulder from above.

Here is an A-P view, meaning anterior (front) to posterior (back). We are looking at a slice of the shoulder from in front.

How to Read MRI Colors on a T2-Weighted MRI

Black = Air and dense bone.
White = Fluid, swelling, and some tendons
Gray = Most muscles and normal tissues.
Dark Gray = Tendons and ligaments

Key Structures to Identify on MRI

Rotator Cuff Tendons
- Appear as dark bands above the ball of the shoulder
- Should be continuous without gaps; tears will show up as bright white areas which indicate fluid/swelling
Labrum
- The uniformly dark ring around the socket
- Tears will show irregular edges or white areas within the dark tissue
Biceps Tendon
- Appears as a dark circle in the front of the shoulder, centered in its groove
- Look for fluid (white) around it which might indicate inflammation
Joint Fluid
- Normal amount appears as a thin white line
- Excessive fluid suggests inflammation
- A bright white pocket of fluid usually just above the rotator cuff tendons can be indicative of bursitis.

I urge you to check out this website if you are overwhelmed

It does a great job of labeling all of the structures as you scroll through the images.

Abnormal MRI: Rotator Cuff Tear

Notice the bright white fluid filling the gap in the band of the tendon.

Abnormal MRI: Labral Tear

Notice the jagged edges and the white coloring of what would be a normally black ring.

Ask the Expert: What Questions Should I Ask?

“Can you show me what normal looks like?”
“What are these different shades showing?"
“Can you point out where the problem is?"
“How do these findings relate to my symptoms?”
“How does this compare to previous scans?”
“Would it be helpful to get imaging of my other side to compare?”

Remember: This guide is meant to help you better understand your imaging studies, but always rely on your healthcare provider's interpretation for medical decisions. Different MRI machines and settings can make images look slightly different, so some variation is normal.

Stay Connected: Join Our Community

Connect with our vibrant online community of fellow overhead athletes, coaches, and sports enthusiasts by giving us a follow on Instagram @TheTrainingRoomOC. Share your experiences, seek advice, and stay updated on the latest developments in sports performance physical therapy for overhead athletes. Together, we can elevate our performance and achieve new heights in our respective sports.