Screening efficacy and considerations for exercise-based interventions.

As a Physiotherapist, I frequently treat athletes with shoulder injuries and believe that injury prevention is often overlooked. Shoulder pain and injuries occur across a diverse range of sports such as: volleyball, handball, football, hockey, baseball, rugby, tennis, and many more^1,3.

The incidence of shoulder injuries in overhead sports varies between 0.2/1000 to 1.8/1000 hours. For reference, an average volleyball team will accumulate 10-20 training/game hours per week, meaning the team has 1000 hours of exposure over 5-6 weeks. The average proportion of athletes reporting reductions in training volume or in sports performance on a weekly basis, or complete inability to participate in sport, due to shoulder injuries/pain, is 5% in secondary school male and female volleyball players and 12% in senior elite male handball players³. Implementing effective injury prevention strategies can significantly reduce these statistics.

 

Effective Injury Prevention for Shoulder Health

Understanding the risk factors for shoulder injuries is crucial for athletes, coaches, and healthcare professionals involved in sports that demand extensive use of the upper body. Here are some key factors to consider: 

Injury prevention should be a priority for all athletes to minimize risks and enhance performance³.

1. Previous Shoulder Pain/Injury: A history of shoulder pain or injury increases the likelihood of future complications. 

2. Sport, Player Position, and Shoulder-Specific Load: Certain sports, positions, and load demands place athletes at a higher risk, such as pitchers in baseball or outside hitters in volleyball.  

3. Rotator Cuff (RC) Strength Ratios (ER:IR): Imbalances in rotator cuff strength, e.g.an ER:IR ratio less than or equal to 0.75, may predispose athletes to injury. However, absolute values are a more valuable metric for assessing shoulder capacity and resilience than ratios which are likely sport, and even player position specific.  

4. Loss of Glenohumeral (GH) Joint Range of Motion (ROM): Total ROM, as well as the relative balance between external rotation (ER) and internal rotation (IR), plays a significant role in shoulder health. 

Most risk factors for the shoulder are inconclusive and debated. This may be due to pooling data from multiple different sports as injury risk is likely to change given sport specific and even position specific load to the shoulder³. Load management, mobility, and strength training are 3 modifiable risk factors that athletes and coaches can easily apply with minimal risk, and potential for both preventative and performance benefits.

 

Efficacy of Screening¹ 

While screening has potential utility in identifying at-risk athletes, it has its limitations: 

• Single Time Point Measurements: Assessing shoulder function at one point in time fails to capture the complex mechanisms underlying injuries. These include factors such as: 

• Sport-specific demands 

• Player position 

• Exercise and lifestyle influences (e.g., sleep quality, nutrition, psychosocial factors like team dynamics and pressure to play) 

Universal Injury Prevention Programs: Instead of relying solely on screening, all athletes should engage in movement- and exercise-based injury prevention programs. These programs are especially critical for: 

• Throwing and overhead athletes, starting at a young age. 

• Those with a history of shoulder injuries. 

These programs are low-risk, minimally invasive, and provide preventative benefits to all athletes 

Secondary Prevention (Physiotherapy): Following a shoulder injury, physiotherapy should begin immediately. This helps promote optimal recovery, coordination between stakeholders, and timely Return to Sport and Performance.  

Principles of Injury Prevention Programs¹ 

Effective prevention programs share the following characteristics:

 

1. Sport-Specific Exercises: Incorporate movements that mimic sport-specific demands. 

2. Kinetic Chain Focus: Include exercises targeting multiple joints to ensure the entire kinetic chain is strengthened. 

3. Minimal Equipment: Use accessible and straightforward equipment. 

4. Incorporate Competition: Add a competitive element, especially for team-based sports. 

5. Frequency and Duration: 

• Perform at least twice per week, integrated into resistance training. 

• Include as part of warm-ups for training or games. 

• Limit to 10-15 minutes, with at least 5 minutes focusing on shoulder-specific exercises. 

6. Target Areas: 

• Address RC imbalances, emphasizing ER strength through a full range. 

• Develop shoulder girdle strength through the entire ROM. 

• Enhance dynamic trunk function specific to the sport. 

• Focus on eccentric deceleration control, particularly ER in 90 degrees of abduction. 

7. Education for Stakeholders: Educate coaches, athletes, and other relevant personnel to ensure adherence and positive attitudes toward prevention programs. These programs can also enhance sport performance. 

Managing Shoulder-Specific Load 

Load management is challenging due to variations across sports and positions. However, here are general guidelines: 

1. Load Exposure: Risk increases when exceeding 16 hours of load exposure per week. If above this threshold, the athlete should be performing an exercise-based injury prevention program focusing on improving shoulder strength².  

2. Gradual Load Increases: Prevent large weekly increases in training and match load (e.g., no more than a 20% increase compared to the average of the last four weeks²). 

3. Comprehensive Monitoring: 

• Use multiple external and internal load measures (e.g., number of swings, pitches thrown, shoulder-specific RPE, session RPE⁾¹.  

• Weekly load monitoring is a minimum requirement¹. 

• Employ recovery questionnaires to facilitate athlete self-monitoring and daily reporting¹. 

Here are some common questionnaires and tools we use to help athletes and coaches monitor load throughout the season:

Key Insights from Research 

Studies highlight that decreased ER strength (relative to IR strength) and large increases in shoulder specific load significantly increase shoulder injury risk in throwing and overhead athletes². By addressing these issues and implementing comprehensive prevention programs, the risk of injury can be minimized while optimizing athletic performance. 

Seamus McFadden

Physiotherapist

Do you have recurring shoulder pain? Do you play a sport that requires strong healthy shoulders?

Book an appointment with one of our Performance Physiotherapists to stay healthy and perform at your best.

References:  

1. Schwank, Ariane, et al. “2022 Bern consensus statement on shoulder injury prevention, rehabilitation, and return to sport for athletes at all participation levels.” journal of orthopaedic & sports physical therapy 52.1 (2022): 11-28. 

2. Møller M, Nielsen RO, Attermann J, et al. Handball load and shoulder injury rate: a 31-weekcohort study of 679 elite youth handball players .Br J Sports Med. 2017;51:231-237. 

3. Asker M, Brooke HL, Waldén M, et al. Risk factors for, and prevention of, shoulder injuries in overhead sports: a systematic review with best-evidence synthesis. Br J Sports Med.2018;52:1312-1319.