The volleyball athlete's shoulder: biomechanical adaptations and injury associations

Common sports-related nerve injuries seen by the electrodiagnostic medical consultant

The high physiologic demands of sports create dynamic stress on joints, soft tissues, and nerves which may lead to injuries in the athlete. Electrodiagnostic (EDx) assessment is essential to identify the correct diagnosis, localization, and prognosis, to guide management of sports-related neuropathies. A comprehensive review was performed to provide the EDx medical consultant with a practical approach to the common peripheral nerve disorders seen in athletes. Sports-related neuropathies reviewed include transient traumatic irritation of the brachial plexus and/or cervical nerve roots ("Burners and stingers,") suprascapular and axillary neuropathies, ulnar neuropathy at the elbow (UNE) in throwers, ulnar neuropathy at the hand/wrist in cyclists, multi-ligamentous knee injury, and foot/ankle neuropathies including tarsal tunnel syndrome. A thorough understanding of peripheral anatomy, possible entrapment sites, mechanisms of injury, and key physical examination findings is essential for correct diagnosis. EDx assessments beyond routine studies are generally required for sports-related neuropathy, which may not necessarily follow typical entrapment patterns. Adjunct diagnostic imaging, such as point-of-care ultrasound and magnetic resonance imaging, are helpful tools to identify associated musculoskeletal pathology such as compressive cysts or nerve entrapment, which may be amenable to interventional or surgical treatment. When no clear reversible structural pathology exists, management of sports-related neuropathy is athlete-specific and generally multi-modal, involving a combination of physical rehabilitation techniques to address muscle imbalances, load management, protective equipment, and interventional pain procedures.

Shoulder range of motion and strength in beach tennis athletes compared to volleyball and tennis players: implications for injury risk and performance

INTRODUCTION

Beach tennis (BT) combines elements of tennis, volleyball, and badminton, attracting a diverse global following. Despite its popularity, research on its link to shoulder injuries remains limited. This study investigates shoulder characteristics among BT athletes, volleyball players, and tennis athletes to identify potential differences and inform injury prevention strategies.

METHODS

A cross-sectional analysis was performed to assess shoulder range of motion (ROM) and rotator cuff strength in 65 athletes using an online questionnaire and biomechanical assessments.

RESULTS

Volleyball players demonstrated superior shoulder ROM compared to tennis and BT athletes, while tennis players exhibited a greater difference in internal rotation between sides. Additionally, volleyball athletes displayed greater external rotation strength on the dominant side than tennis players, with BT athletes also exhibiting significant strength advantages.

CONCLUSION

These findings emphasise the distinct demands of BT and highlight the need for tailored interventions to optimise performance and minimise injury risks. Customised training and injury prevention approaches are warranted.

Adaptation Characteristics in the Range of Motion of the Shoulder Among Young Male Volleyball Players

Background/Objectives: Repeated spiking and serving movements in volleyball can lead to alterations in shoulder range of motion among athletes, potentially increasing the risk of shoulder instability and injury. Hence, assessing and understanding the shoulder range of motion of volleyball players is a critical concern. Therefore, this study aimed to understand and evaluate the bilateral shoulder joint range of motion (ROM) in high-school male volleyball athletes and to discover the adaptation characteristics. Methods: Forty high-school male volleyball athletes participated in this study. Shoulder ROM measurements were taken via video with an iPhone 12 Pro Max, and we analyzed the ROM data using Kinovea software (Version 0.9.5) for both the dominant and non-dominant side. The shoulder ROM measurements included shoulder hyper-extension (SE), flexion (SF), internal rotation (IR), external rotation (ER), horizontal adduction (Sadd), and horizontal abduction (Sabd). After taking shoulder ROM measurements, the total rotational range of motion (TROM) was calculated based on the participants' shoulder internal rotation and external rotation data, and we calculated the incidence of glenohumeral internal rotation deficiency (GIRD) among participants. Paired samples t-tests were used to analyze shoulder ROM differences between the dominant and non-dominant side. Results: The dominant side of the shoulder showed significantly lower internal rotation (dominant side: 42.17 ± 11.23°; non-dominant side: 52.14 ± 10.46°; p = 0.000) and total rotational ROM (dominant side: 137.11 ± 13.09°; non-dominant side: 141.96 ± 13.22°; p = 0.021) compared to the non-dominant side. Conversely, the dominant side of the shoulder exhibited significantly greater external rotation (dominant side: 94.96 ± 10.02°; non-dominant side: 89.83 ± 7.84°; p = 0.001) and shoulder horizontal adduction (dominant side: 44.87 ± 8.10°; non-dominant side: 39.60 ± 7.24°; p = 0.000) than the non-dominant side. No significant differences were found in other measured parameters. The incidence of glenohumeral internal rotation deficiency (GIRD) among all subjects was 37.5%. Conclusions: High-school male volleyball athletes in this study exhibited tightness in the posterior shoulder of their dominant side, indicating specific adaptations in shoulder ROM and a considerable prevalence of GIRD, observed in approximately one-quarter of the athletes. In conclusion, these data suggest that stretching and eccentric muscle training focusing on the posterior shoulder have potential value in mitigating these adaptations and reducing the risk of shoulder injuries.

Nontraumatic Shoulder Pain Affects Proprioception and Dynamic Stability in Female High School Volleyball Players

CONTEXT

Nontraumatic shoulder pain (NSP) is common in volleyball, affecting performance and well-being. It is more prevalent in female players. Previous studies lack comprehensive assessments of shoulder pain that consider multiple factors, including range of motion, muscle strength, joint position sense, dynamic stability, and volleyball-specific mechanics.

OBJECTIVE

To investigate NSP prevalence in female high school volleyball players, considering shoulder joint functional parameters and volleyball-specific factors.

DESIGN

Cross-sectional study.

SETTING

High school gymnasiums.

PATIENTS OR OTHER PARTICIPANTS

Fifty-nine female high school volleyball players (15-17 years).

MAIN OUTCOME MEASURE(S)

Demographic data, environmental factors (years of experience, spiking technique, and serve type), shoulder joint function (passive glenohumeral joint's range of motion, muscle strength, joint position sense, and dynamic stability), and NSP prevalence during spiking and serving. Logistic regression analysis was conducted to identify significant factors associated with NSP.

RESULTS

Nontraumatic shoulder pain prevalence was 54.2%, with 68.8% not informing coaches. Significant associations were found between NSP and factors such as Upper Quarter Y-Balance Test-Medial (P = .008; odds = 0.892; 95% confidence interval = 0.82, 0.97) and joint position sense of internal rotation (P = .031; odds = 1.411; 95% confidence interval = 1.03, 1.93).

CONCLUSION

Shoulder pain leads to impaired proprioception and dynamic stability. Effective communication between players and coaches is crucial for managing and preventing pain. Targeted training programs to enhance proprioception and dynamic stability may reduce shoulder pain and injuries. Educating players on the importance of reporting pain and encouraging early intervention is essential.

The Development and Content of Movement Quality Assessments in Athletic Populations: A Systematic Review and Multilevel Meta-Analysis

BACKGROUND

Despite their prominence in the sport and human movement sciences, to date, there is no systematic insight about the development and content of movement quality assessments in athletic populations. This is an important gap to address, as it could yield both practical and scientific implications related to the continued screening of movement quality in athletic contexts. Hence, this study aimed to systematically review the (i) developmental approach, (ii) movements included, (iii) scoring system utilised, and (iv) the reliability of movement competency assessments used in athletic populations.

METHODS

Electronic databases (SPORTDiscus, MEDLINE, CINAHL, Web of Science, Scopus) were searched for relevant articles up to 12 May 2023. Studies were included if they reported data about the developmental approach, movements included, scoring system utilised and reliability of assessment in an athletic population. A modified Downs and Black checklist was used to measure study quality.

RESULTS

From a total of 131 identified studies: (i) 26 (20%) described the developmental approach of an assessment; (ii) 113 (86%) included descriptions of the movements included; (iii) 106 (81%) included a description of scoring system and criteria; and (iv) 77 (59%) studies included reliability statistics. There were 36 assessments identified within these studies, comprising 59 movements in total. Each assessment scored movement quality through a Likert or binary classification system.

CONCLUSION

First, the results demonstrate that choosing an appropriate movement quality assessment in an athletic population may be a complex process for practitioners as the development approach, movements included and scoring criteria vary substantially between assessments. Second, academics could use these results to help design new assessments for novel applications that meet rigour and reliability requirements. Third, these results have the potential to foster guidelines of use for the reliable assessment of movement quality in athletic populations.

Prevalence of Upper Extremity Volleyball Injuries Within Different Adult Age Groups: A Comprehensive Analysis of National Data From 2013-2022

Background

The mean age of volleyball athletes has increased over the past decade, raising concerns about musculoskeletal injuries. There is no literature on how different mechanisms of injury (MOI) affect different adult age groups.

Purpose

To evaluate epidemiologic trends, diagnoses, and mechanisms of volleyball-related upper extremity injuries within different adult age groups.

Study Design

Descriptive epidemiology study.

Methods

Data from the National Electronic Injury Surveillance System for volleyball-related upper extremity injuries in patients aged between 19 and 79 years, between January 1, 2013, and December 31, 2022, were analyzed. Data included body parts, diagnosis, MOI, and disposition. Calculations used corresponding hospital sample weights for national estimates (NEs). Patients were divided into either 20-39, 40-59, or 60+ years age groups. Linear regressions were used to analyze annual trends, chi-square tests were used to analyze categorical variables, and the Holm P value adjustment method was utilized in post hoc analysis.

Results

A weighted NE of 41,164 volleyball-related upper extremity injuries occurred in the study period. The mean age was 35.8 ± 14 years, and male patients constituted 49.4% of all patients. The most injured body parts of all age groups were fingers (33.2%), shoulders (28.9%), and wrists (16%). The most common identifiable MOI were impacts with the floor (24%), impacts with the ball (18.7%), and spikes/serves (6.9%). The 20-39 age group experienced shoulder dislocations at the greatest rate of all age groups (NE = 3362 [37%]) and sustained injuries from spike/serve movements at the greatest rates (NE = 2214 [8.2%]; P < .01). Of the 3362 shoulder dislocations in the 20-39 age group, 1445 (43%) were during spikes/serves. The 60+ age group had the greatest rates of sprains/strains (NE = 1353 [41.1%]). Additionally, the 60+ age group suffered from injuries secondary to impacts on the floor (NE = 1242 [37.7%]) and impacts with the ball (NE = 769 [23.4%]) at the greatest rates (P < .01).

Conclusion

Our study demonstrated that adult populations are at risk for volleyball-related upper extremity injuries, specifically affecting the finger, wrist, and shoulder. MOI among age groups differed, as younger adults more often sustained injuries from dynamic movements, whereas older adults sustained injuries from trauma.

Upper limb functional testing: does age, gender, and sport influence performance?

Background

Musculoskeletal adaptations are common in overhead athletes. As they also are involved in injury prevention, there has been an increase in their evaluation through shoulder screening over the last years. However, for some evaluations, and especially for functional testing, there is a lack of normative values, which limits the interpretation of the values measured. Moreover, the influence of age, gender, and sport on upper limb functional tests remains underexplored.

Methods

Five hundred eighty seven athletes (handball players, rugby players, swimmers, tennis players, and volleyball players) performed a battery of upper limb functional tests between 2018 and 2023, including the Modified-Athletic Shoulder Test, the Single Arm Medicine Ball Throw, the Seated Single Arm Shot Put Test, the Upper Limb Rotation Test, the Upper Quarter Y Balance Test, the Modified Closed Kinetic Chain Upper Extremity Stability Test, and the Posterior Shoulder Endurance Test. In total, normative values as well as the influence of age, gender, and sport on upper limb functional performance were obtained for 496 of them.

Results

The Modified-Athletic Shoulder Test revealed sport-specific adaptations, with dominant arms significantly outperforming nondominant arms, notably in handball, rugby, and tennis. The Single Arm Medicine Ball Throw and Seated Single Arm Shot Put Test highlighted the influence of age and gender on upper limb power, with males consistently outperforming females. The Upper Limb Rotation Test demonstrated similar rotation in both arms across sports, while gender disparities were still observed. The Upper Quarter Y Balance Test exhibited surprising consistency in upper-quarter balance across sports and age groups (P > .05). The Modified Closed Kinetic Chain Upper Extremity Stability Test showed age-related improvements in stability, while the Posterior Shoulder Endurance Test demonstrated age-related differences in posterior shoulder endurance in swimmers.

Conclusion

This study contributes to advances in sports medicine by better understanding functional shoulder performances in upper limb athletes. The differences observed according to the sport, gender, or age underscore the importance of sport-specific assessments and interventions. Moreover, the normative values provided will be essential for primary prevention as well as for determining return-to-play capacity after an injury or surgery.

Prevalence and associated factors of nontraumatic shoulder pain during spike and serve movements in male high school volleyball players: a cross-sectional study

BACKGROUND/HYPOTHESIS

Nontraumatic shoulder pain is a prevalent issue among male high school volleyball players, yet prior research has often limited its assessment to isolated aspects of shoulder function. This study aimed to identify contributing factors to shoulder pain in this population. We hypothesized that limited shoulder internal rotation (IR) range of motion (ROM), imbalance in rotator cuff muscle strength, intrinsic sensory disturbance, and joint stability are associated with shoulder pain in male high school volleyball players. Additionally, we anticipated that a substantial proportion of players would experience shoulder pain but refrain from reporting it to coaches.

METHODS

Forty-nine male volleyball players aged 15-17 years were evaluated between February and June 2023. Questionnaires assessed the prevalence of shoulder pain during spiking and/or serving and the frequency of reporting this pain to coaches. Factors such as acromio-humeral distance, shoulder passive ROM, isometric strength, proprioception, joint stability (Upper Quarter Y-Balance Test), joint position sense, and upper extremity power (Seated Medicine Ball Throw Test) were quantified. Logistic regression analyses were conducted to explore associations between these variables and shoulder pain.

RESULTS

Shoulder pain was reported by 39% of participants, with only 5% communicating it to coaches. Jump serves (odds ratio 1.84, P = .02) and reduced shoulder IR ROM (odds ratio 0.94, P = .03) were associated with shoulder pain.

CONCLUSION

This study provides critical insights into the prevalence, severity, and factors associated with shoulder pain among male high school volleyball players. The findings underscore the importance of improving athlete-coach communication for early intervention and prevention. Significant associations between jump serves, reduced shoulder IR ROM, and shoulder pain highlight the role of specific volleyball techniques in injury prevention, offering valuable guidance for coaches and trainers in developing targeted interventions to mitigate shoulder pain and enhance player performance.

Motor alterations along the kinetic chain in amateur volleyball and handball athletes with shoulder pain: An observational comparative study

Overhead sports overload the shoulder complex due to movement repetition and the great amount of force created during the athletic motion, which may cause adaptations in the shoulder and lead to shoulder pain. However, overhead movements include the kinetic chain, and alterations in some of the structures throughout the kinetic chain may increase stress on the shoulder complex and be associated with shoulder pain.

PURPOSE

To compare kinetic chain components in overhead athletes with and without shoulder pain.

METHODS

Forty-one volleyball and handball athletes (21 with and 20 without shoulder pain) were included and assessed for hip internal (IR) and external rotation (ER) range of motion (ROM), hip and trunk isometric strength, trunk endurance and neuromuscular control of the lower and upper limbs (Y balance test).

RESULTS

Athletes with shoulder pain showed smaller IR ROM in both hips, lower endurance time for trunk extensors and flexors, decreased reach distance in the anterior and posteromedial direction, as well as a smaller composite score in the Y balance test (p < 0.05).

CONCLUSION

Volleyball and handball athletes with shoulder pain showed changes in ROM throughout the kinetic chain in addition to lower core endurance, and decreased neuromuscular control of lower limbs.

An evidence-informed rehabilitation management framework for posterior shoulder tightness: A scoping review

Objective

To systematically scope the literature on posterior shoulder tightness (PST) and define a therapist-instructed and therapist-administered management framework.

Design

Scoping review.

Literature search

We searched MEDLINE, EMBASE, CINAHL, Scopus and Google Scholar from inception to December 2021.

Study selection criteria

Peer-reviewed studies written in English, French, Greek, Japanese or Tamil, with extractable pre- and post-intervention data. Physiotherapy interventions amenable for posterior shoulder structural (muscle, capsule) causes of PST within an adult population.

Data synthesis

Arksey and O'Malley's framework was implemented and the PRISMA extension for scoping reviews directed our data synthesis. The data charted from each study included authors, title, study year, location, study design; participant number, age, sex; PST intervention and parameters; patient-reported outcomes; and results. Themes were organized into therapist-instructed and therapist-administered rehabilitation strategies, as well as combined treatment methods.

Results

Of 2777 articles identified from our search strategy, 21 articles were included. Therapist-instructed interventions included cross-body stretch (CBS), sleeper stretch (SS), a combination of the two and general stretching. Therapist-administered interventions included CBS, SS, instrument-assisted soft tissue mobilization (IASTM), muscle energy techniques, dry needling and Fauls protocol (12 therapist-assisted stretches). Combined interventions of tape with self-stretching and IASTM and stretching were also identified.

Conclusion

Based on the current evidence, CBS and SS are the most researched treatments for PST and seem to be effective at improving PST. Furthermore, stabilization of the scapula while performing these stretches optimized the stretch targeted to the PST and ROM benefits for horizontal adduction.

Glenohumeral internal rotation deficit in volleyball players with and without a history of shoulder pain

This study aimed to investigate physiological and pathological Glenohumeral Internal Rotation Deficit (GIRD) in volleyball players with and without a history of shoulder pain. Volleyball players with a history of shoulder pain (n = 18) and without a history of shoulder pain (n = 18), who were matched in age, weight, height, BMI, years of experience and frequency of practice were recruited for this cross-sectional study. Shoulder internal and external rotation Range of Motion (ROM) was measured for the dominant and non-dominant shoulders of each participant using a digital inclinometer. Measurements of GIRD, External Rotation Gain (ERG), and Total Range of Motion (TROM) were calculated. There were significantly higher degrees of GIRD in the pain group (15.65⁰) than the no-pain group (9.06⁰) (p=0.004) and significantly higher differences in the TROM in the pain group (16.17⁰) than the no-pain group (10.17⁰) (p=0.007). There was no correlation between the level of pain and the presented ROM adaptations. The study showed that for volleyball players, pathological GIRD should be defined at 10-18⁰ degrees of GIRD that are accompanied by differences in the TROM that exceeds 8⁰.

Damage for gain: The useful damage of the Pitcher's paradox

INTRODUCTION

Sport-specific adaptations of the glenohumeral joint may arise in adolescent overhead athletes who begin high-performance sports early in life. Research mainly addresses overuse injuries, leaving gaps in prevention, with adults studied more than youths.

OBJECTIVE

This study aims to investigate sport-adaptations of the glenohumeral joint in asymptomatic adolescent volleyball players to identify potential shoulder injury risk factors.

DESIGN

Observational study.

SETTING

Clinical screening campaign conducted at the Physical Medicine and Rehabilitation Unit of Policlinic Hospital in Catania, Italy.

PARTICIPANTS

Forty asymptomatic under-16 athletes were evaluated.

INTERVENTIONS

Shoulder internal rotation (IR) and external rotation (ER), range of motion (ROM), total-rotation ROM, glenohumeral IR deficit (GIRD), general joint laxity using Beighton score, apprehension, relocation, O'Brian tests, and ultrasound (US) glenohumeral distance were tested bilaterally. Variables such as the player's position, the age they began the sport, limb dominance, weight, and height were also considered.

RESULTS

The median US glenohumeral distance was at 0.42 ± 0.26 cm, which is consistent with the range found in non-dislocated shoulders of a healthy non-athletic population. The ER ROM was significantly greater in the dominant shoulder than the contralateral one (P = 0.0001), and there was a significant correlation between the ER ROM of attackers and their US glenohumeral distance (P = 0.0413). Furthermore, shoulder IR ROM and US glenohumeral distance were not significantly different between the dominant and contralateral limbs (P = 0.05). None of the athletes presented GIRD. Other tests, including the Beighton score, apprehension, and relocation tests, yielded no significant differences between the dominant and contralateral limbs.

CONCLUSIONS

Despite an increased shoulder ER in the dominant limb, the glenohumeral joint remains stable, suggesting that greater ROM in ER does not equate to instability in overhead athletes without hyperlaxity. Nevertheless, increased ER impacts glenohumeral distance in attacker volleyball players. This finding suggests that the shoulder morphological adaptation process starts early in attackers.

The Finger, Wrist, and Shoulder are the Most Commonly Injured Areas in Youth Volleyball Players but the Incidence of Injuries Decreased Overall Between 2012 and 2022

Purpose

To analyze epidemiology, mechanisms, and diagnoses of upper extremity volleyball injuries in youth who present to United States emergency departments.

Methods

Data from the National Electronic Injury Surveillance System were analyzed for upper extremity volleyball injuries in patients ≤18 years old from January 1, 2012, to December 31, 2022. Data were collected for body part, diagnosis, mechanism of injury, and disposition. Weighted national estimates were calculated using the hospitals' corresponding statistical sample weights. Linear regressions were used to analyze annual trends. χ2 tests were used to analyze categorical variables.

Results

A weighted national estimate of 131,624 upper extremity volleyball-related injuries occurred in the study period. Average age was 13.9 ± 2.3 years. Female patients constituted 77.6% of patients; 99.3% of patients did not require admission. The most common body parts injured were fingers (43.0%), wrists (22.8%), and shoulders (12.2%). The most common identifiable mechanisms of injury were impacts with the floor (19.4%), impacts with the ball (14.7%), and spikes/serves (5.7%). Most common diagnoses were strains/sprains (42.6%) and fractures (19.5%). Most common locations of fracture were fingers (57.4% of all fractures), wrists (16.6%), and lower arms (12.4%). There was a decrease of 544 overall injuries per year (P = .03, 95% confidence interval [CI] -1031 to -58). Female players experienced more contusions/abrasions (16.0% vs 9.9%, P < .001) and strains/sprains (46.1% vs 30.4%, P < .001) compared with male players. Female patients had decreases of 513 overall injuries (P = .01, 95% CI -881 to -144), 349 strains/sprains (P = .002, 95% CI -530 to -168), 102 contusions/abrasions (P = .008, 95% CI 170 to -34), and 92 fractures per year (P = .03, 95% CI -175 to -10).

Conclusions

Youth volleyball players are at risk of upper extremity injury, particularly involving the fingers, wrist, and shoulder. Despite increasing national participation in youth volleyball, there is a decreasing incidence of upper extremity injuries.

Level of Evidence

Level IV, prognostic case series.

Risk and protective factors for shoulder complaints in indoor volleyball players: A comprehensive systematic review

OBJECTIVE

This systematic review aimed to answer the question: "What are the risk and protective factors for shoulder complaints (pain, injury, or problem) in indoor volleyball players?".

METHODS

Searches were conducted in electronic databases: PubMed/MEDLINE, Embase, CINAHL, and SPORTDiscus, as well as reference lists of the included studies. We included studies evaluating potential intrinsic and extrinsic factors associated with shoulder complaints in indoor volleyball players of any country, age, sex, and competitive level. The Quality in Prognosis Studies (QUIPS) tool was used to assess the risk of bias.

RESULTS

The risk factors for shoulder complaints in volleyball players were identified through four prospective studies, which exhibited a moderate to low risk of bias. These factors included previous shoulder pain or injury, playing in outside and opposite positions, subacromial bursa thickening, and having an average external rotator (ER) isokinetic eccentric torque lower than the average internal rotator (IR) concentric torque. Protective factors were enhancing shoulder IR and ER isokinetic eccentric strength, being male sex, being older, and maintaining a concentric strength ratio ER/IR within the 0.60-0.75 range.

CONCLUSIONS

This systematic review highlights risk factors that clinicians and researchers should consider when assessing and tracking indoor volleyball players.

Comparison of isometric strength in rotator cuff and scapulothoracic muscles between elite volleyball athletes versus non-athletes

BACKGROUND

Volleyball is an exceptionally popular global sport that involves repetitive, rapid, powerful and wide overhead movements, which can seriously alter normal shoulder kinematics. A recognized hallmark of shoulder muscle balance is the ratio of shoulder external (ER) and internal (IR) rotators. By extension, objective measurement of shoulder muscles' strength could help identify at risk athletes and preempt those injuries by engaging in prescriptive strength training programs.

METHODS

This cross-sectional study measured the isometric strengths of 1) shoulder internal and external rotator muscles, as well as the 2) supraspinatus, 3) rhomboid, and 4) middle and inferior trapezius muscles, in addition to calculation of ER:IR ratios, in professional volleyball players as well as in non-athletes. Measurements were made for dominant- and non-dominant upper limbs, in different position of the body (supine and orthostatic) and in different position of upper limb (adducted and abducted position). Our subject population included 11 male professional volleyball players as well as 14 healthy male orthopedic interns from Orthopedics and Trauma school of University of Milano Bicocca. Strengths were assessed by a handheld dynamometer. Each subject's isometric strength was assessed in triplicate in each limb position through a "make test" procedure; the greatest of each triplicate value was the accepted measure of isometric strength.

RESULTS

We observed a gradient in muscle strength in the scapulothoracic complex in both groups; the rhomboid, middle trapezius, and lower trapezius ranked from greatest to least strength, respectively. The data suggest also that intrarotators are stronger in rotation adducted position than in rotation abducted position; however, extrarotators seem to be weaker in rotation adducted position than in rotation abducted position. There is also some indication that force development is enhanced in the supine position compared with the orthostatic position.

CONCLUSIONS

Our findings indicate a scapulothoracic strength gradient with a rank order of strength of the rhomboid>middle trapezius>lower trapezius. The data further suggest that volleyball players have stronger intrarotation in rotation adducted position than in the rotation abducted position, while extra rotation shows the opposite trend. Finally, our data suggest that force development is greater in the supine position compared to the orthostatic position.

Physical therapy management of an athlete with a Kim lesion using physical agents, manual therapy, and therapeutic exercise: a case report

BACKGROUND

Several operative procedures have been described for treating a Kim lesion. However, no physical therapy intervention has been documented as conservative treatment for these cases.

OBJECTIVE

The purpose of this report was to describe a physical therapy management protocol for an athlete with a Kim lesion.

CASE DESCRIPTION

A 22-year-old female volleyball athlete presented to physical therapy with an 8-month history of right shoulder pain when performing the serve and attack sports gestures. Pain was 5/10 on the visual analogue scale (VAS). Pain was localized along the glenohumeral joint, around the long head of the biceps brachii tendon, and at the subscapularis tendon insertion. Shoulder range of motion (ROM) was limited to flexion (150°), abduction (158°), and internal rotation (80°). Kim lesion was confirmed by clinical tests (Kim test and Jerk test) and via magnetic resonance imaging. Shoulder functional outcomes were verified through the University of California Los Angeles (UCLA) shoulder rating scale. Upper extremity sensorimotor control was verified in bimanual support by stabilometry on a baropodometer. Core function was assessed through a plank test and a side plank test. The 8-week course of treatment included manual therapy, physical agents, shoulder and scapular mobilizations, resistance and sensorimotor exercises, core strengthening, and functional exercises.

OUTCOMES

Physical therapy interventions resulted in a decrease in VAS pain (3/10), an increase in shoulder ROM (10.8°) and in UCLA shoulder score (from 22 to 33 points), a reduction in the center of pressure displacement (27-56%), and an increase in plank test (45%) and side plank test (21-29%) performance. The athlete had a full return to sport after the treatment.

CONCLUSION

We concluded that the protocol used for conservative management of Kim lesion resulted in clinical satisfactory physical and functional outcomes for the athlete.

Prediction of injuries, traumas and musculoskeletal pain in elite Olympic and Paralympic volleyball players

The study aimed to identify the prevalence and location of injuries, traumas, and musculoskeletal complaints in Paralympic and Olympic volleyball players with different impairments and initial playing positions (sitting/standing); and to identify the predictors of the abovementioned variables using a multivariate CRT model. Seventy-five elite volleyball players from seven countries took part in the study. They were divided into three study groups: (SG1)-lateral amputee Paralympic volleyball players, (SG2)-able-bodied Paralympic volleyball players, (SG3)-able-bodied Olympic volleyball players. The prevalence and location of the analyzed variables were assessed with surveys quessionaires, while game-related statistics was interpreted based on the CRT analysis. Regardless of the impairment or initial playing position, both the humeral and knee joints were found to be the most frequent locations of musculoskeletal pain and/or injuries in all studied groups, followed by LBP. Players from SG1 and SG3 were characterized by an almost identical prevalence of reported musculoskeletal pain and injuries, what was not noted in SG2. Extrinsic compensatory mechanism (playing position) may be a crucial variable for prediction of musculoskeletal pain and injuries in volleyball players. Lower limb amputation seems to impact the prevalence of musculoskeletal complaints. Training volume may predict the prevalence of LBP.

Prevalence of Glenohumeral Internal Rotation Deficit and Sex Differences in Range of Motion of Adolescent Volleyball Players: A Case-Control Study

Shoulder range of motion (ROM) adaptation is common observed among volleyball players, but studies on the shoulder joint function of adolescent athletes are lacking. This study aimed to clarify the prevalence of glenohumeral internal rotation deficit (GIRD) among adolescent players and differences in ROM based on sex. A questionnaire survey and ROM measurements of the shoulder joint and trunk using a plastic goniometer were conducted on 123 volleyball players (63 males and 60 females; mean age, 15.8 years). The prevalence of GIRD was investigated for internal rotation differences of >10° and total rotation motion of <5°. Questionnaire items and ROM were compared between GIRD and non-GIRD patients, and sex differences in ROM were also presented. Of the participants, 38.2% (n = 47/123) had GIRD. The GIRD group showed a decrease in external rotation on the dominant side (p = 0.003, 1 − beta = 0.84), but this was not associated with a history of shoulder injury. Sex differences in shoulder ROM showed hypomobility in males and hypermobility in females. However, there was no association between shoulder injury and GIRD among adolescent players. There are sex differences in ROM, which should be considered in future studies.

Spike Arm Swing Techniques of Olympics Male and Female Elite Volleyball Players (1984-2021)

In the last decades, indoor volleyball has experienced significant rule changes and a high player specialization in both sexes. Different spike attack arm swing techniques have developed which might affect performance and risk of injury. While a variety of arm swing techniques was already shown in world class beach volleyball players, it is unclear if this is also true for world class indoor volleyball. Therefore, the purpose of this study was to assess the spike attack arm swing techniques of Olympic volleyball winners and finalists (1984-2021) and to investigate possible differences between sex, playing position, scoring system, and compared to beach volleyball. Eighty-two male (M) and 85 female (F) players were assessed from video recordings from ten competitions. Five different arm swing techniques in the cocking phase (Straight, Bow-and-arrow high, Bow-and-arrow low, Snap, Circular) were classified by two experts. The most frequent technique for both sexes was the Circular (M = 40.2%; F = 38.8%), followed by Snap (M = 28.0%; F = 23.5%), Bow-and-arrow low (M = 20.7%; F = 21.2%), Bow-and-arrow high (M = 7.3% F = 11.8%), and Straight (M = 3.7%; F = 4.7%). Bow-and-arrow high and Straight techniques were significantly less used than other techniques in both sexes. There were no significant differences (p &gt; 0.05) in arm swing techniques between sexes, playing positions, and scoring system but significant differences (p &lt; 0.001) to beach volleyball. Although most volleyball textbooks only describe the Bow-and-arrow techniques, most of the world class indoor volleyball players used Circular and Snap arm swing techniques. Reasons for that could be the implicit knowledge of players (and coaches) regarding increased performance (ball speed) and injury prevention. Based on these results we suggest to critically revise arm swing technique training especially for young players and players with shoulder problems.

Goal-Oriented Optimization of Dynamic Simulations to Find a Balance between Performance Enhancement and Injury Prevention during Volleyball Spiking

Performance enhancement and injury prevention are often perceived as opposite sides of a coin, where focusing on improvements of one leads to detriment of the other. In this study, we used physics-based simulations with novel optimization methods to find participant-specific, whole-body mechanics of volleyball spiking that enhances performance (the peak height of the hitting hand and its forward velocity) while minimizing injury risk. For the volleyball spiking motion, the shoulder is the most common injury site because of the high mechanical loads that are most pronounced during the follow-through phase of the movement. We analyzed 104 and 209 spiking trials across 13 participants for the power and follow-through phases, respectively. During the power phase, simulations increased (p < 0.025) the peak height of the hitting wrist by 1% and increased (p < 0.025) the forward wrist velocity by 25%, without increasing peak shoulder joint torques, by increasing the lower-limb forward swing (i.e., hip flexion, knee extension). During the follow-through phase, simulations decreased (p < 0.025) peak shoulder joint torques by 75% elicited by synergistic rotation of the trunk along the pathway of the hitting arm. Our results show that performance enhancement and injury prevention are not mutually exclusive and may both be improved simultaneously, potentially leading to better-performing and injury-free athletes.

How to Assess Shoulder Functionality: A Systematic Review of Existing Validated Outcome Measures

The objective of this review was to compile validated functional shoulder assessment tools and analyse the methodological quality of their validations. Secondarily, we aimed to provide a comparison of the tools, including parameter descriptions, indications/applications, languages and operating instructions, to choose the most suitable for future clinical and research approaches. A systematic review (PRISMA) was conducted using: PubMed, WoS Scopus, CINHAL, Dialnet and reference lists until 2020. The main criteria for inclusion were that papers were original studies of validated tools or validation studies. Pre-established tables showed tools, validations, items/components, etc. The QUADAS-2 and COSMIN-RB were used to assess the methodological quality of validations. Ultimately, 85 studies were selected, 32 tools and 111 validations. Risk of bias scored lower than applicability, and patient selection got the best scores (QUADAS-2). Internal consistency had the highest quality and PROMs development the lowest (COSMIN-RB). Responsiveness was the most analysed metric property. Modified UCLA and SST obtained the highest quality in shoulder instability surgery, and SPADI in pain. The most approached topic was activities of daily living (81%). We compiled 32 validated functional shoulder assessment tools, and conducted an analysis of the methodological quality of 111 validations associated with them. Modified UCLA and SST showed the highest methodological quality in instability surgery and SPADI in pain.

Shoulder Rotation Range of Motion and Serve Speed in Adolescent Male Volleyball Athletes: A Cross-Sectional Study

BACKGROUND

Throwing athletes present alterations in shoulder rotation range of motion (ROM), but not much is known about the relationship between these alterations and performance measurements in volleyball practitioners.

PURPOSE

To compare the passive ranges of motion of internal rotation (IR), external rotation (ER), and total rotation motion (TRM) of the shoulder in dominant and nondominant limbs of young volleyball athletes and to investigate their relationship with ball speed during serves with and without precision (inside and outside court, respectively). The possible association of anthropometrics and competitive practice time with these velocities was also investigated.

STUDY DESIGN

Cross-sectional study.

METHODS

Fifty-seven male volleyball athletes (mean age 17.11 ± 1.88 y; weight 74.68 ± 9.7 kg; height 1.87 ± 0.09 cm) were evaluated for shoulder IR and ER with a bubble goniometer and serve speed inside and outside court was measured with a radar gun. Simple and multiple regression analyses were applied to investigate associations of ROM, anthropometrics, and competitive practice time with serve speed.

RESULTS

Dominant shoulders had diminished IR ROM compared to nondominant shoulders (59.1º ± 16.7º vs 66.4º ± 16.9º; p < 0.001) as well as diminished TRM (173.5º ± 31.8º vs 179.1º ± 29.9º; p < 0.001). Simple regression showed negative association between dominant ER and serve speed outside the court (p = 0.004). Positive associations existed between age and serve speed in both conditions (p < 0.001), BMI and speed inside (p = 0.009) and outside the court (p = 0.008), and between competitive practice time and speed inside (p = 0.008) and outside court (p = 0.003). However, multiple analysis confirmed only age (p < 0.001) and BMI to be associated with ball velocities (inside court p = 0.034; outside court p = 0.031).

CONCLUSION

The results of this study demonstrated that young volleyball athletes presented lower IR and TRM of the shoulder in the dominant upper limb. Age and BMI were directly associated with ball velocities when serving. Passive rotation ROM did not have a relationship with this performance measurement.

LEVEL OF EVIDENCE

3b.

The Effect of Shoulder Injury Prevention Program on Shoulder Isokinetic Strength in Young Male Volleyball Players

The purpose of this study was to examine the effects of an eight-week 11 + S programme on isokinetic shoulder strength in young male volleyball players. Twenty-eight top-level young male volleyball players were recruited for this study. The players were randomly assigned into intervention (14 players) and control (14 players) groups. The intervention group performed the 11 + S as a warm-up before training at least three times a week for eight weeks. Dominant shoulder strength was measured using an isokinetic dynamometer at 60°/s and 180°/s. The functional deceleration ratio (FDR) was calculated as a functional strength profile. 20% FDR improvement after eight weeks of 11 + S at 180°/s (p = 0.003) were observed. No other statistically significant effects for shoulder strength improvement was observed (p > 0.05). Eight weeks of 11 + S warm-up programme improved the glenohumeral muscle imbalance by increasing the functional deceleration ratio (FDR) of shoulder muscles in young male volleyball players.

Kinetic Chain Exercise Intervention Improved Spiking Consistency and Kinematics in Volleyball Players With Scapular Dyskinesis

Chang, C-C, Chang, C-M, and Shih, Y-F. Kinetic chain exercise intervention improved spiking consistency and kinematics in volleyball players with Scapular Dyskinesis. J Strength Cond Res XX(X): 000-000, 2020-Scapular dyskinesis (SD) is a common problem among volleyball players with chronic shoulder pain. This randomized controlled study examined the effectiveness of kinetic chain (KC) training on neuromuscular performance of the scapula and trunk during volleyball spikes. Forty volleyball players with SD and chronic shoulder pain received 4 weeks of KC training or the conventional shoulder exercise training (CT). Shoulder pain was assessed using the visual analogue scale (VAS) every week. The kinematics and muscle activation of the shoulder and upper trunk, and proprioceptive feedback magnitude (PFM) for scapular movement consistency, were recorded at the maximum shoulder flexion (T1) and ball contact (T2) during spiking tasks. The two-way repeated measures analysis of variances was used to assess the between-group differences before and after the intervention. The results showed a significant time by group interaction for the upper trunk rotation (p < 0.001) and PFM (p = 0.03) at T2. The post-hoc test indicated that the KC group significantly increased contralateral rotation of the upper trunk (9.63 ± 4.19° vs. -4.25 ± 10.05°), and improved movement consistency (error: 8.88 ± 11.52° vs. 19.73 ± 12.79°) at T2 compared with the CT group. Significant time effects were also identified for VAS, scapular upward rotation (T1 and T2), upper trunk contralateral side-bending and PFM at T1, and upper trunk contralateral rotation at T2. In conclusion, both KC and CT training would relieve shoulder pain and improve scapular and trunk movement, whereas the KC program was more effective for increasing scapular movement consistency and upper trunk rotation during volleyball spikes.

Shoulder complaints more likely in volleyball players with a thickened bursa or supraspinatus tendon neovessels

Shoulder problems are common in volleyball and greatly impede both training and player performance. Subacromial bursa (SAB) thickening and tendon neovascularity have shown relevance in other populations, but their relationship with the development of shoulder complaints has not been investigated in volleyball players or overhead-throwing athletes. The study aim was to examine the role of SAB thickness, neovascularization of the supraspinatus tendon, shoulder strength, range of motion (ROM), player position, and age in the development of shoulder complaints in professional volleyball players. Players underwent preseason baseline testing (n = 86) and reported shoulder complaints during the subsequent 12-week period. Generalized estimating equations were used to model for probabilities of complaints after adjusting for player position, SAB side-to-side difference, neovessel presence, shoulder external rotation (ER) ROM, and age. Outside hitters and opposites were 12.2-fold more likely to develop complaints, and greater shoulder ER ROM increased risk by 8% for each additional degree. A side-to-side difference in SAB thickness ≥0.3 mm in the dominant compared with the non-dominant arm was associated with a 10.2-fold increased risk. Those with neovessels were 6.5 times more likely to develop complaints. Players without neovessels and with normal SAB thickness were very unlikely to develop complaints. This stark contrast to players with neovessels or increased SAB thickness, where nearly half of the players developed complaints, is of interest. Players with current complaints at baseline presented with greater IR:ER strength ratios; however, neither strength nor IR ROM at baseline was associated with an increased risk of developing complaints.

Comparison of shoulder range of motion, strength, and upper quarter dynamic balance between NCAA division I overhead athletes with and without a history of shoulder injury

OBJECTIVE

To determine differences in shoulder range of motion, strength, and upper quarter dynamic balance between collegiate overhead athletes with and without a history of a shoulder injury.

DESIGN

Cross-sectional study.

SETTING

Athletic training clinic.

PARTICIPANTS

58 overhead athletes who were fully participating in NCAA Division I overhead sports (baseball, softball, volleyball, and tennis) and free of any current shoulder injury were included. Participants were divided into a shoulder injury history group (n = 25) and uninjured group (n = 33). Participants in the shoulder injury history group had a previously resolved shoulder injury.

MAIN OUTCOME MEASURES

Active range of motion assessments for shoulder internal rotation, external rotation, and horizontal adduction. Isometric strength assessments for shoulder IR and ER. The Upper Quarter Y-Balance Test.

RESULTS

The shoulder injury history group demonstrated a lower Upper Quarter Y-Balance Test mean score in the superolateral direction (p = .03, d = 0.56), but no group differences existed for other results (p > .05).

CONCLUSIONS

Overhead athletes with a history of shoulder injury had worse upper quarter dynamic balance versus those without the history. From a clinical perspective, the findings may have significant implications for developing shoulder re-injury prevention and rehabilitation protocols in relation to their shoulder injury history.

Do the benefits of participation in sport and exercise outweigh the negatives? An academic review

Public health campaigns promote regular exercise and physical activity. These campaigns are founded on global recommendations that a combination of aerobic and resistance exercise is required, on a weekly basis, to maximise physical and mental health. However, participation in all forms of sports and physical activity has inherent risks that need to be considered by both health practitioners making activity recommendations and the people participating. This review examines biological, psychological and social benefits and harms of the three highest participation physical activities: walking/running, multidirectional sports and resistance exercise. While the remaining evidence indicates that the positives do outweigh the negatives, it demonstrates that moderate amounts of exercise provide the most optimal balance and that potential harms are typically associated with low or high participation.

Profiling Isokinetic Strength of Shoulder Rotator Muscles in Adolescent Asymptomatic Male Volleyball Players

The aim of the study was to describe the strength symmetry of internal and external rotator muscles and the conventional and functional strength balance ratios between these muscles in adolescent male volleyball players. Twenty-eight male adolescent volleyball players (15.5 ± 1.1 years (15–17 years); 73.2 ± 10.9 kg (55.3–100.1 kg) and 184.9 ± 8.4 cm (170–209 cm)) participated in this cross-sectional study. Concentric and eccentric peak torque of external and internal rotator muscles were measured, and conventional and functional strength balance ratios were calculated. The dominant limb presented significantly higher values for peak torque than the non-dominant limb of internal rotator muscles at concentric action assessed at 60°/s (48.7 ± 13.7 Nm and 43.9 ± 11.6 Nm, p = 0.01 and d value = 0.37) and at 240°/s (44.7 ± 11.2 Nm and 41.1 ± 11.0 Nm, p = 0.03 and d = 0.32). However, there was no difference in the peak torque of external rotator muscle between limbs for either angular speed. Regarding strength balance ratios, neither conventional (74.8 ± 14.3 for dominant limb and 80.1 ± 14.0 for non-dominant limb, p = 0.06 and d = 0.37) nor functional ratio (1.2 ± 0.4 for dominant limb and 1.3 ± 0.5 for non-dominant limb, p = 0.06 and d = 0.22) presented significant contralateral differences. Despite the short practice time, adolescent male volleyball athletes already have significant contralateral differences for internal rotator muscles and conventional ratio tends to be asymmetrical. Thus, preventive shoulder-strengthening programs, focused on the internal rotator muscles of the non-dominant limb, aiming to correct contralateral deficiency and conventional ratio, may be warranted for this population in the process of biological growth, maturation and development.

Shoulder Injuries in the Overhead-Throwing Athlete: Epidemiology, Mechanisms of Injury, and Imaging Findings

The unparalleled velocity achieved by overhead throwers subjects the shoulder to extreme forces, resulting in both adaptive changes and pathologic findings that can be detected at imaging. A key biomechanical principle of throwing is achieving maximum external rotation, which initially leads to adaptive changes that may result in a pathologic cascade of injuries. In addition to the well-established concepts of glenohumeral internal rotation deficit and internal impingement, osseous and soft-tissue injuries of the shoulder unique to overhead athletes are illustrated. The epidemiology and biomechanics of throwing injuries are reviewed, and examples from the authors' institutional experience with competitive, collegiate, and professional baseball players are provided to demonstrate the constellation of unique imaging findings seen in overhead throwing athletes. Given the widespread popularity of baseball, and other sports relying on overhead throwing motions at all playing levels from recreational to professional, it is important for radiologists in various practice settings to be familiar with the special mechanisms, locations, and types of shoulder injuries seen in the overhead throwing population. ^© RSNA, 2018.

Risk factors for, and prevention of, shoulder injuries in overhead sports: a systematic review with best-evidence synthesis

Objective

To assess the evidence for risk factors and prevention measures for shoulder injuries in overhead sports.

Design

Systematic review with best-evidence synthesis.

Data sources

Medline (Ovid), PubMed (complementary search), Embase (Elsevier), Cochrane (Wiley), SPORTDiscus (Ebsco) and Web of Science Core Collection (Thomson Reuters), from 1 January 1990 to 15 May 2017.

Eligibility criteria for selecting studies

Randomised controlled trials, cohort studies and case-control studies on risk factors or prevention measures for shoulder injuries in overhead sports. The eligible studies were quality assessed using the Scottish Intercollegiate Guidelines Network criteria.

Results

Of 4778 studies identified, 38 were eligible for quality review and 17 met the quality criteria to be included in the evidence synthesis. One additional quality study presented a shoulder injury prevention programme. Most studies focused on baseball, lacrosse or volleyball (n=13). The risk factors examined included participation level (competition vs training) (n=10), sex (n=4), biomechanics (n=2) and external workload (n=2). The evidence for all risk factors was limited or conflicting. The effect of the prevention programme within the subgroup of uninjured players at baseline was modest and possibly lacked statistical power.

Conclusions

All investigated potential risk factors for shoulder injury in overhead sports had limited evidence, and most were non-modifiable (eg, sex). There is also limited evidence for the effect of shoulder injury prevention measures in overhead sports.

PROSPERO trial registration number

CRD42015026850.

Insights into the epidemiology, aetiology and associations of infraspinatus atrophy in overhead athletes: a systematic review

Infraspinatus atrophy (IA) is much more prevalent in overhead sports compared with the general population. Its exact aetiology in this group of athletes remains unclear and definitive associations with pathology and performance have not yet been reached. The aim of this systematic review is to present the evidence on IA in overhead athletes focussing on the proposed mechanisms of suprascapular neuropathy and its associations with shoulder pathology and performance. A thorough literature search via Medline, EMBASE and Scopus was performed. From the nine articles identified, the majority of authors propose suprascapular nerve (SN) injury at the spinoglenoid notch; however, the suprascapular notch has also been suggested as a potential site of injury. With regard to the exact mechanism of suprascapular neuropathy, the majority of authors propose repeated traction of the nerve during extreme shoulder abduction and horizontal adduction and/or eccentric contractions of the infraspinatus. In the limited relevant literature, convincing links between IA and performance or shoulder pathology have not been identified. IA in overhead sports is most likely of multi-factorial aetiology. Important questions about IA and its significance in overhead sports remain unanswered and more biomechanical and prospective studies are warranted to provide further insights into this athletic injury.