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

Background: Superior labrum anterior-posterior (SLAP) lesion is a common shoulder injury, particularly in overhead athletes. While surgical management has traditionally consisted of SLAP repair, high rates of revision and complications have led to alternative techniques, such as biceps tenodesis (BT). While BT is commonly reserved for older nonoverhead athletes, indications for its use have expanded in recent years. Purpose: To determine functional outcomes and return-to-sport rates among overhead athletes after BT for SLAP tear. Study Design: Systematic review. Methods: A systematic review was performed for any articles published before July 2019. The search phrase “labral tear” was used to capture maximum results, followed by keyword inclusion of “SLAP tear” and “biceps tenodesis.” Inclusion criteria included outcome studies of BT for isolated SLAP tear in athletes participating in any overhead sports, not limited to throwing alone. Abstracts and manuscripts were independently reviewed to determine eligibility. When clearly delineated, outcome variables from multiple studies were combined. Results: After full review, 8 articles met inclusion criteria (99 athletes; mean age, 19.8-47 years), with baseball and softball players the most common among them (n = 62). Type II SLAP tear was the most common diagnosis, and 0% to 44% of athletes had a failed previous SLAP repair before undergoing BT. Only 1 study included patients with concomitant rotator cuff repair. Open subpectoral BT was most commonly used, and complication rates ranged from 0% to 14%, with wound erythema, traumatic biceps tendon rupture, brachial plexus neurapraxia, and adhesive capsulitis being reported. Combined reported postoperative functional scores were as follows: American Shoulder and Elbow Surgeons, 81.7 to 97; 12-Item Short Form Health Survey physical, 50 to 54; visual analog scale for pain, 0.8-1.5; Kerlan Jobe Orthopaedic Clinic, 66 to 79; and satisfaction, 80% to 87%. The overall return-to-sports rate for overhead athletes was 70% (60 of 86). For studies that clearly delineated outcomes based on level of play/athlete, the combined return-to-sports rate was 69% (11 of 16) for recreational overhead athletes, 80% (4 of 5) for competitive/collegiate athletes, and 60% (18 of 30) for professionals. Conclusion: BT in the overhead athlete offers encouraging functional outcomes and return-to-sports rates, particularly in the recreational athlete. It can be successfully performed as an index operation rather than SLAP repair, as well as in a younger patient population. Careful consideration should be given to elite overhead athletes, particularly pitchers, who tend to experience poorer outcomes.

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Risk Factors of Overuse Shoulder Injuries in Overhead Athletes: A Systematic Review

Sports Health A Multidisciplinary Approach ◽

10.1177/1941738120931764 ◽

2020 ◽

Vol 12 (5) ◽

pp. 478-487 ◽

Cited By ~ 1

Author(s):

Camille Tooth ◽

Amandine Gofflot ◽

Cédric Schwartz ◽

Jean-Louis Croisier ◽

Charlotte Beaudart ◽

...

Keyword(s):

Risk Factors ◽

Systematic Review ◽

Rotator Cuff ◽

Range Of Motion ◽

Training Load ◽

Shoulder Injuries ◽

Shoulder Injury ◽

Overhead Athletes ◽

Modifiable Factors ◽

And Training

Context: Shoulder injuries are highly prevalent in sports involving the upper extremity. Some risk factors have been identified in the literature, but consensus is still lacking. Objectives: To identify risk factors of overuse shoulder injury in overhead athletes, as described in the literature. Data Sources: A systematic review of the literature from the years 1970 to 2018 was performed using 2 electronic databases: PubMed and Scopus. Study Selection: Prospective studies, written in English, that described at least 1 risk factor associated with overuse shoulder injuries in overhead sports (volleyball, handball, basketball, swimming, water polo, badminton, baseball, and tennis) were considered for analysis. Study Design: Systematic review. Level of Evidence: Level 3. Data Extraction: Data were extracted from 25 studies. Study methodology quality was evaluated using the Modified Coleman Methodology Score. Results: Intrinsic factors, previous injury, range of motion (lack or excess), and rotator cuff weakness (isometric and isokinetic) highly increase the risk of future injuries. Additionally, years of athletic practice, body mass index, sex, age, and level of play seem to have modest influence. As for the effect of scapular dysfunction on shoulder injuries, it is still controversial, though these are typically linked. Extrinsic factors, field position, condition of practice (match/training), time of season, and training load also have influence on the occurrence of shoulder injuries. Conclusion: Range of motion, rotator cuff muscle weakness, and training load are important modifiable factors associated with shoulder injuries. Scapular dysfunction may also have influence. The preventive approach for shoulder injury should focus on these factors.

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Effect of Plyometric Training on Sport Performance in Adolescent Overhead Athletes: A Systematic Review

Sports Health A Multidisciplinary Approach ◽

10.1177/1941738120938007 ◽

2020 ◽

Vol 13 (1) ◽

pp. 37-44

Author(s):

Leyla Eraslan ◽

Birgit Castelein ◽

Valentien Spanhove ◽

Ceren Orhan ◽

Irem Duzgun ◽

...

Keyword(s):

Systematic Review ◽

Sport Performance ◽

Sprint Performance ◽

Current Evidence ◽

Training Intervention ◽

Control Group ◽

Plyometric Training ◽

Inclusion Criteria ◽

Overhead Athletes ◽

Mesh Terms

Context: Plyometric training has been shown to be beneficial in adolescent overhead athletes. However, existing research on the effects of plyometrics on sport performance has been limited. Objective: To systematically review the current literature to investigate whether plyometric training intervention improves upper- and lower-body sport performance. Data Sources: Two electronic databases (MEDLINE and Web of Science) were searched using specific Medical Subject Headings (MeSH) terms up to February 2019, and hand-searching was performed by looking to relevant studies that were cited in other studies. Study Selection: A total of 932 items were identified and were further assessed for the eligibility in the systematic review. For a study to be eligible, each of the following inclusion criteria had to be met: (1) participants were aged 13 to 18 years and selected from a sports or athletic population and the study (2) involved the evaluation of a plyometric training intervention with an aim to improve sports performance; (3) must have included a control intervention and/or control group; (4) included a quantitative objective measure of sport performance variables concerning throwing, jumping, running, and sprinting; and (5) was published in English. Study Design: Systematic review. Level of Evidence: Level 3. Data Extraction: A first screening was conducted based on title and abstract of the articles. In the second screening, the full text of the remaining articles was evaluated for the fulfillment of the inclusion criteria. Results: A total of 14 studies were included in this review. The methodological quality of the included studies ranged from low to moderate. There is moderate evidence that plyometric training intervention improves throwing and jumping performances. There is also preliminary evidence that plyometric training intervention improves sprint performance. Conclusion: The current evidence suggests that sport performance consisting of throwing capacity, jumping ability, and sprint performance significantly improved due to plyometric training interventions in adolescent overhead athletes.

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Glenohumeral Internal Rotation Deficit and Risk of Upper Extremity Injury in Overhead Athletes: A Meta-Analysis and Systematic Review

Sports Health A Multidisciplinary Approach ◽

10.1177/1941738118756577 ◽

2018 ◽

Vol 10 (2) ◽

pp. 125-132 ◽

Cited By ~ 22

Author(s):

Robert A. Keller ◽

Anthony F. De Giacomo ◽

Julie A. Neumann ◽

Orr Limpisvasti ◽

James E. Tibone

Keyword(s):

Systematic Review ◽

Range Of Motion ◽

Upper Extremity ◽

Internal Rotation ◽

Meta Analysis ◽

Mean Difference ◽

Extremity Injury ◽

Overhead Athletes ◽

Glenohumeral Internal Rotation Deficit ◽

Upper Extremity Injury

Context: Current perception dictates that glenohumeral internal rotation deficit (GIRD) is a chronic adaptation that leads to an increased risk of pathologic conditions in the dominant shoulder or elbow of overhead athletes. Objective: To determine whether adaptations in glenohumeral range of motion in overhead athletes lead to injuries of the upper extremity, specifically in the shoulder or elbow. Data Sources: An electronic database search was performed using Medline, Embase, and SportDiscus from 1950 to 2016. The following keywords were used: GIRD, glenohumeral internal rotation deficit, glenohumeral deficit, shoulder, sport, injury, shoulder joint, baseball, football, racquet sports, volleyball, javelin, cricket, athletic injuries, handball, lacrosse, water polo, hammer throw, and throwing injury. Study Selection: Seventeen studies met the inclusion criteria for this systematic review. Of those 17 studies, 10 included specific range of motion measurements required for inclusion in the meta-analysis. Study Design: Systematic review and meta-analysis. Level of Evidence: Level 4. Data Extraction: Data on demographics and methodology as well as shoulder range of motion in various planes were collected when possible. The primary outcome of interest was upper extremity injury, specifically shoulder or elbow injury. Results: The systematic review included 2195 athletes (1889 males, 306 females) with a mean age of 20.8 years. Shoulders with GIRD favored an upper extremity injury, with a mean difference of 3.11° (95% CI, –0.13° to 6.36°; P = 0.06). Shoulder total range of motion suggested increased motion (mean difference, 2.97°) correlated with no injury ( P = 0.11), and less total motion (mean difference, 1.95°) favored injury ( P = 0.14). External rotational gain also favored injury, with a mean difference of 1.93° ( P = 0.07). Conclusion: The pooled results of this systematic review and meta-analysis did not reach statistical significance for any shoulder motion measurement and its correlation to shoulder or elbow injury. Results, though not reaching significance, favored injury in overhead athletes with GIRD, as well as rotational loss and external rotational gain.

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Are muscle weakness and stiffness risk factors of the development of rotator cuff tendinopathy in overhead athletes: a systematic review

Therapeutic Advances in Chronic Disease ◽

10.1177/20406223211026178 ◽

2021 ◽

Vol 12 ◽

pp. 204062232110261

Author(s):

Cheuk-Kin Kwan ◽

Man-Chi Ko ◽

Sai-Chuen Fu ◽

Hio-Teng Leong ◽

Samuel Ka-Kin Ling ◽

...

Keyword(s):

Risk Factors ◽

Systematic Review ◽

Risk Factor ◽

Rotator Cuff ◽

Muscle Weakness ◽

Prospective Studies ◽

Shoulder Injuries ◽

Limited Evidence ◽

Overhead Athletes ◽

Rotator Cuff Tendinopathy

Background: Underlying muscle weakness and stiffness may increase the risk of developing rotator cuff tendinopathy. This systematic review aims to assess existing prospective studies to summarize whether muscle weakness and stiffness are risk factors for the development of rotator cuff tendinopathy in overhead athletes. Methods: A systematic search was performed using PRISMA guidelines. Prospective studies measuring muscle strength or stiffness and the incidence of rotator cuff tendinopathy were included. Quality assessment was performed with the Newcastle-Ottawa quality assessment scale. Results: The search yielded six studies, with a total of 523 trained overhead athletes followed up for one season. External rotation (ER) and internal rotation (IR) strength were described as protective factors against the development of rotator cuff tendinopathy. Athletes who did not sustain shoulder injuries had statistically stronger eccentric IR ( p < 0.01) and ER ( p < 0.05) strength in the pre-season assessment. Muscle stiffness indicated by limited range of motion of <106° for shoulder ER was described as a risk factor with an odds ratio of 1.12 ( p < 0.001). Imbalance between ER and IR strength was reported as risk factors for shoulder injuries in two studies, with a relative risk of 2.57 ( p < 0.05) reported in one study. Supraspinatus weakness was also reported as a risk factor for shoulder injuries in one study. Conclusion: Limited evidence support ER, IR weakness, limited ER range of motion, and very limited evidence support imbalance in ER/IR strength, and supraspinatus weakness as risk factors for rotator cuff tendinopathy in overhead athletes. No existing studies investigated the general population on this topic. Future cohort studies may improve on existing evidence with investigations on the general public, a longer follow-up time, clearly documented injury history, and a stringent diagnosis to rotator cuff tendinopathy.

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Exercise prescription for overhead athletes with shoulder pathology: a systematic review with best evidence synthesis

British Journal of Sports Medicine ◽

10.1136/bjsports-2016-096915 ◽

2017 ◽

Vol 52 (4) ◽

pp. 231-237 ◽

Cited By ~ 12

Author(s):

Alexis A Wright ◽

Eric J Hegedus ◽

Daniel T Tarara ◽

Samantha C Ray ◽

Steven L Dischiavi

Keyword(s):

Systematic Review ◽

Upper Extremity ◽

Exercise Prescription ◽

Evidence Synthesis ◽

Inclusion Criteria ◽

Single Plane ◽

Overhead Athletes ◽

Shoulder Pathology ◽

Best Evidence Synthesis ◽

Level I

ObjectiveTo produce a best evidence synthesis of exercise prescription used when treating shoulder pathology in the overhead athlete.DesignA systematic review of exercises used in overhead athletes including case studies and clinical commentaries.Data sourcesMEDLINE, PubMed, SPORTDiscus and CINAHL from database inception through July 8, 2016.MethodsWe examined data from randomised controlled trials and prospective cohort (level I–IV evidence) studies that addressed exercise intervention in the rehabilitation of the overhead athlete with shoulder pathology. Case studies and clinical commentaries (level V evidence) were examined to account for expert opinion-based research. Data were combined using best evidence synthesis and graded (A–F) recommendations (Centre for Evidence-Based Medicine).ResultsThere were 33 unique exercises in six level I–IV studies that met our inclusion criteria. Most exercises were single-plane, upper extremity exercises performed below 90oof elevation. There were 102 unique exercises in 33 level V studies that met our inclusion criteria. These exercises emphasised plyometrics, kinetic chain and sport-specific training.Conclusions and relevanceOverall, evidence for exercise interventions in overhead athletes with shoulder pathology is dominated by expert opinion (grade D). There is great variability between exercise approaches suggested by experts and those investigated in research studies and the overall level of evidence is low. The strongest available evidence (level B) supports the use of single-plane, open chain upper extremity exercises performed below 90° of elevation and closed chain upper extremity exercises. Clinical expert pieces support a more advanced, global treatment approach consistent with the complex, multidimensional nature of sport.

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Considerations of Conservative Treatment After a Partial Ulnar Collateral Ligament Injury in Overhead Athletes: A Systematic Review

Sports Health A Multidisciplinary Approach ◽

10.1177/1941738119853589 ◽

2019 ◽

Vol 11 (4) ◽

pp. 367-374

Author(s):

Nicole Cascia ◽

Kelsey Picha ◽

Carolyn M. Hettrich ◽

Tim L. Uhl

Keyword(s):

Systematic Review ◽

Conservative Treatment ◽

Study Design ◽

Ulnar Collateral Ligament ◽

Return To Play ◽

Evidence Based ◽

Collateral Ligament ◽

Level Of Evidence ◽

Rehabilitation Protocol ◽

Overhead Athletes

Context: Ulnar collateral ligament (UCL) reconstructions continue to increase without consensus on an evidence-based treatment protocol for nonoperative management. Currently, there is no consensus on an effective nonoperative protocol for partial UCL injuries that uses return-to-play (RTP) rates in determining the outcome of conservative treatment. Objective: To systematically review RTP rates after conservative treatment of partial UCL injuries in overhead athletes along with descriptive components of each conservative intervention to identify an effective evidence-based nonoperative rehabilitation protocol. Data Sources: Articles in PubMed, CINAHL, MEDLINE, Academic Search Complete, and SPORTDiscus were identified in October 2018 based on the following terms: overhead athlete, ulnar collateral ligament, nonoperative treatment, and return to play. Study Selection: Seven retrospective, level 4 studies (n = 196) qualified for analysis. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: Study design, level of evidence, demographics, sample size, sports involved, level of competition, grade or type of UCL diagnosis, conservative treatment components, and percentage RTP were extracted. Results: Overall, RTP rates after conservative treatment ranged between 42% and 100% (mean, 78% ± 20%). The most frequently reported components of rehabilitation protocols were (1) a period of rest, (2) stretching, (3) strengthening, and (4) a throwing program. Platelet-rich plasma injections were included in 5 (71%) of the 7 protocols with a rehabilitation period. Conclusion: Conservative treatment is a viable option for partial UCL tears in overhead athletes. A successful rehabilitation protocol includes the use of patient-reported outcomes, a sport-specific tailored treatment plan, kinetic chain strengthening, and an interval throwing program. Factors such as age, grading of tear, level of play, sport, and athlete’s perceived well-being should all be considered during treatment decisions.

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Glenohumeral Internal Rotation Deficit and Injuries: A Systematic Review and Meta-analysis

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118773322 ◽

2018 ◽

Vol 6 (5) ◽

pp. 232596711877332 ◽

Cited By ~ 9

Author(s):

Jordan E. Johnson ◽

Joshua A. Fullmer ◽

Chaseton M. Nielsen ◽

Joshua K. Johnson ◽

Claude T. Moorman

Keyword(s):

Systematic Review ◽

Internal Rotation ◽

Meta Analysis ◽

Study Groups ◽

Weighted Mean ◽

Level Of Evidence ◽

Overhead Athletes ◽

Glenohumeral Internal Rotation Deficit ◽

Increased Risk ◽

Definition Of

Background: There is an association between throwing activity and glenohumeral internal rotation deficit (GIRD). An 18° to 20° deficit has been adopted as the standard definition of pathological GIRD, but specific findings as to how GIRD relates to an injury are inconsistent. Purpose: To systematically review the literature to clarify the definition of GIRD diagnosis for adolescent and adult overhead athletes and to examine the association between GIRD and an increased risk of injuries in these athletes. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed. Observational studies comparing glenohumeral internal rotation range of motion (ROM) in injured and uninjured overhead athletes were included for the meta-analysis. Studies of adolescent and adult athletes were analyzed separately. ROM was compared for the injured and uninjured groups, and a weighted mean GIRD was estimated. To account for potential heterogeneity across studies, both fixed- and random-effects models were used to calculate a standardized mean difference (SMD). Results: Nine studies of level 3 or 4 evidence were included. From these, 12 study groups (4 adolescent, 8 adult) comprising 819 overhead athletes (226 injured, 593 uninjured) were included in the meta-analysis. The estimated SMD in GIRD between the injured and uninjured groups was 0.46 (95% CI, 0.15-0.77; P < .01) for the overall sample. The between-group effect was larger for adults (SMD, 0.60 [95% CI, 0.18 to 1.02]; P < .01) than adolescents (SMD, 0.20 [95% CI, –0.24 to 0.63]; P = .13). The weighted mean GIRD for the injured and uninjured groups was 13.8° ± 5.6° and 9.6° ± 3.0°, respectively, which also differed by age group. Moderate study heterogeneity was observed ( I2 = 69.0%). Conclusion: Based on this systematic review, the current definition of pathological GIRD may be too conservative, and a distinct definition may be required for adolescent and adult athletes. While the results indicate a link between internal rotation deficits and upper extremity injuries in the overhead athlete, higher quality prospective research is needed to clarify the role that GIRD plays in future injuries to overhead athletes of various ages.

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Return to Sport After Arthroscopic Superior Labral Anterior-Posterior Repair: A Systematic Review

Sports Health A Multidisciplinary Approach ◽

10.1177/1941738119873892 ◽

2019 ◽

Vol 11 (6) ◽

pp. 520-527 ◽

Cited By ~ 1

Author(s):

Aarabi Thayaparan ◽

James Yu ◽

Nolan S. Horner ◽

Timothy Leroux ◽

Bashar Alolabi ◽

...

Keyword(s):

Systematic Review ◽

English Language ◽

Data Extraction ◽

Return To Sport ◽

Level Of Evidence ◽

Overhead Athletes ◽

Slap Repair ◽

Arthroscopic Slap Repair ◽

Return To Activity ◽

Anterior Posterior

Context: Superior labral anterior-posterior (SLAP) lesions often result in significant sporting limitations for athletes. Return to sport is a significant outcome that often needs to be considered by athletes undergoing the procedure. Objective: To evaluate return to sport among individuals undergoing arthroscopic SLAP repair. Data Sources: Four databases (MEDLINE, EMBASE, PubMed, and Cochrane) were searched from database inception through January 29, 2018. Study Selection: English-language articles reporting on return-to-activity rates after arthroscopic SLAP repairs were included. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: Data including patient demographics, surgical procedure, and return to activity were extracted. The methodological quality of included studies was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) tool. Results: Of 1938 screened abstracts, 22 articles involving a total of 944 patients undergoing arthroscopic SLAP repair met inclusion criteria. Of the total included patients, 270 were identified as overhead athletes, with 146 pitchers. Across all patients, 69.6% (657/944 patients) of individuals undergoing arthroscopic SLAP repair returned to sport. There was a 69.0% (562/815 patients) return to previous level of play, with a mean time to return to sport of 8.9 ± 2.4 months (range, 6.0-11.7 months). The return-to-sport rate for pitchers compared with the return-to-activity rate for nonpitchers, encompassing return to work and return to sport, was 57.5% (84/146 patients) and 87.1% (572/657 patients), respectively, after arthroscopic SLAP repair. Conclusion: Arthroscopic SLAP repair is associated with a fair return to sport, with 69.6% of individuals undergoing arthroscopic SLAP repair returning to sport. SLAP repair in pitchers has significantly decreased return to sport in comparison with nonpitching athletes. Athletes on average return to sport within 9 months postoperatively.

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