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Overhead Athletes- Latest Assessment of Shoulder-Injury Prevention, Diagnosis

Sports wherein the athlete’s hand frequently goes over the athlete’s head see high frequencies of shoulder injuries. Such athletes are sometimes referred to as “overhead athletes.”

These sports include swimming, volleyball, handball, baseball, and waterpolo. For instance, 23% to 38% of swimmers report shoulder injuries within one year.1,2 Nearly a quarter of volleyball players report shoulder pain during the season.3 Handball players report previous shoulder pain at a rate of 44% to 75%. Injuries may occur as sudden, cumulative trauma, or a combination of both.5

For most presentations of shoulder pain, experts tend to recommend conservative, non-pharmacological interventions as first-line treatments, especially exercise therapy.6 While an important percentage of patients will require surgery, as a first-line treatment, exercise therapy generally achieves results on par with decompression surgery, with short-term pain relief on par with corticosteroid injections.6,7 However, most of this research concerns general populations of patients with shoulder complaints. What about the management of overhead athletes with their higher demands and higher risks? Enter Dr. Behnam Liaghat and colleagues from the University of Southern Denmark. The British Journal of Sports Medicine published their comprehensive, systematic review in April.8 Researchers assessed the scientific literature regarding shoulder injury management for overhead athletes specifically.

Here is a quick summary of their findings. Diagnosis: For anterior instability, the positive apprehension test proved the most reliable single test. However, a combination of the apprehension and relocation tests was found to have the highest reliability. The relocation test alone also had a good likelihood ratio. For biceps-labrum complex injuries, the reviewers deemed the three-pack test to have a good rationale, but research proving or disproving it was largely not available. For SLAP injuries, the Biceps Load II test proved highly reliable for a positive diagnosis. Tests for subacromial impingement syndrome proved largely unreliable, perhaps owing to the unclear pathogenesis for this diagnosis.9 

The authors recognised the uncertainty surrounding the diagnosis. Separately, the authors add that diagnostic ultrasound may be a supportive tool for most sports injuries to the shoulder. Prevention: Various studies have described shoulder training protocols applied preventatively for overhead athletes. Results are mixed. Four studies included in the review found encouraging effect sizes with programs that aimed to increase glenohumeral rotation, external rotation, thoracic mobility, balance, scapular strength, upper extremity strength, and/or trunk strength. Three low-quality studies found no results from such programs. The authors remain positive toward prevention programs, noting that sport-specific design as well as optimal frequency, dose, and volume may play a crucial role in the varying effectiveness of such programs.

Treatment: Strengthening exercise alone, or in combination with manual therapies, showed a large effect in reducing shoulder pain. Manual treatment alone was associated with a small effect. Compared to no treatment, large effects were also seen with programs combining strengthening, stretching, ice packs, electrotherapy, and compression. Study Quality: For the general population, multiple, high-quality studies demonstrate the efficacy of exercise therapy.9 On the other hand, regarding research focused on the overhead athlete population, the authors graded the studies as very-low to moderate quality of evidence. There is a call for more research. However, the best evidence healthcare has associates exercise therapy with large effect sizes, even for this population of athletes with high demands on their shoulders.


1. Walker H, Gabbe B, Wajswelner H, Blanch P, Bennell K. Shoulder pain in swimmers: a 12-month prospective cohort study of incidence and risk factors. Physical Therapy in Sport. 2012 Nov 1;13(4):243-9.

2. Chase KI, Caine DJ, Goodwin BJ, Whitehead JR, Romanick MA. A prospective study of injury affecting competitive collegiate swimmers. Research in Sports Medicine. 2013 Apr 1;21(2):111-23.

3. Forthomme B, Wieczorek V, Frisch A, Crielaard JM, Croisier JL. Shoulder pain among high-level volleyball players and preseason features. Medicine and Science in Sports and Exercise. 2013 Oct 1;45(10):1852- 60.

4. Andersson SH, Bahr R, Clarsen B, Myklebust G. Preventing overuse shoulder injuries among throwing athletes: a cluster-randomised controlled trial in 660 elite handball players. British Journal of Sports Medicine. 2017 Jul 1;51(14):1073-80.

5. International Olympic Committee Injury and Illness Epidemiology Consensus Group, Bahr R, Clarsen B, Derman W, Dvorak J, Emery CA, Finch CF, Hägglund M, Junge A, Kemp S, Khan KM. International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sports 2020 (including the STROBE extension for sports injury and illness surveillance (STROBE-SIIS)). Orthopaedic Journal of Sports Medicine. 2020 Feb 14;8(2):2325967120902908.

6. Pieters L, Lewis J, Kuppens K, Jochems J, Bruijstens T, Joossens L, Struyf F. An update of systematic reviews examining the effectiveness of conservative physical therapy interventions for subacromial shoulder pain. Journal of Orthopaedic & Sports Physical Therapy. 2020 Mar; 50 (3):131-41.

7. Lo IK, Denkers MR, More KD, Nelson AA, Thornton GM, Boorman RS. Partial-thickness rotator cuff tears: clinical and imaging outcomes and prognostic factors of successful nonoperative treatment. Open Access Journal of Sports Medicine. 2018;9:191.

8. Liaghat B, Pedersen JR, Husted RS, Pedersen LL, Thorborg K, Juhl CB. Diagnosis, prevention and treatment of common shoulder injuries in sport: grading the evidence–a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF). British Journal of Sports Medicine. 2023 Apr 1;57(7):408- 16.

9. Pieters L, Lewis J, Kuppens K, Jochems J, Bruijstens T, Joossens L, Struyf F. An update of systematic reviews examining the effectiveness of conservative physical therapy interventions for subacromial shoulder pain. Journal of Orthopaedic & Sports Physical Therapy. 2020 Mar;50(3):131-41.


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