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Ann cools 4 screening tennis players [compatibiliteitsmodus]
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Ann cools 4 screening tennis players [compatibiliteitsmodus]

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  • 1. SCREENING THE SHOULDERGIRDLE IN ELITE TENNISPLAYERS Ann Cools, PT, PhD Dept Rehab. Sciences & Physiotherapy Ghent University, Belgium Ann Cools Wrightington Nov 2012 1
  • 2. Purpose of this presentation:1. Rationale for strength and ROM screening in the overhead athlete2. Results from studies on elite adolescent tennis players (Swedish Tennis Federation)3. Implications for injury prevention programs and return to play criteria Ann Cools Wrightington Nov 2012 2
  • 3. Why performing screening in healthy elite overhead athletes?Performance enhancement: longitudinalfollow up in view of performance/rankingInjury prevention - risk factors forinjury and preventive programsReturn to play – normative data andindividual results after injury Ann Cools Wrightington Nov 2012 3
  • 4. INTERNATIONAL PhD PROJECT:Age-related adaptations of the shouldergirdle in elite Swedish adolescent tennisplayers Ann Cools, PT, PhD & Fredrik Johansson, PT, MsC Ghent University – Gent - Belgium Swedish Tennis Federation – Stockholm - Sweden Ann Cools Wrightington Nov 2012 4
  • 5. INTERNATIONAL PhD PROJECT:Age-related adaptations of the shouldergirdle in elite Swedish adolescent tennisplayers – Fredrik Johansson/Ann Cools Musculoskeletal tests: shoulder girdle strength, flexibility, ROM and position Physical tests: physical capacity, functional strength, velocity… Imaging: bilateral MRI both shoulders Ann Cools Wrightington Nov 2012 5
  • 6. Subjects: Swedish National Selection Tennis 35 players, Age 10-17 years Number of years playing in competition: 7.1(±1.4) years Hours playing / week: 13.9 ± 2.4 hours Male players (n=19) Female players (n=16) p-value independent t-testsAge (years) 13.6 (± 1.4) 12.6 (± 1.3) 0.34Height (cm) 163.6 (± 12) 156.6 (± 10.5) 0.84Weight (kg) 53 (± 11.8) 46.1 (± 7.8) Ann Cools Wrightington Nov 2012 0.053 6
  • 7. Scapulo-thoracic Outcome Measurements:(Pro 3600 digital inclinometer)1. Scapular upward inclination: 0° - 90° - 180° Ann Cools Wrightington Nov 2012 7 (Downar 2005, Myers 2005, Laudner 2007, Oyama 2008)
  • 8. Scapulo-thoracic Outcome Measurements:2. Strength: (HandHeld dynamometer CompuFET, Biometrics) – Upper Trapezius (UT) – Serratus Anterior (SA) – Middle Trapezius (MT) – Lower Trapezius (LT) Ann Cools Wrightington Nov 2012 8 (Mullaney 2005, Michener 2005, Trakis 2008)
  • 9. Scapulo- thoracic Outcome Measurements:3. Pectoralis minor length: coracoid – 4th rib Ann Cools Wrightington Nov 2012 9 (Borstad 2005, Borstad 2008)
  • 10. Results (1) Scapular upward inclination 60 50 40 ND 30 D 20 10 0 0° 90° 180° Significant side-difference dominant versusNov 2012 Ann Cools Wrightington non-dominant p< 0.001 10
  • 11. DiscussionConflicting results in literature: Scapularupward (Downar 2005, Myers 2005) ordownward (Laudner 2007, Omaya 2008)rotation in baseball pitchersMore upward rotation possibly protectsthe player from injury Ann Cools Wrightington Nov 2012 11
  • 12. Results(2) Scapular Muscle Strength180160 * *140120100 ND 80 D 60 40 20 0 UT SA MT LT Ann Cools Wrightington Nov 2012 12
  • 13. DiscussionCools et al. 2007 : elite gymnastsshow side differences and muscle“imbalance” in the scapular musclesdue to high performance adaptationsTrakis et al. 2008: side differences inMT and LT strength in pitchers withthrowing related shoulder pain Ann Cools Wrightington Nov 2012 13
  • 14. Results (3) Pectoralis minor length13,5 1312,5 * 1211,5 * ND D 1110,5 10 9,5 female male Significant side differences with shorter PML on Nov 2012 Ann Cools Wrightington the dominant side (p<0.001) 14
  • 15. DiscussionBorstad et al. JOSPT 2005:short PM influences scapularkinematics and induceschanges similar toimpingement relateddyskinesis Ann Cools Wrightington Nov 2012 15
  • 16. Limitation of the first study: Descriptive profile of elite tennis players 11-17y, no subdivision in age groups, limited sample size Only scapular position and strength, no shoulder measurementsPurpose of the 2nd study: Age- related changes in shoulder and scapular variables in elite tennis players between 10-20 years Ann Cools Wrightington Nov 2012 16
  • 17. Tennis-screening Båstad/Stockholm-Sweden April 2009 – April 2011Subjects: Swedish National Selection Tennis 59 players, age 10-20y 3 age-cathegories: -14y, 14-16y, +16y 31 boys, 28 girls 56 right handed, 3 left handed N Hours/ Height (cm) Weight (kg) w-14y (12,7y±0,8) 24 12,3 154,1 ± 8,8 44,8 ± 6,914-16y 22 15,3 168,8 ± 8,4 57,1 ± 9,1(14,2y±0,4)+16y (17,4±1,5) 13 15,6 172,4 ± 7,8 72,5 ± 9,0 Ann Cools Wrightington Nov 2012 17
  • 18. MethodsScapular measurements– Upward inclination (pro 3600 inclinometer)– Muscle strength (CompuFET - Biometrics)Glenohumeral measurements– ROM (Acumar inclinometer)– RC strength (CompuFET- biometrics) Ann Cools Wrightington Nov 2012 18
  • 19. Results(1) Scapular upward rotation:16+ players have less upward rotation at higherelevation angles on their dominant side (p=0.012), possiblyincreasing the risk for scapular dyskinesis and chronic Ann Cools Wrightington Nov 2012 19shoulder pain
  • 20. Results(2) Scapular Muscle Strength: 4 UT 4 SA 3,5 3 ND 3 ND 2 D D 2,5 1 2 0 -14 14-16 16+ -14 14-16 16+ 2 LT 2 MT 1,5 1,5 ND ND 1 1 D D 0,5 0,5 0 0 -14 14-16 16+ -14 14-16 16+no increase in normalised muscle strength ofscapular stabilizers (middle/lower trap, serr ant), in spite Ann Cools Wrightington Nov 2012 20of general increase in shoulder strength
  • 21. Results(3) Glenohumeral ROM IR Total RMin general age-related decrease of IR-ROM (-10°) enTRM (-15°), however not significant (p=0.077 andp=0.06) Ann Cools Wrightington Nov 2012 21
  • 22. Results(4) Rotator Cuff strength: IR, ER, ER/IR ratioIR strength ER strength ER/IR ratiobetween 14-16y IR strength increases (p=0.03) andER/ER ratio decreases (below 70%) Ann Cools Wrightington Nov 2012 22
  • 23. ConclusionsAge-related changes in shoulder and scapular variables possibly increase the risk for overuse injury in the shoulder - Decrease of glenohumeral ROM - Insufficient gain in scapular stabilizing muscle strength - Changes in rotator cuff muscle balance Ann Cools Wrightington Nov 2012 23
  • 24. Physical testing&MRI screening of the shoulderin Elite Swedish Tennis PlayersFredrik Johansson, Stockholm, Sweden, SVTFAnn Cools, PhD, Ghent University, BelgiumEdin De Bri PhD, Orthopeadic Surgeon, Stockholm, Sweden Ann Cools Wrightington Nov 2012 24
  • 25. MRI screening Ann Cools Wrightington Nov 2012 25(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012)
  • 26. Subjects MRI Elite Swedish National Players N = 35 (15 boys and 20 girls) Median age 17 (range 13-24) Antropometry – Heigth 171 cm – Weigth 65 kg – Heigth 178,6 cm – 71,8 kg Hours playing / week: 17 ± 2-5 hours Matches per year 100-120 Ann Cools Wrightington Nov 2012 26(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012)
  • 27. MRI findings results 19 players (54,2%) had a normal MRI examination 16 players (45.8%) had an abnormal examination. 14 players showed a total of 16 tendinosis (2 players both in IS/SS), predominately in Infraspinatus (10), Supraspinatus (5) and Subscapularis (1). Ann Cools Wrightington Nov 2012 27(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012)
  • 28. Most common MRI findings Boys 13-24 years Infraspinatus tendinosis Supraspinatustendinosis DA DA 3 out of 15 players (20%) 0 out of 15 players Ann Cools Wrightington Nov 2012 28(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012)
  • 29. Most common MRI findings Girls 13-24 years Infraspinatus tendinosis Supraspinatustendinosis DA DA 7 out of 20 players (35%) 5 out of 20 players (25%) Ann Cools Wrightington Nov 2012 29(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012)
  • 30. Aerobe/Anaerobe tests Modified 30 s wingate Treadmill test test Ann Cools Wrightington Nov 2012 30(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012)
  • 31. Correlation divided into gender(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012) Ann Cools Wrightington Nov 2012 31
  • 32. Threshold/SvTF criteria for Girls (Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012) Only 1 girl (5,5%) Threshold meet the SvTF square for criteria for both aerobic/anaerobic Sprintbike capacity (anaerobic) Threshold ”under square for threshold Vo2 max in both” (aerobic) Ann Cools Wrightington Nov 2012 32
  • 33. Threshold/SvTF criteria for Boys(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012) 6 boys 28% Ann Cools Wrightington Nov 2012 33
  • 34. Is general physical capacity related to localjoint load?Are the shoulders in the girls more prone todegeneration/injury because the physicalcapacity is not keeping up with thedemand?Are tendinopathy findings on MRI correlatedto decreased muscle strength? Ann Cools Wrightington Nov 2012 34
  • 35. Implications of shoulderscreening for injuryprevention and returnto play after injury? Ann Cools Wrightington Nov 2012 35
  • 36. Ann Cools Wrightington Nov 2012 36
  • 37. “Ideal” criteria for return to playMcCarty et al. Clin Sports Med 23 (2004) 335-351Little/no painPatient subjectivityNear normal ROMNear normal strengthNormal functional abilityNormal sport-specific skills Ann Cools Wrightington Nov 2012 37
  • 38. Normal ROM?< 20° side difference for IR< 10% side difference for total ROM(ER + IR) (Ellenbecker & Cools BJSM 2010, 2012 Ann Cools Wrightington Nov Braun et al. JBJS 2009, 38 Tate et al. JAT 2012, Shanley et al. AJSM 2011)
  • 39. Measurement of shoulderROM into ER and IR Loss of ROM >25° increases risk for shoulder injury (Ellenbecker & Ann CoolsBJSM 2010, 2012 Cools Wrightington Nov Braun et al. JBJS 2009 39 Tate et al. JAT 2012, Shanley et al. AJSM 2011)
  • 40. Normal strength RC? – No side differences (10% more strength on dominant side) – ER/IR ratio 66% (isokinetic testing) or 75% (isometric testing) – Special attention to ER (Ellenbecker Ann Cools 2010,Nov 2012 et al. AJSM 2010, & Cools Wrightington Byram 40 Niederdracht et al. 2008)
  • 41. Measurement of RCstrengthER/IR ratio <66% increases the risk for shoulder injury in overhead athletes (Byram et al. AJSM 2010) Ann Cools Wrightington Nov 2012 41
  • 42. Normal strengthscapular muscles? – No side differences (10% more strength on dominant side) – Protraction/retraction ratio = 100% – Special attention to middle and lower trap (Cools et al. BJSM 2004, JAT 2005, JAT 2007, BJSM 2010, Ann Cools Wrightington Nov 2012 42 Tate et al. JAT 2012, Kawasaki 2012)
  • 43. Functional tests? Eccentric strength RC: – new protocol for ecc strength measurement using compuFET HHD: 90° - 3 seconds - ER Ann Cools Wrightington Nov 2012 43
  • 44. Functional tests? Within- and between tester reliability and validity of a new protocol for measuring eccentric RC strength (Johansson & Cools, unpublished data 2012) Within tester tester 1 Tester 2 reliability Trial 1 127,2N 119,1N Trial 2 122,0N 112,2N Trial 3 110,9N 111,5N ICC between trials 0.88 0.86 (Cools et al. BJSM 2010, Nov 2012 Ann Cools Wrightington 44 Cools & Johansson, unpublished data 2012)
  • 45. Functional tests? Within- and between tester reliability and validity of a new protocol for measuring eccentric RC strength (Johansson & Cools, unpublished data 2012) Between tester reliability Tester 1 120,1N Tester 2 114,2N ICC between testers 0,71 Validity with Biodex CompuFET 114,2N Biodex 110,9N Pearson Correlation 0,78 coefficient Ann Cools Wrightington Nov 2012 45
  • 46. Functional tests? Endurance test in sport-specific position(Maenhout et al. 2012, IJSM under revision) Ann Cools Wrightington Nov 2012 46
  • 47. Injury Prevention Program(Ellenbecker & Cools BJSM 2010)1. Stretching of the posterior shoulder Ann Cools Wrightington Nov 2012 47
  • 48. Injury Prevention Program(Cools et al. BJSM 2008, Ellenbecker & Cools BJSM 2010)2. Strengthening the posterior cuff Ann Cools Wrightington Nov 2012 48
  • 49. Injury Prevention Program(Cools et al. AJSM 2007, De Mey et al. JOSPT 2009,Ellenbecker & Cools BJSM 2010)3. Scapular training Ann Cools Wrightington Nov 2012 49
  • 50. Take home messageReturn to play criteria after shoulderinjury? 1. ROM: <20° side difference for IR 2. RC strength: ratio 66-75% 3. Scapular strength ratio 100% 4. Functional tests?? 5. Preventive stretching and strengthening program Ann Cools Wrightington Nov 2012 50
  • 51. (Gent- Belgium) Ann Cools Wrightington Nov 2012 51

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