This document discusses screening tests for the shoulder girdle in elite tennis players. It describes studies that examined strength, range of motion, and muscle imbalances in adolescent tennis players in Sweden. The studies found increased upward rotation of the scapula on the dominant side, as well as strength imbalances between dominant and non-dominant sides. MRI screening of elite players found high rates of tendinosis, especially in the infraspinatus and supraspinatus tendons. The implications are that screening can help identify risk factors for injury and guide return-to-play criteria focusing on normal strength, range of motion, and function.

1. SCREENING THE SHOULDER
GIRDLE IN ELITE TENNIS
PLAYERS
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 athlete
2. 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: longitudinal
follow up in view of performance/
ranking
Injury prevention - risk factors for
injury and preventive programs
Return to play – normative data and
individual results after injury
Ann Cools Wrightington Nov 2012 3

4. INTERNATIONAL PhD PROJECT:
Age-related adaptations of the shoulder
girdle in elite Swedish adolescent tennis
players
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 shoulder
girdle in elite Swedish adolescent tennis
players – 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-tests
Age (years) 13.6 (± 1.4) 12.6 (± 1.3) 0.34
Height (cm) 163.6 (± 12) 156.6 (± 10.5) 0.84
Weight (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. Discussion
Conflicting results in literature: Scapular
upward (Downar 2005, Myers 2005) or
downward (Laudner 2007, Omaya 2008)
rotation in baseball pitchers
More upward rotation possibly protects
the player from injury
Ann Cools Wrightington Nov 2012 11

12. Results(2)
Scapular Muscle Strength
180
160
* *
140
120
100 ND
80 D
60
40
20
0
UT SA MT LT
Ann Cools Wrightington Nov 2012 12

13. Discussion
Cools et al. 2007 : elite gymnasts
show side differences and muscle
“imbalance” in the scapular muscles
due to high performance adaptations
Trakis et al. 2008: side differences in
MT and LT strength in pitchers with
throwing related shoulder pain
Ann Cools Wrightington Nov 2012 13

14. Results (3)
Pectoralis minor length
13,5
13
12,5
*
12
11,5 * ND
D
11
10,5
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. Discussion
Borstad et al. JOSPT 2005:
short PM influences scapular
kinematics and induces
changes similar to
impingement related
dyskinesis
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 measurements
Purpose 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 2011
Subjects: 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 ± 6,9
14-16y 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. Methods
Scapular 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 higher
elevation angles on their dominant side (p=0.012), possibly
increasing the risk for scapular dyskinesis and chronic
Ann Cools Wrightington Nov 2012 19
shoulder 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 of
scapular stabilizers (middle/lower trap, serr ant), in spite
Ann Cools Wrightington Nov 2012 20
of general increase in shoulder strength

21. Results
(3) Glenohumeral ROM
IR Total RM
in general age-related decrease of IR-ROM (-10°) en
TRM (-15°), however not significant (p=0.077 and
p=0.06)
Ann Cools Wrightington Nov 2012 21

22. Results
(4) Rotator Cuff strength: IR, ER, ER/IR ratio
IR strength ER strength ER/IR ratio
between 14-16y IR strength increases (p=0.03) and
ER/ER ratio decreases (below 70%)
Ann Cools Wrightington Nov 2012 22

23. Conclusions
Age-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 shoulder
in Elite Swedish Tennis Players
Fredrik Johansson, Stockholm, Sweden, SVTF
Ann Cools, PhD, Ghent University, Belgium
Edin 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 local
joint load?
Are the shoulders in the girls more prone to
degeneration/injury because the physical
capacity is not keeping up with the
demand?
Are tendinopathy findings on MRI correlated
to decreased muscle strength?
Ann Cools Wrightington Nov 2012 34

35. Implications of shoulder
screening for injury
prevention and return
to play after injury?
Ann Cools Wrightington Nov 2012 35

36. Ann Cools Wrightington Nov 2012 36

37. “Ideal” criteria for return to play
McCarty et al. Clin Sports Med 23 (2004) 335-351
Little/no pain
Patient subjectivity
Near normal ROM
Near normal strength
Normal functional ability
Normal 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 shoulder
ROM 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 RC
strength
ER/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 strength
scapular 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 message
Return to play criteria after shoulder
injury?
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