Ann cools 4 screening tennis players [compatibiliteitsmodus]

SCREENING THE SHOULDER GIRDLE IN ELITE TENNIS PLAYERS

Ann Cools, PT, PhDDept Rehab. Sciences & PhysiotherapyGhent University, Belgium

Ann Cools Wrightington Nov 2012 1

Purpose of this presentation:

1. Rationale for strength and ROM screening in the overhead athlete

2. Results from studies on elite adolescent tennis players (SwedishTennis Federation)

3. Implications for injury prevention programs and return to play criteria

Ann Cools Wrightington Nov 2012 2

Why performing screening in healthy elite overhead athletes?

� Performance enhancement: longitudinalfollow up in view of performance/ ranking

� Injury prevention - risk factors forinjury and preventive programs

� Return to play – normative data andindividual results after injury

Ann Cools Wrightington Nov 2012 3

INTERNATIONAL PhD PROJECT:Age-related adaptations of the shoulder girdle in elite Swedish adolescent tennis players

Ann Cools, PT, PhD & Fredrik Johansson, PT, MsCGhent University – Gent - Belgium

Swedish Tennis Federation – Stockholm - Sweden Ann Cools Wrightington Nov 2012 4

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, functionalstrength, velocity…

Imaging: bilateral MRI both shoulders

Ann Cools Wrightington Nov 2012 5

Ann Cools Wrightington Nov 2012

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 independentt-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) 0.053 6

Ann Cools Wrightington Nov 2012

Scapulo-thoracic Outcome Measurements:(Pro 3600 digital inclinometer)

1. Scapular upward inclination: 0° - 90° - 180°

(Downar 2005, Myers 2005, Laudner 2007, Oyama 2008)

7

Ann Cools Wrightington Nov 2012

Scapulo-thoracic Outcome Measurements:

2. Strength: (HandHeld dynamometer CompuFET, Biometrics)

– Upper Trapezius (UT)

– Serratus Anterior (SA)

– Middle Trapezius (MT)

– Lower Trapezius (LT)

(Mullaney 2005, Michener 2005, Trakis 2008)8

Ann Cools Wrightington Nov 2012

Scapulo- thoracic Outcome Measurements:

3. Pectoralis minor length: coracoid – 4th rib

(Borstad 2005, Borstad 2008)9

Ann Cools Wrightington Nov 2012

Results (1)

� Scapular upward inclination

0

10

20

30

40

50

60

0° 90° 180°

ND

D

Significant side-difference dominant versus non-dominant p< 0.001 10

Ann Cools Wrightington Nov 2012

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

11

Ann Cools Wrightington Nov 2012

Results(2)

� Scapular Muscle Strength

0

20

40

60

80

100

120

140

160

180

UT SA MT LT

ND

D

* *

12

Ann Cools Wrightington Nov 2012

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

13

Ann Cools Wrightington Nov 2012

Results (3)

� Pectoralis minor length

9,5

10

10,5

11

11,5

12

12,5

13

13,5

female male

ND

D*

*

Significant side differences with shorter PML on the dominant side (p<0.001)14

Ann Cools Wrightington Nov 2012

Discussion

� Borstad et al. JOSPT 2005: short PM influences scapular kinematics and induces changes similar to impingement related dyskinesis

15

Ann Cools Wrightington Nov 2012

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 16

Ann Cools Wrightington Nov 2012

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/w

Height (cm) Weight (kg)

-14y (12,7y±0,8) 24 12,3 154,1 ± 8,8 44,8 ± 6,9

14-16y (14,2y±0,4)

22 15,3 168,8 ± 8,4 57,1 ± 9,1

+16y (17,4±1,5) 13 15,6 172,4 ± 7,8 72,5 ± 9,017

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

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 chronicshoulder pain

Ann Cools Wrightington Nov 2012 19

Results

� (2) Scapular Muscle Strength:

no increase in normalised muscle strength of scapular stabilizers (middle/lower trap, serr ant), in spiteof general increase in shoulder strength

Ann Cools Wrightington Nov 2012

2

2,5

3

3,5

4

-14 14-16 16+

ND

D

0

0,5

1

1,5

2

-14 14-16 16+

ND

D

0

0,5

1

1,5

2

-14 14-16 16+

ND

D

0

1

2

3

4

-14 14-16 16+

ND

D

UT SA

LT MT

20

Results

� (3) Glenohumeral ROM

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

IR Total RM

21

Results

� (4) Rotator Cuff strength: IR, ER, ER/IR ratio

between 14-16y IR strength increases (p=0.03) and ER/ER ratio decreases (below 70%)

Ann Cools Wrightington Nov 2012

IR strength ER strength ER/IR ratio

22

Conclusions

Age-related changes in shoulder and scapular variables possibly increasethe risk for overuse injury in the shoulder

- Decrease of glenohumeral ROM

- Insufficient gain in scapular stabilizingmuscle strength

- Changes in rotator cuff muscle balanceAnn Cools Wrightington Nov 2012 23

Physical testing &

MRI screening of the shoulder in Elite Swedish Tennis Players

Fredrik Johansson, Stockholm, Sweden, SVTFAnn Cools, PhD, Ghent University, BelgiumEdin De Bri PhD, Orthopeadic Surgeon, Stockholm, Sweden

Ann Cools Wrightington Nov 2012 24

MRI screening

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(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012)

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)

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)

Most common MRI findingsBoys 13-24 yearsInfraspinatus tendinosisDA

� 3 out of 15 players (20%)

SupraspinatustendinosisDA

� 0 out of 15 players

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(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012)

Most common MRI findingsGirls 13-24 years

Infraspinatus tendinosisDA

� 7 out of 20 players (35%)

SupraspinatustendinosisDA

� 5 out of 20 players (25%)

Ann Cools Wrightington Nov 2012 29

(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012)

Aerobe/Anaerobe tests

Treadmill testModified 30 s wingate

test

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(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012)

Correlation divided into gender

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(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012)

Threshold/SvTF criteria for Girls

Only 1 girl (5,5%)

meet the SvTF

criteria for both

aerobic/anaerobic

capacity

Threshold

square for

Sprintbike

(anaerobic)

”under

threshold

in both”

Threshold

square for

Vo2 max

(aerobic)

Ann Cools Wrightington Nov 2012 32

(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012)

Threshold/SvTF criteria for Boys

6

boys

28%

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(Fredrik Johansson, Scand Congress Sports Medicine, Malmö Sept 2012)

� 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 the demand?

� Are tendinopathy findings on MRI correlatedto decreased muscle strength?Ann Cools Wrightington Nov 2012 34

Implications of shoulderscreening for injuryprevention and return to play after injury?

Ann Cools Wrightington Nov 2012 35

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“Ideal” criteria for return to playMcCarty 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

Normal ROM?

� < 20° side difference for IR

� < 10% side difference for total ROM (ER + IR)

(Ellenbecker & Cools BJSM 2010, Braun et al. JBJS 2009, Tate et al. JAT 2012, Shanley et al. AJSM 2011)

Ann Cools Wrightington Nov 2012 38

Measurement of shoulderROM into ER and IR

Loss of ROM >25° increases risk for shoulderinjury

(Ellenbecker & Cools BJSM 2010, Braun et al. JBJS 2009Tate et al. JAT 2012, Shanley et al. AJSM 2011)

Ann Cools Wrightington Nov 2012 39

Normal strength RC?

– No side differences (10% more strengthon dominant side)

– ER/IR ratio 66% (isokinetic testing) or75% (isometric testing)

– Special attention to ER

(Ellenbecker & Cools 2010, Byram et al. AJSM 2010, Niederdracht et al. 2008)

Ann Cools Wrightington Nov 2012 40

Measurement of RC strength

ER/IR ratio <66% increases the risk forshoulder injury in overhead athletes(Byram et al. AJSM 2010)

Ann Cools Wrightington Nov 2012 41

Normal strengthscapular muscles?

– No side differences (10% more strengthon dominant side)

– Protraction/retraction ratio = 100%

– Special attention to middle and lower trap

(Cools et al. BJSM 2004, JAT 2005, JAT 2007, BJSM 2010, Tate et al. JAT 2012, Kawasaki 2012)

Ann Cools Wrightington Nov 2012 42

Functional tests?

� Eccentric strength RC:

– new protocol for ecc strengthmeasurement using compuFET HHD: 90°- 3 seconds - ER

Ann Cools Wrightington Nov 2012 43

Functional tests?Within- and between tester reliability and

validity of a new protocol for measuringeccentric RC strength (Johansson & Cools, unpublished data 2012)

Within tester reliability

tester 1 Tester 2

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, Cools & Johansson, unpublished data 2012)

Ann Cools Wrightington Nov 2012 44

Functional tests?Within- and between tester reliability and

validity of a new protocol for measuringeccentric 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 Correlationcoefficient

0,78Ann Cools Wrightington Nov 2012 45

Functional tests?

� Endurance test in sport-specific position

(Maenhout et al. 2012, IJSM under revision)Ann Cools Wrightington Nov 2012 46

Injury Prevention Program

1. Stretching of the posterior shoulder

(Ellenbecker & Cools BJSM 2010)

Ann Cools Wrightington Nov 2012 47

Injury Prevention Program

2. Strengthening the posterior cuff

(Cools et al. BJSM 2008, Ellenbecker & Cools BJSM 2010)

Ann Cools Wrightington Nov 2012 48

Injury Prevention Program

3. Scapular training

(Cools et al. AJSM 2007, De Mey et al. JOSPT 2009,Ellenbecker & Cools BJSM 2010)

Ann Cools Wrightington Nov 2012 49

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 programAnn Cools Wrightington Nov 2012 50

(Gent- Belgium)

Ann Cools Wrightington Nov 2012 51