97 results in the potential for injary but no significant correlation botweon flexibility and shoulder pain was found. Further long-term research is necessary in three areas: AA study should aim to find out whether the imbalance Is charaetorieti of all players at every level or only of lite players. A prospective investigation of a group of pain-free water polo players should be undectaken to see ‘whether it is possible ta predict the incidence of pain on the basis of flexibility, The technique of throwing and swimming should be analysed as another possible cause of shoulder pain in water polo players. Acknowledgmems ‘Many thanks to tho mombors ofthe Great rtm Water Po Team | for their hap inthis investigation ‘This work was eampiead during study for @cislomain academic and practeal physiatherapy for spars al the Departmonto Sports Macicine, The Roya Londen Hospital, in 1092. ‘Address tor Correspondence Miss Jacqueine Elion BSe MCSP, Department of Sports Madicine, The Royal Landen Hosp Medical Golega, Turner ‘Sveet, London E¥ 2AD. References “American Aeademy of thopasdic Surgeons (1968). Joint Moon: Motiod of maasuing and recording, MOS, Cig, pages Cut, J 1880) ‘Suimmer's shoulder’ Clinics in Sports Moccine, 5 NB -1a7, ut, J and Stevens, & (1988). The prevention ana teatmant Of Injuries fo the shoulder in suieeming™. Spors Medicina, 7, 82206 Dominguez (1886), Water polo ie’, Ces in Sports Mace, 5, 4,588" 168 * Ekstrand, J and Gillauist, J (1982). "The frequency of muscle tightness and irra in socear players, Amorican Journal of ‘Sports Medicine, 10. 2, 76-78 Foley, 0 (1987) “Swimmer’s shoulder — A ditferont cinicat Aapproaon, Exesl, 4, 9-1" CGoipp, J (1985). ‘Swimmers shoulder: The uence ot fxibuity and weight Vaining, The Physician and Sports Medicine, 13. 8, 92-105 Hawkins, Rana Hope, P1981). Impingement syndrome in the athelte shoulder Symposium cn nuries ta the Shoulder io the athite’, Gfincs in Spons Medicine, 351 - 405 Hinton, # (1968), “‘Isekinaic evaluation of shoulder rotational rang in schoolagec baseball pitchers: Amencen Jovinal of ‘Sports Medicine, 16, 274~278 Mektaser, W (198). ‘Anterior glenoid labrum darnage: A painful lesion in gvimmers; Amencan Journal of Sports Medicise, 14, 5, 383-367 Metastr, W. Long. S anc Catorza, V (1989, “Iookinatic torque Imbalances in the rotator cult othe Sita water pole player, American Journal of Spore Modicine, 19,3. 72-75 ‘Murray. M, Gore, D. Gardner, Gand Molinge (1988). Shoulder mation end muscle sraqgth of normal men aid women in 0 ‘age groups, Cicai Ontopaadics and Ratated Rasaaren, 192, 268-27. Peal L (1991), "Water poles benstis surface’, The Physician and Sports Medicine, 18.4, 119-128. oeves, 0 (1990), 'A short history of water pols, Swimming Yearbook, Hugmans, London, pages 312-313 Archardaon A (1983). ‘Overuso syndromes in basabsll, tenis, gyrrmastioe and swimming’, Clines in Sports Medicine, 2,2, 373-391 Alchardson, A. Jobe, F and Coline, F (1880) “Th shoulder in Compatilve saimming!, American Jowrzal cf Sports Medicine, 2,3 50163 Polins. J Pures, J, Whiting, W. Grog: an Finerman,G (1985) ‘Waterpolo injuries to the upper extremity’, niuries fo tho Throwing Arm. WB Saunders, Preladelphia, pages 317 ~317. Wilson, G, Eliott, B and Wood, G (1992). 'Sirtch shorten eyale Performance echancomont through fx ily taining’, Madicine ‘and Science in Spor and Exercise, 24,1, 16-120 publications and reports Care Packages for Elderly People = A guide to assessment and ‘care management Festive Publeatone, B& Dowanbit Rowe, Lenaon SEB 15,1092 (SON 0 o5804€ Muses pages. £580 pus > pesage Sue Milne, formerly principal ficer, care management, Kent Sovia: Sorviees Department, and wow an indepondsnt community ‘care adviser, whe. was 3 fnaallant fr this timely publication ‘which dg intended for health ear. pro Fationals and oacil services and volar tary workere required to interpre the Gamavanity Care Ai 1900 ICCAD, with particular reference to tho are of blder people. "The cimprehensive contents suction Teads ito 2 soll presented booklet Unal {kas the reader thrauh the backsround, Limolable, assessment. procass, ule ot tho various agencies to'the production of cere pickoges and the oxparionees ot the Kent home care services laa ilostrations in chapler Ligh light the problems of the growth of the ‘bierly population and the soaring oats Hospital posing slmoat rule forbidden of resdentiol ear ta the social services. Further illustrations in the ferro flow charts holpclanfy the assessment procere A Pictorial History of Netherne by Jone € Wolo ana Frogey. Puishes by ear Sutey Heats Authority. ard aati rom Md ath 30 Woodcote Grove Fea Coiaaom, Sunny ORS. 24m 1900 USER 0 Beton? 2 1) thse 64 pugus £8 Hncusg ‘Written and printed by longatonding staff members at Netherne Horpitel, and ‘witha foreword by Dane Judi Dench ic book iz well tiled —- the pictures predominate ovar the short text "Whon the hospital it was considered ‘somewhat lavish for some patients clahorate" Treatment. was bated on @ ‘mrvctared (fe nd aff were organtced rigidly, with early nights the 1 visite butween the ances atrcily ‘Conditions or both types of inhabit. fanis) relaxed ‘over the yours, and [Netherne Hospital was visited a8 contre of excellence by many distinguished Viectors It is now mainly a centre fr ‘treatment of patients ving inthe com munity “Tae. photographs record almost a ‘entry ef progress in mental health care Picture 79 shows the spacious physio- therapy department opened in 1981, wit fiveebietes and ehree members of taf Health Pickup Case Studies IMS Traning Ouecrot6, St Bacracren's Cour, 18 Conga Seoc Bist! B87 88 ion 12 pagee Health Pickup madules in management ils for huulth care professional have been in uae in the NHS for three yenra Tis booklet gives one example each page ofa named and pictured individual ‘ohn bas uned the modules enhamee her ‘career prospects and improve the care ee ‘or er department provides to patients. "The model selected are all women and Include several from the profeasans allied medicine, sidhoughy there is ue hyslotheraphe opened in 1909 "and “unnecessarily Physiotherapy, October 1983, vol78, noDiscussion ‘The aim of this study was to compare the flexibility of ‘the dominunt shoulders of lite water polo players with ‘their own nondominant shoulders and the shoulders of a control group. Swimming is a bi-latoral action fand throwing is a unilateral action and therefore a ference in flexibility between the dominant and non- dominant shoulders in watar polo players would indicate that it is caused by repetitive throwing rather than the swirnming action. A significant restriction in functional medial rotation was found in the dominant shoulder of the élite water pulo players(y < 0.01). Medial and lateral rotation were also restricted in the dominant shoulder compared to the nondominant shoulder, and to ‘meaurements ofthe control group. The water polo players showed greater flexibility in their dominant shoulder for the other movements, but these differences were only small and similar to both the control group and values ‘quoted by Murray etal (1985) for a normal population, Assignificant increase in flexion was also seen bilaterally in the water polo players (p< 0.001). ‘This restriction in one aspect of the water polo players’ shoulder flexibility and increase in another aspect indicates an imbalance that is not found in the control group. MeMaster (1991) showed that élite watar polo players are significantly stronger than control subjeets sand have an imbalance of muscle strength fevouring the sadductors and medial rotatora. This inerease in strength can lead to muscle hypertrophy ofthe rotator ew muscles in the throwing arm, leading ta stiffness and reduced flexibility. The throwing action relies heavily on the rotator cuff muscles to stabilise the head ofthe humerus, ‘while other more powerful muscles, namely pectoralis major and latisimus dorsi, propel the ball ‘The position ofthe shoulder in functional medial rotation isa position in which the supraspinatus muscle and the posterior portion of the capsule are strutched (Richardson, 1983), It appears therefore, that the water polo players exhibit a Lightness in supraspinatus or the posterior capsule, or both, Acrestriction in medial rotation in water polo players might be unexpected heeause both the swimming and throwing motions eequire Lhe shoulder to move from full Isteral rotation to full medial rotation. However, most of the rotation oecurs above the head and the water level prevents full medial rotation during the deceleration phase of throwing. The swimming stroke in water polo is also very different from that used by compstitive swimmers who are encouraged to push their hand back to their thigh during the propulsive phase to use as much water as possible, thus encouraging full medial rotation. ‘The swimming skills in water polo rely heavily on short bursts of high speed sprinting to optimise position for play. The stroke rate tends to be much faster and the stroke length shorter, A head-up technique is also necessary for visibility in pursuit ofthe ball, paesing and shooting; and a high elbow recovery is used to protect the ball from a defensive player when swimming with the bell. This technique not oxly prevents full rotation but also ‘body roll’ which is seen in competitive swimmers, MeMaster (1986) believes that body rll is inversely related to shoulder pain in freestyle and backstroke because it inereuses the mechanieal offciency of the stroke, theroby putting less strain ou the shoulde. Also, lack of flexibility in a swimmer ean be compensated by an inerease in body roll (Rielaudson ef al, 1980), Pain and Flexibility Although an imbalance in flexibility was found in this study, indicating « potential for injury, a signifieant correlation between flexibility and pain was not found. However, the scattergrams for medial rotation and ‘otal flexibility (ig 2) show that the water polo players with high pain ratings had either reduced ar increased Alexibility compared to the other players, They also had redveed lateral rotation compared tp the water polo playera with lower pain ratings, The reauls eu that water polo players with restricted lateral rotation, fr too much or too little medial rotation or general exibility, are most nt risk of shoulder pain, but there {a no conclusive evidence, Injury and Flexibility Many authors suggest shat muscular tightness whith restricts range of movement can predispose the muscle to rupturo and cause tendiniuis, Wilson e& a! (1982) Adeseribe the mechanism underlying this relationship as the extention of the museulotendinoue unit heyend itt normal limit. This results in repetitive micretrauma, inflammation and pain. A restriction in lateral rotation in water polo players is important in the ‘wind uf or ‘eocking’ position of abduction, lateral rotation and extension. Hare fibrous tissues are woand up to create ‘an elastic force ready for the acceleration phase of rowing the sof tissues are stretched to their limit. Bkstrand and Gillquist (1982) found that foothall players wore lees flexible than controls but-na eorrclation as found between injury and flexibility: The authors blame the emphasis on strengthening at the expense of stretching for the reduced flexibility. Warm-up routines, which include selective Nexibility exercises as well ag general exercises to raise the body temperature, are rocommendod by Hawkins and Hoboika (1991). However, it is also thought that forced or improper stretching may aggravate or eanse injury. MeMascer (1886), belioves that stretching ehould be individual and never competitive ‘Therefore stretching with a partner should be eliminated. Richardson (1983) questions at which point floxibiity becomes @ liability rather than an asset. The cocking position described eatlier is the elassie portion of apprehension in patients with recurrent, subluxation of their glenohumeral joint. In vary flexible water polo players the repeated forced lateral rotation causes the anterior capsule to stroteh and becorne las, resulting in instability. Rollins et af (985) report shoulder dislocation to be frequent among water polo players, The mechanism of injury is the striking of the arm by an opposing player with foreod abduction, extension and loteral retation, causing a typical anterior dislocation. ‘Therefore, both excessive and restricted shoulder flexibility appear to predispose to injury in water poto players Conclusions ‘This study has demonstrated that élite water polo players develop an imbalance in the flexibility of their dominant shoulder due to the vepetitive throwing action. Thi Phiyelotherapy, October 1983, v0l79, no 10‘Mean = standard deviation andthe significant aiference for dominant and non-dominant shoulders in bth groups of subjects Functional — Functional Tolar Medal — Lateral modal fatoral — loity Prexion Extension Abduction rotation rotation relation rotation inden a 0 o 0 o en) (em) (arvirary) Water polo players Dominant wens: 7a 1958 454 762 ane ne 860 ‘shoulder 218 ser 2S a2 std 288 e480 2427 Nondominant 17961 77.3 142 508 736 26 9876 shoulder uy £87 0 2850 att 80 8 70, 217 2388 controle Dominant 158. 781 1767 566 B38 a4 2788 shoulder st 2820 242 aS 7 be #21 = 364 Nondlominart 158.8 8 1767 50 BIT 76 3089 shoulser e102 S77 e183 sta 87 $22 49465 4P<0.01: untlated Mest of dominant versus non-dominaat shoulder. * p<0,01. 1 p< 0.001: unrelated Hest of water poe player oreus contel rotation compared to the control group. The difference is greater in the dominant shoulders compared to the non-dominant shoulders and greater for medial rather than Ieteral rotation, although none of the differences ‘are significant, In abduction, the water polo players chow moro ‘movement than the eontrots in both shoulders, but again the difforonce is not significant, No differences were seen between the groups or shoulders in extension or functional lateral rotation. Pain versus Flexibility ‘The values obtained from tho pain sealo in the weator polo group were used to draw scattergrams for each range of ‘movement to see if there was evidence of a correlation between pain and flexibility (ig 2). Apparently, there is no relationship betweon reported lovels of pain and any of the measured ranges of movement, Fig 2: Scattergrame to show correlation between paln and range of mavement of dominant shoulder In waterpolo players spe xx xm wee xox * fo x : x x 3 Bol em xm x wee a a ’ . . « ° Fedor 6) Eaeraion ©) tater itaton "Function! mal ation (om) da . . * x 3 al ate nn ae won 5 eo Fc ‘Abduction * ‘Medial rotation (°) Functional lateral Total flexibility (arbitrary) roan fe) Pain Seales = 0 pan, 2 = cosetoal pi, 2 = pin tering wih uston = pin ertering wt uncon and euiing rmedeal advice, 6 = pale preventing play In an Imporian maichimissed Iralning for > 2 WoSks Physictherapy, October 1883, vl 79, n0 10