Ann Cools 4

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
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
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
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
Ann Tennis
Cools Wrightington Federation – Stockholm - Sweden
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, functional

strength, velocity…
Imaging: bilateral MRI both shoulders

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
Scapulo-thoracic Outcome Measurements:
(Pro 3600 digital inclinometer)
1. Scapular upward inclination: 0° - 90° - 180°
(Downar 2005, Myers 2005, Laudner 2007, Oyama 2008)

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)
Scapulo- thoracic Outcome Measurements:
3. Pectoralis minor length: coracoid – 4th rib

(Borstad 2005, Borstad 2008)
Results (1)
Scapular upward inclination

60
50
40
ND
30
D
20
10
0
0° 90° 180°
Significant side-difference dominant versusNov

Ann Cools Wrightington non-dominant
2012 p< 0.001 10
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
Results(2)
Scapular Muscle Strength

180
160
* *
140
120
100 ND
80 D
60
40
20
0
UT SA MT LT

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

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 the dominant side (p<0.001)
Discussion
Borstad et al. JOSPT 2005:

short PM influences scapular
kinematics and induces
changes similar to
impingement related
dyskinesis

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
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
Methods
Scapular measurements
– Upward inclination (pro 3600 inclinometer)
– Muscle strength (CompuFET - Biometrics)
Glenohumeral measurements
– ROM (Acumar inclinometer)
– RC strength (CompuFET- biometrics)

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
shoulder pain
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
of general increase in shoulder strength

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)
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%)

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
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

MRI screening
(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

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).

Most common MRI findings
Boys 13-24 years
Infraspinatus tendinosis Supraspinatustendinosis
DA DA
3 out of 15 players (20%) 0 out of 15 players

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%)

Aerobe/Anaerobe tests
Modified 30 s wingate
Treadmill test test

Correlation divided into gender

Threshold/SvTF criteria for Girls
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)

Threshold/SvTF criteria for Boys
6
boys
28%

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?
Implications of shoulder
screening for injury
prevention and return
to play after injury?
“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

Normal ROM?
< 20° side difference for IR

< 10% side difference for total ROM
(ER + IR)
(Ellenbecker & Cools

Ann CoolsBJSM 2010,
Wrightington Braun et al. JBJS 2009,
Nov 2012 38
Tate et al. JAT 2012, Shanley et al. AJSM 2011)
Measurement of shoulder
ROM into ER and IR
Loss of ROM >25° increases risk for shoulder

injury
(Ellenbecker & Ann
Cools
CoolsBJSM 2010,
Wrightington Braun et al. JBJS 2009
Nov 2012 39
Tate et al. JAT 2012, Shanley et al. AJSM 2011)
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 Wrightington Nov 2012

& Cools 2010, Byram et al. AJSM 2010, 40
Niederdracht et al. 2008)

Measurement of RC
strength
ER/IR ratio <66% increases the risk for

shoulder injury in overhead athletes
(Byram et al. AJSM 2010)

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,
Tate et al. JAT 2012, Kawasaki 2012)
Functional tests?
Eccentric strength RC:

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

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

Ann Cools2010,
Wrightington Nov 2012 44
Cools & Johansson, unpublished data 2012)
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
Functional tests?
Endurance test in sport-specific position
(Maenhout et al. 2012, IJSM under revision)

Injury Prevention Program
(Ellenbecker & Cools BJSM 2010)
1. Stretching of the posterior shoulder

(Cools et al. BJSM 2008, Ellenbecker & Cools BJSM 2010)
2. Strengthening the posterior cuff

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

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

(Gent- Belgium)

Ann Cools 4

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SCREENING THE SHOULDER

GIRDLE IN ELITE TENNIS

Ann Cools, PT, PhD

2. Results from studies on elite

3. Implications for injury prevention

Performance enhancement: longitudinal

Injury prevention - risk factors for

Return to play – normative data and

Ann Cools, PT, PhD & Fredrik Johansson, PT, MsC

Physical tests: physical capacity, functional

Imaging: bilateral MRI both shoulders

Male players (n=19) Female players (n=16) p-value independent

Height (cm) 163.6 (± 12) 156.6 (± 10.5) 0.84

Weight (kg) 53 (± 11.8) 46.1 (± 7.8)

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

Ann Cools Wrightington Nov 2012 7

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

Ann Cools Wrightington Nov 2012 8

3. Pectoralis minor length: coracoid – 4th rib

Ann Cools Wrightington Nov 2012 9

Scapular upward inclination

Significant side-difference dominant versusNov

Conflicting results in literature: Scapular

More upward rotation possibly protects

Scapular Muscle Strength

Ann Cools Wrightington Nov 2012 12

Cools et al. 2007 : elite gymnasts

Trakis et al. 2008: side differences in

Ann Cools Wrightington Nov 2012 13

Pectoralis minor length

Borstad et al. JOSPT 2005:

Ann Cools Wrightington Nov 2012 15

Only scapular position and strength,

Purpose of the 2nd study: Age-

Subjects: Swedish National Selection Tennis

14-16y 22 15,3 168,8 ± 8,4 57,1 ± 9,1

Ann Cools Wrightington Nov 2012 18

16+ players have less upward rotation at higher

no increase in normalised muscle strength of

of general increase in shoulder strength

(3) Glenohumeral ROM

in general age-related decrease of IR-ROM (-10°) en

(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

Ann Cools Wrightington Nov 2012 22

Age-related changes in shoulder and

MRI screening of the shoulder

Ann Cools Wrightington Nov 2012 24

Ann Cools Wrightington Nov 2012 25

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

Ann Cools Wrightington Nov 2012 26

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

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

Ann Cools Wrightington Nov 2012 28

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

Ann Cools Wrightington Nov 2012 29

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

Ann Cools Wrightington Nov 2012 30

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

Ann Cools Wrightington Nov 2012 31

Only 1 girl (5,5%)

Ann Cools Wrightington Nov 2012 32