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BackgroundLabral repair and biceps tenodesis are routine operations for superior labrum anterior posterior (SLAP) lesion of the shoulder, but evidence of their efficacy is lacking. We evaluated the effect of labral repair, biceps tenodesis and sham surgery on SLAP lesions.MethodsA double-blind, sham-controlled trial was conducted with 118 surgical candidates (mean age 40 years), with patient history, clinical symptoms and MRI arthrography indicating an isolated type II SLAP lesion. Patients were randomly assigned to either labral repair (n=40), biceps tenodesis (n=39) or sham surgery (n=39) if arthroscopy revealed an isolated SLAP II lesion. Primary outcomes at 6 and 24 months were clinical Rowe score ranging from 0 to 100 (best possible) and Western Ontario Shoulder Instability Index (WOSI) ranging from 0 (best possible) to 2100. Secondary outcomes were Oxford Instability Shoulder Score, change in main symptoms, EuroQol (EQ-5D and EQ-VAS), patient satisfaction and complications.ResultsThere were no significant between-group differences at any follow-up in any outcome. Between-group differences in Rowe scores at 2 years were: biceps tenodesis versus labral repair: 1.0 (95% CI −5.4 to 7.4), p=0.76; biceps tenodesis versus sham surgery: 1.6 (95% CI −5.0 to 8.1), p=0.64; and labral repair versus sham surgery: 0.6 (95% CI −5.9 to 7.0), p=0.86. Similar results—no differences between groups—were found for WOSI scores. Postoperative stiffness occurred in five patients after labral repair and in four patients after tenodesis.ConclusionNeither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions in the population studied.Trial registration numberClinicalTrials.gov identifier: NCT00586742

BackgroundShoulder problems are highly prevalent among elite handball players. Reduced glenohumeral rotation, external rotation weakness and scapula dyskinesis have been identified as risk factors.AimEvaluate the effect of an exercise programme designed to reduce the prevalence of shoulder problems in elite handball.Methods45 elite handball teams (22 female teams, 23 male teams, 660 players) were cluster randomised (22 teams, 331 players in the intervention group, 23 teams, 329 players in the control group) and followed for 1 competitive season (7 months). The Oslo Sports Trauma Research Center (OSTRC) Shoulder Injury Prevention Programme, an exercise programme to increase glenohumeral internal rotation, external rotation strength and scapular muscle strength, as well as improve kinetic chain and thoracic mobility, was delivered by coaches and captains 3 times per week as a part of the handball warm-up. The main outcome measures, prevalence of shoulder problems and substantial shoulder problems, were measured monthly.ResultsThe average prevalence of shoulder problems during the season was 17% (95% CI 16% to 19%) in the intervention group and 23% (95% CI 21% to 26%) in the control group (mean difference 6%). The average prevalence of substantial shoulder problems was 5% (95% CI 4% to 6%) in the intervention group and 8% (95% CI 7% to 9%) in the control group (mean difference 3%). Using generalised estimating equation models, a 28% lower risk of shoulder problems (OR 0.72, 95% CI 0.52 to 0.98, p=0.038) and 22% lower risk of substantial shoulder problems (OR 0.78, 95% CI 0.53 to 1.16, p=0.23) were observed in the intervention group compared with the control group.ConclusionsThe OSTRC Shoulder Injury Prevention Programme reduced the prevalence of shoulder problems in elite handball and should be included as a part of the warm-up.Trial registration numberISRCTN96217107.

Background Validated clinician outcome scores are considered less associated with psychosocial factors than patient-reported outcome measurements (PROMs). This belief may lead to misconceptions if both instruments are related to similar factors. Questions We asked: In patients with chronic shoulder pain, what biopsychosocial factors are associated (1) with PROMs, and (2) with clinician-rated outcome measurements? Methods All new patients between the ages of 18 and 65 with chronic shoulder pain from a unilateral shoulder injury admitted to a Swiss rehabilitation teaching hospital between May 2012 and January 2015 were screened for potential contributing biopsychosocial factors. During the study period, 314 patients were screened, and after applying prespecified criteria, 158 patients were evaluated. The median symptom duration was 9 months (interquartile range, 5.5–15 months), and 72% of the patients (114 patients) had rotator cuff tears, most of which were work injuries (59%, 93 patients) and were followed for a mean of 31.6 days (SD, 7.5 days). Exclusion criteria were concomitant injuries in another location, major or minor upper limb neuropathy, and inability to understand the validated available versions of PROMs. The PROMs were the DASH, the Brief Pain Inventory, and the Patient Global Impression of Change, before and after treatment (physiotherapy, cognitive therapy and vocational training). The Constant-Murley score was used as a clinician-rated outcome measurement. Statistical models were used to estimate associations between biopsychosocial factors and outcomes. Results Greater disability on the DASH was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.64; 95% CI, 0.25–1.03; p = 0.002) and social factors (language, professional qualification combined coefficient, −6.15; 95% CI, −11.09 to −1.22; p = 0.015). Greater pain on the Brief Pain Inventory was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.076; 95% CI, 0.021–0.13; p = 0.006). Poorer impression of change was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia coefficient, 0.93; 95% CI, 0.87–0.99; p = 0.026) and social factors (education, language, and professional qualification coefficient, 6.67; 95% CI, 2.77–16.10; p < 0.001). Worse clinician-rated outcome was associated only with psychological factors (Hospital Anxiety and Depression Scale (depression only), Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia combined coefficient, −0.35; 95% CI, −0.58 to −0.12; p = 0.003). Conclusions Depressive symptoms and catastrophizing appear to be key factors influencing PROMs and clinician-rated outcomes. This study suggests revisiting the Constant-Murley score. Level of Evidence Level III, prognostic study.

Purpose To prospectively identify preseason physical factors for shoulder and elbow injuries during the season in high school baseball pitchers. Methods The study included 105 high school baseball pitchers [median age 16 (15–17) years]. The range of motion of the shoulder (90° abducted external and internal rotation) and elbow (extension/flexion), shoulder muscle strength (abduction and prone internal and external rotation), shoulder and elbow laxity, horizontal flexion, and scapular dyskinesis were assessed. After the season, the participants completed questionnaires regarding shoulder and/or elbow injuries, with injury defined as an inability to play for ≥1 week due to elbow/shoulder problems. The results of two groups (injured and noninjured) were compared using t tests and Chi-square analyses. Stepwise forward logistic regression models were developed to identify risk factors. Results Twenty-one injuries were observed. In univariate analysis, 90° abducted internal rotation and total arc of the dominant shoulder and the ratio of prone external rotation in the dominant to nondominant sides in the injured group were significantly less than those in the noninjured group ( P  = 0.02, 0.04, and 0.01, respectively). In logistic regression analysis, 90° abducted internal rotation in the dominant shoulder and prone external rotation ratio were significantly associated with injuries ( P  = 0.02 and 0.03, respectively). Conclusion A low prone external rotation ratio and decreased 90° abducted internal rotation in the dominant shoulder in the preseason were significant risk factors for shoulder and elbow injuries in high school baseball pitchers. The results may contribute to reduce the incidence of these injuries. Level of evidence II.

ObjectiveTo investigate if a combination of an online and onsite implementation strategy was superior to an online-only strategy in enhancing the use of an injury prevention exercise programme (IPEP) and in reducing the risk of shoulder, knee and ankle injuries in youth community handball players (age 11–17) over a handball season.MethodsIn this 30-week hybrid effectiveness-implementation cluster randomised type 3 study, 20 youth handball clubs were randomly assigned 1:1 to either a combined online and onsite implementation strategy (coach workshop using the health action process approach behaviour change model and health service provider (HSP) support) or an online-only strategy (control group). The primary implementation outcome was coach-reported adherence, measured as the average IPEP exercise usage by the team over 30 weeks. The primary effectiveness outcome was player-reported handball playing time to any new handball-related shoulder, knee and ankle injuries, reported weekly using the Oslo Sports Trauma Research Centre Questionnaire on Health Problems.ResultsWe enrolled 63 coaches (27% women) and 945 players (mean age 14.5 years, 55% girls). Intention-to-treat analyses showed no statistically significant difference between implementation strategies in adherence (between-group difference 1.4, 95% CI −0.5 to 3.4) or in cumulative injury risk (between-group difference 5.5% points, 95% CI −2.2 to 13.1).ConclusionOur findings demonstrate that in youth community handball, a combined online and onsite implementation strategy, including a coach workshop and HSP support, was not superior to an online-only strategy regarding adherence to an IPEP or in reducing shoulder, knee and ankle injury risk.Trial registration numberNCT05294237.

ObjectiveTo characterise whether preseason screening of shoulder range of motion (ROM) is associated with the risk of shoulder and elbow injuries in overhead athletes.DesignSystematic review and meta-analysis.Data sourcesSix electronic databases up to 22 September 2018.Eligibility criteriaInclusion criteria were (1) overhead athletes from Olympic or college sports, (2) preseason measures of shoulder ROM, (3) tracked in-season injuries at the shoulder and elbow, and (4) prospective cohort design. Exclusion criteria were (1) included contact injuries, (2) lower extremity, spine and hand injuries, and (3) full report not published in English.ResultsFifteen studies were identified, and they included 3314 overhead athletes (baseball (74.6%), softball (3.1%), handball (16.1%), tennis (2.0%), volleyball (2.0%) and swimming (2.2%)). Female athletes are unrepresented (12% of the overall sample). Study quality ranged from 11 to 18 points on a modified Downs and Black checklist (maximum score 21, better quality). In one study, swimmers with low (<93°) or high (>100°) shoulder external rotation were at higher risk of injuries. Using data pooled from three studies of professional baseball pitchers, we showed in the meta-analysis that shoulder external rotation insufficiency (throwing arm <5° greater than the non-throwing arm) was associated with injury (odds ratio=1.90, 95% confidence interval 1.24 to 2.92, p<0.01).ConclusionPreseason screening of shoulder external rotation ROM may identify professional baseball pitchers and swimmers at risk of injury. Shoulder ROM screening may not be effective to identify handball, softball, volleyball and tennis players at risk of injuries. The results of this systematic review and meta-analysis should be interpreted with caution due to the limited number of studies and their high degree of heterogeneity.PROSPERO registration numberCRD42017072895.

ObjectiveTo assess the evidence for risk factors and prevention measures for shoulder injuries in overhead sports.DesignSystematic review with best-evidence synthesis.Data sourcesMedline (Ovid), PubMed (complementary search), Embase (Elsevier), Cochrane (Wiley), SPORTDiscus (Ebsco) and Web of Science Core Collection (Thomson Reuters), from 1 January 1990 to 15 May 2017.Eligibility criteria for selecting studiesRandomised controlled trials, cohort studies and case-control studies on risk factors or prevention measures for shoulder injuries in overhead sports. The eligible studies were quality assessed using the Scottish Intercollegiate Guidelines Network criteria.ResultsOf 4778 studies identified, 38 were eligible for quality review and 17 met the quality criteria to be included in the evidence synthesis. One additional quality study presented a shoulder injury prevention programme. Most studies focused on baseball, lacrosse or volleyball (n=13). The risk factors examined included participation level (competition vs training) (n=10), sex (n=4), biomechanics (n=2) and external workload (n=2). The evidence for all risk factors was limited or conflicting. The effect of the prevention programme within the subgroup of uninjured players at baseline was modest and possibly lacked statistical power.ConclusionsAll investigated potential risk factors for shoulder injury in overhead sports had limited evidence, and most were non-modifiable (eg, sex). There is also limited evidence for the effect of shoulder injury prevention measures in overhead sports.PROSPERO trial registration number CRD42015026850.

This statement paper summarises and appraises the evidence on diagnosis, prevention, and treatment of common shoulder injuries in sports. We systematically searched Medline and Embase. The Grading of Recommendations Assessment, Development and Evaluation tool was applied to evaluate the overall quality of evidence.For diagnosis, we included 19 clinical tests from mixed populations. Tests for anterior instability, biceps-labrum complex injuries and full subscapularis rupture had high diagnostic accuracy (low to moderate quality of evidence).For prevention, the Oslo Sports Trauma Research Center, the Shoulder Control, the FIFA 11+ shoulder injury prevention programmes, and a baseball-specific programme (range of motion, stretching, dynamic stability and strengthening exercises) showed moderate to large effect size in reducing the risk of shoulder injury compared with no intervention (very low to moderate quality of evidence).For treatment, a rehabilitation programme including stretching, ice packs, electrotherapy and compression, and strengthening exercises showed a large effect size in reducing pain and disability compared with no intervention in athletes with subacromial impingement syndrome (very low to moderate quality of evidence). For the treatment of supraspinatus tendinopathy, hyperthermia treatment (heating the skin to 38°C–40°C) resulted in large effect size in reducing pain and disability compared with ultrasound or pendular swinging and stretching exercises (moderate quality of evidence). Strengthening exercise alone or in combination with stretching exercises promoted a large effect in reducing shoulder pain (cohort studies, no comparators) (very low quality of evidence). The quality of evidence for most estimates was low to moderate, indicating that future high-quality research may alter our recommendations for clinical practice.

To assess the effectiveness of exercise-based injury-prevention programs in preventing sports injuries in team handball players. Scopus, PubMed, Web of Science, SPORTDiscus, and CINAHL from inception until April 2023. Studies were included if they were randomized controlled trials or prospective cohort studies, contained a population of competitive team handball players, included an intervention designed specifically to prevent or reduce the risk of team handball injuries, and reported injury incidence rates specific to team handball players. Two researchers independently evaluated studies for inclusion and assessed their methodological quality. Study design, intervention details, participant characteristics, and the number of injuries in each group were extracted from each study by 2 independent researchers. The outcome of interest was the incidence rate of injury. Injury data were classified into 5 groups: shoulder injuries, lower extremity injuries, knee injuries, anterior cruciate ligament injuries, and ankle injuries. Extracted data were analyzed using a random-effects model to compute the overall effect estimates of injury-prevention programs in reducing the risk of injuries. Odds ratios (ORs) with 95% CIs were calculated based on the number of injuries in each group. Meta-analyses were conducted independently for each injury classification. Results indicated that prevention programs reduced the risk of shoulder injuries (OR = 0.60; 95% CI = 0.42, 0.85; P = .004), lower extremity injuries (OR = 0.59; 95% CI = 0.37, 0.95; P = .03), knee injuries (OR = 0.53; 95% CI = 0.35, 0.78; P = .002), anterior cruciate ligament injuries (OR = 0.66; 95% CI = 0.45, 0.96; P = .03), and ankle injuries (OR = 0.57; 95% CI = 0.40, 0.81; P = .002) in team handball players. In team handball players, injury-prevention programs appear to effectively reduce the risk of shoulder, lower extremity, knee, ankle, and anterior cruciate ligament injuries.

Background Both acute and overuse injuries are common among recreational volleyball players, especially finger/wrist, ankle, shoulder and knee injuries. Consequently, an intervention (‘VolleyVeilig’) was developed to prevent or reduce the occurrence of finger/wrist, shoulder, knee and ankle injuries among recreational volleyball players. This article describes the design of a study evaluating the effectiveness of the developed intervention on the one-season occurrence of finger/wrist, shoulder, knee and ankle injuries among recreational adult volleyball players. Methods A randomized prospective controlled trial with a follow-up period of one volleyball season will be conducted. Participants will be healthy recreational adult volleyball players (18 years of age or older) practicing volleyball (training and/or match) at least twice a week. The intervention (‘VolleyVeilig’) consists of a warm-up program based on more than 50 distinct exercises (with different variations and levels). The effect of the intervention programme on the occurrence of injuries will be compared to volleyball as usual. Outcome measures will be incidence of acute injury (expressed as number of injuries per 1000 h of play) and prevalence of overuse injuries (expressed as percentage). Discussion This study will be one of the first randomized prospective controlled trials evaluating the effectiveness of an intervention on the occurrence of both acute and overuse injuries among recreational adult volleyball players. Outcome of this study could possibly lead to the nationwide implementation of the intervention in all volleyball clubs in The Netherlands, ultimately resulting in less injuries. Trial registration Dutch Trial Registration NTR6202 , registered February 1st 2017. Protocol: Version 3, February 2017.